Hiring foreign trained nursing staff is sometimes thought of as challenging, raising concerns about possible collaboration and performance issues. A new research, however, shows that such concerns may not be necessary.


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The study (Ma et al. 2020), conducted by researchers at NYU Rory Meyers College of Nursing and published in the journal Nursing Economic$, looked at the proportion of internationally educated nurses (IENs) in U.S. hospitals and assessed various factors, such as collaboration among health professionals. The analysis shows that having more nursing staff trained outside of the country does not hurt collaboration and may increase the education and retention levels within a hospital unit.

The ever-increasing shortage of skilled workers and growing demands in the healthcare sector are the drivers for hiring IENs in many countries, including the U.S. According to the authors of the research, the estimates are that as many as 5.6–16% of over 3 million nurses in the U.S. have received their primary nursing education abroad. But their impact on quality of care and patient outcomes has not been extensively studied, and the available findings have been mixed.

Ma and colleagues aimed to evaluate the association between levels of IENs and collaboration on a unit, which was measured using a nurse-nurse and a nurse-physician interaction scales. They also set to describe and compare nursing characteristics of units with different levels of IENs.

Using 2013 survey data from the National Database of Nursing Quality Indicators, the researchers analysed responses from 24,034 nurses, including 2,156 IENs, from 958 units across 168 U.S. acute care hospitals.

Of the 2,126 IENs, the majority (over 80%) were female, held a bachelor’s degree in Nursing and worked full-time. Compared to the overall sample, they were older and with longer RN tenure and unit tenure. They mostly worked in non-profit (76%) and teaching (59%) hospitals. The average share of IENs on a unit was 9% while nearly half (47%) of the 958 units did not have any IENs.

For the majority of cases, there was no evidence found that having more IENs led to decreased collaboration among nurses and between nurses and physicians. Specifically, units with10-20% IENs had lower RN-MD collaboration than units without IENs, but this was not the case in units with other IENs levels (less than 10% or more than 20%).

Other findings suggest that units with higher proportions of IENs had notable differences, eg had nurses with higher levels of education and less turnover, contributing to improved health outcomes. On the other hand, such units had lower nurse staffing levels or higher patient-to-nurse ratios, which could potentially worsen patient outcomes.

The researchers note that helping IENs to integrate into the U.S. workforce, eg by providing country-specific training or running workshops on culture, communication and teamwork, and recognising their contributions could lead to a healthy work environment and workforce and potentially benefit the whole system. 



Ma Ch et al. (2020)Unit Utilization of Internationally Educated Nurses and Collaboration in U.S. Hospitals. Nursing Economics, 38(1):33–50. Available from http://www.nursingeconomics.net/necfiles/2020/JF20/33.pdf

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