Internationally trained nurses improve healthcare

With Chenjuan Ma |

I organized this study because internationally educated nurses (IENs) are an important and unique part of the US nursing workforce and there are controversial opinions regarding the influence of IENs on quality of care and patient outcomes. Those controversies are mainly because of the scarcity of relevant empirical evidence. In addition, my international background also contributed to my interest on this topic. I completed both my BSN and MSN in China. In addition, our team received a grant from the Sigma Foundation for Nursing that helped us successfully complete this project. 

Why is this research important to nursing?
IENs are an important part of the nursing workforce in the US and many other countries. In the US, it is estimated that approximately 6-16% of the over 3 million nurses are IENs. Despite this fact, there are debates regarding the impact of IENs on quality of care and patient outcomes, which causes confusion to managers and policymakers in their decision-making of hiring IENs. One reason of the confusion is the lack of research on this topic, especially studies using quantitative data on a large scale. As a nurse scientist conducting research on nurse workforce, my colleagues and I feel that we are obligated to fill the knowledge gap by investigating IENs’ roles within the US healthcare system. Such evidence will inform future policymaking for a healthy and sustainable nursing workforce in the US. 

What do you think the impact of IENs can be on rural areas?
IENs have the potential to address staffing shortages in rural areas. The challenges most rural hospitals face is that they cannot afford to sponsor green cards or other visas in order to hire IENs. Some IENs may not want to work in rural areas, preferring to be in more urban areas where there is an established community they identify with, or simply for easier access to cultural events. There should be deliberate and focused efforts to facilitate this recruitment and transition of IENs in rural areas.

You noted that hospitals with IENs have less turnover. Why do you think that is?
Our statement that hospitals with IENs may have less turnover is based on our findings that units with higher proportion of IENs had longer unit tenure, and IENs in general stayed longer on a unit than US nurses. In this study, unit tenure was defined as the average years working on current unit among all nurses on the unit. There are several possible explanations: 

  1. For many IENs, their legal statuses in the US (i.e., US work visa) is dependent on their employment status. 
  2. Similarly, many IENs’ applications for permanent residence (also known as green card) require sponsorship from their hospital employers, and this process may take many years. Therefore, those IENs have limited mobility.
  3. Some IENs prefer to work in specific areas where there is an established community they identity with culturally.
  4. For many IENs, they are the breadwinner in their families in the US and/or in their home country, and thus they are reluctant to take the risk of unemployment between jobs.
  5. Though less common, it is possible that some IENs are from a society that values job stability over other things such as new opportunities. Future research is warranted to examine this topic. 

What are some quick tips that nurses and hospitals can use to integrate IENs into the US workforce? 
Transitional education programs tailored to IENs are key. They can be a blend of traditional hospital orientation programs but should also draw content from the existing literature that highlights those successful programs. In helping IENs transition to their roles as RNs in the US, administrators and managers should make sure that their transitional education programs include components specifically designed for IENs. For example, modules on basics of the healthcare system within the employer care settings and the US and regulations of the nursing profession, and workshops focusing on communication skills. In addition, it can be helpful to include mentoring programs pairing them with a team of mentors consisting of experienced IENs and US nurses. It is also important to recognize individual needs and help support the IENs with navigating their new community, especially if they have brought family members with them. Pairing them with a “peer buddy” who can help them with setting up bank accounts, phones, internet service, and when applicable, enroll children in public schools, are some examples of ways to help IENs transition.

Why are IENs critical to creating healthy work environments?
IENs help fill nursing position vacancies. When units have enough staff for the safest nurse-to-patient ratio, happier work environments prevail because people are less stressed. IENs can also serve as important cultural consultants if they come from the same country as patients served by the unit. They bring with them a wealth of experience, expertise, and diverse viewpoints that further strengthen interprofessional teamwork and collaboration. 


Chenjuan Ma, PhD; Allison Squires, PhD, RN, FAAN; Emerson Ea, PhD, DNP, APRN, FAAN; and Lauren Ghazal, FNP-BC, MS, are members of Sigma’s Upsilon Chapter at NYU Rory Meyers College of Nursing in New York, where they also teach. Sophia Chou, BSN, RN, is a NYU Rory Meyers graduate and an Operating Room nurse in New York. 

Acknowledgement: The authors thank Dr. Emily Cramer at University of Kansas School of Nursing for her assistance in obtaining the dataset, and Press Ganey Associates, Inc. for access to the data. The research was conducted independently. Neither the funder (i.e., STTI) nor Press Ganey involved in or influenced any research activities. 

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