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Understanding post-hire transitional challenges of foreign-educated nurses

I nternational migration of healthcare workers is an inevitable reality in the era of globalization. The percentage of internationally educated RNs licensed in the United States increased from 3.7% to 5.6% between 2004 and 2008, representing an estimated 170,235 RNs.1,2 The United States is projecting a nursing shortage between 400,000 and 800,000 by the year 2020.3 Federal and state governments are increasing efforts to expand nursing programs to relieve this shortage; however, shortages of qualified faculty, lack of clinical facilities, and an aging nurse educator workforce are noted as potential barriers to this expansion.4 U.S. healthcare agencies have been actively recruiting foreign-educated nurses (FENs) since the 1960s.5 FENs come to the United States from around the world, although more than two-thirds of them live in one of six states, including New Jersey, New York, Illinois, Texas, California, and Florida. The majority (72%) work in hospitals.6 Migration issues aside, the retention of FENs requires successful adaptation to the U.S. healthcare environment. Most FENs come to the United States with a wealth of clinical experiences, yet challenges arising from their different linguistic, professional, and cultural backgrounds need to be addressed for them to make a successful transition, creating challenges for nurse managers.7-10 For instance, although the majority of FENs speak English, only 5% to 6% of the applicants to the Commission on Graduates of Foreign Nursing Schools (CGFNS) identified English as their primary language.8 This means that although the didactic education may have taken place in English, FENs used their native language for most communication. In addition, ineffective use of English in verbal and written communication has been identified as a major barrier that FENs encounter. In a survey done by CGFNS, 70% of the 138 hospital administrators surveyed identified lack of English language skills among FENs as the most critical barrier to their integration.7 Unfortunately, research on transitional barriers of FENs in the United States is limited. Although there were early studies in the 1970s, the majority of literature on international nurses is nonresearch-based.11-13 It was only recently that a renewed interest in international nurses occurred, coinciding with the surge of foreign nurse migration to the United States in the current nurse shortage cycle.5,8,9,14-17 With this study, we examine the transitional/ adaptation challenges of FENs in the U.S. healthcare system from multiple stakeholders: clinical educators, preceptors, and the FENs themselves.