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This literature review explored the available cultural support existing in the United States and abroad for internationally-educated nurses (IEN) and foreign-born student nurses (FBSN) in order to better understand how to improve patient outcomes by ensuring a successful cultural and linguistic transition into American nursing schools and clinical facilities. Fourteen articles regarding IEN and twelve articles regarding FBSN were used to compile recommendations to help create a more inclusive and supportive environment for IEN and FBSN in the United States.
The results of this literature review indicate that there is an abundance of information regarding interventions for FBSN, but much research is lacking with regards to transitional programs for IEN coming to the United States. Recommendations are to conduct more research on barriers to implementation of transitional programs for IEN and to consider policy changes to make transitional programs mandatory; with regards to FBSN, it is recommended to conduct more evidence-based research regarding interventions for FBSN while also increasing funding and resources available to nursing schools for implementation of well-supported interventions.
The United States is one of the primary recipients of migrant nurses worldwide (Li, Nie, & Li, 2014). Different occupational standards and nursing roles, language barriers, and cultural differences all pose challenges for migrant nurses coming to the U.S., and many migrant nurses also face discrimination and limited opportunities (Li et al., 2014). Patient safety and quality of care may be affected by the different work experiences and training that the migrant workers had in their home countries (Xiao,Willis, &Jeffers, 2014). Language proficiency and cultural differences can be significant barriers to FBSN success because of the higher-level discussions during class and examinations given in an unfamiliar format (Crawford&Candlin, 2013; Jeonget al., 2011; Malecha,Junious,& Tart, 2012). Patient outcomes may also be affected as student nurses must give culturally-competent patient care during clinicals (Crawford&Candlin, 2013; Xu, Shen, Bolstad, Covelli, &Torpey, 2010). This paper includes both student nurses and professional nurses, because many of the issues and interventions mirror one another in each population.
As of 2010, 16% of all U.S. healthcare workers were foreign-born (McCabe, 2017). An increasing percentage of the student nursing population in the U.S. comes from diverse cultural backgrounds (McCabe, 2017). The National League for Nursing reports that as of 2014, the percentage of minority nurses enrolled in basic RN programs was 28% (American Association of Colleges of Nursing, 2016). TheU.S. is becoming increasingly diverse (McCabe, 2017), and this diversity should be reflected in the nursing population in order to provide culturally-competent care (Crawford &Candlin, 2013; Li et al., 2014).
Nurses and student nurses that lack an understanding of local cultural differences and nuances or have difficulty communicating in a clinical setting experience higher stress levels, frustration, and feelings of isolation (Jeong et al., 2011). If those from culturally diverse backgrounds are not supported in and assisted with integration, it can affect the quality of care (Cheung,Aiken, Clarke, & Sloane, 2008). IEN and FBSN have lower NCLEX-RN pass rates and often cite language difficulty and cultural differences as barriers to success in their career or nursing school (Hansen&Beaver, 2012; Bednartz, Doorenbos, &Schim, 2010; Crawford&Candlin, 2013; He, Leigh, &Lopez, 2011; Jeong et al., 2011; Malecha et al., 2012; Parker & McMillan, 2008; Olson, 2012; Sanner and Wilson, 2008; Scheele, Pruitt, Johnson, & Xu, 2011; Squires, 2017; Xuet al., 2010; Xiao et al., 2014; Zheng, Everett, Glew, &Salamonson, 2014).This paper reviews the available literature and examines whether cultural support or the lack thereof to these populations can improve patient outcomes and help foreign-born Registered Nurses and Student Nurses succeed. Cultural support in this paper will be defined as providing a supportive, inclusive environment for foreign-born student nurses and foreign-born Registered Nurses in the United States.
The entry of IEN into the U.S. healthcare workforce will likely continue, despite the decline in numbers in recent years (Squires, 2017). Healthcare facilities may continue to seek IEN to fill important vacancies and temporarily resolve nursing staff shortages; therefore, there is a need to evaluate what kind of cultural support is provided to IEN in the U.S. and whether it can improve patient outcomes and increase retention of diverse faculty. I will first present the setbacks to a successful transition and then the solutions that can help overcome them.
Language proficiency. Several studies emphasize that language competency in English and in nursing terminology is important to ensure adequate patient care and safety in a clinical setting (Alexis, 2012; He & Xu, 2012; Squires, 2017; Xu et al., 2010). Basic language proficiency in English is not enough due to the abundance of colloquialisms and abbreviations used between patients and staff (He & Xu, 2012; Shenet al., 2012). According to Deegan and Simkin (2010), IEN reported experiencing difficulty reporting to staff at shift changes. Nursing staff reported that the presence of an accent alone can change the perception of the IEN and their competence, which can lead to decreased job satisfaction and decreased retention of IEN (Shenet al., 2012; Deegan &Simkin, 2010).
Cultural barriers. One example of cultural conflict in nursing is that some IEN come from cultural backgrounds that promote deferment to authority and obeying doctors’ orders regardless of the consequences for patients, and feel that nurses are not responsible for intervening (Campbell & Nichols, 2010). This is an issue that needs to be addressed, because being a strong patient advocate is critical to the role of an RN in the U.S. Studies in the U.S. found that IEN and FBSN reported difficulty with being more assertive in a clinical setting, therefore these findings from England are likely applicable in the U.S. (Sanner& Wilson, 2008; Olson, 2012; Scheele et al., 2011; Jeong et al., 2011; Alexis, 2012). Campbell and Nichols (2010) also found that some IEN reported that they were reluctant to perform personal cares with patients, because they considered it below their level of expertise and expected that untrained staff or families complete personal cares instead. IEN with advanced skills in this study were also being placed in jobs below their level of expertise (Campbell & Nichols, 2010). This became an issue for IEN, because many were "routinely recruited to NHS hospitals and care homes" and they found that this "created a situation where deskilling occur[ed]" (Campbell & Nichols, 2010, pg. 33). Religious differences make it difficult for the IEN to understand which actions are appropriate (Okougha&Tilki, 2010). Eye contact, politeness, nuances in speech and tone, how to show respect and patient-family expectations were all cited by IEN as part of the cultural shock they experienced (Okougha&Tilki, 2010; Campbell & Nichols, 2010). Differences in documentation (such as abbreviations and terminology) were also reported anecdotally to be a barrier for the IEN (Alexis, 2012; Deegan &Simkin, 2010).
NCLEX-RN pass rate. IEN have significantly lower NCLEX-RN pass rates than U.S.-educated nurses; in 2016, IEN had a pass rate of 38.9%, compared with a pass rate of 84.6% for U.S.-educated nurses (National Council of State Boards of Nursing, 2017). According to Lujan and Little (2010), the NCLEX-RN pass rate for Mexican-educated RNs is only 22%.
Transitional support. A cross-sectional study by Ohr, Brazil, and Holm (2016) showed that IEN strongly found support prior to arrival, upon arrival, and during commencement of their work to be very useful. One hundred percent of the 65 nurses in this study reported that having a support person upon arrival, a meet-and-greet service, and “overseas staff specific orientation” were “very useful” (Ohr et al., 2016). Zizzo and Xu (2009) cited one program that approached transitional support from the viewpoint of Maslow’s hierarchy of needs; it prioritized logistical support as the IEN arrived, such as ensuring that their essential needs upon arrival were taken care of to provide a smoother transition and decrease stress.
Management support. The successful transition of IEN may involve many years of adjustment (Hansen& Beaver, 2012; Scheeleet al., 2011), and this places a strain on both the IEN and the domestic staff working with the IEN (Xiaoet al., 2014). When management did not formally recognize the increased effort put forth by local staff and IEN during the transition period, it was “associated with a burden felt by host nurses and an unwillingness to work with [IEN]” (Xiaoet al., 2014, pg. 646). Campbell and Nichols (2010) suggested that there should be extended monitoring of the progress of IEN transition to ensure that the IEN have access to all of the resources they need.
Language competency programs. More research is needed on language competency program content efficacy, but the need for language competency is present (Xuet al., 2010). Transition programs in Canada and Australia generally have a language component to them, and programs in the UK have an “effective communication” component, but program structure in the U.S. is decided by employers (Xu & He, 2012). A systematic review expressed concern regarding the lack of programs that address language competency and offered this as evidence of a “dissonance between the identified need and the reality” (Zizzo& Xu, 2009, pg. 59).
Cultural sharing. Upon recruitment, the role of a nurse in the recipient country should be clearly communicated to IEN, as this was cited anecdotally by IEN in their review as a source of their “frustration, resentment and poor commitment” (Campbell & Nichols, 2010, pg. 32). Presenting clear expectations of the IENat hire in the recipient country will help prevent misunderstandings and disappointments, which should increase retention rates (Xiaoet al., 2014). Cultural sharing such as role-playing, video segments, comparison of cultural values, presentations with domestic nurses, and simulations can be used to increase cultural competence (Lujan & Little, 2010; Squires, 2017).
NCLEX-RN preparation. In a study examining the effects of an NCLEX-RN success program on IEN from Mexico, Lujan & Little(2010) concluded that Mexico-educated RNs can successfully pass the NCLEX-RN exam with multiple-choice strategy and cultural training. Although the sample size was small, the results of this study are compelling: the NCLEX-RN pass rate increased from 22% to 50% at first attempt (Lujan & Little, 2010). A study by Squires (2017) found that a program (focusing on Mexican nurses) that provided a clinical rotation and a NCLEX-prep course achieved an impressive 88% pass rate. This indicates that NCLEX-prep alone can increase pass rates for IEN and increase the number of IEN able to fill shortages in the U.S.
Transition programs. Anecdotal evidence reported by IEN shows that IEN found the programs “useful” (Zizzo& Xu,2009; Ohret al., 2016), and transition programs that focus on increasing NCLEX-RN pass rates among IEN have been statistically successful (Lujan & Little, 2009; Squires, 2017). Unfortunately, there is very little research available on transition programs in the U.S. (Zizzo& Xu, 2009; He & Xu, 2012). Most of the studies on transition programs originated from the UK; it is the only country to make transition programs for IEN mandatory in nature, and Zizzo and Xu(2009) concluded that making transition programs mandatory could have been the driving force for such abundant research on the topic. Recommendations are to make transition programs mandatory for IEN (Zizzo& Xu, 2009; He & Xu, 2012). In the U.S., facilities “neither have the resources nor the expertise to develop specific transition programs for international nurses” (Zizzo& Xu, 2009, pg. 58), and most facilities simply had the IEN participate in the regular orientation programs that domestic nurses participated in upon hire (Zizzo& Xu, 2009). Mentorship, logistical support, and a language component were found to be useful in transition programs (Zizzo& Xu, 2009). Mentorship in particular seemed critical to the success of a program, since even facilities without obligation to implement transition programs included mentorship (Zizzo& Xu, 2009). A case example by Squires (2017) provides evidence that transition programs would not only be beneficial for the IEN but also for prospective employers due to the fact that they could become familiar with the IEN before hiring them. The program was so effective that employers reported that the nurses “required no more orientation than a standard U.S. educated new graduate nurse” (Squires, 2017, pg. 36).
Management support. If there is little involvement of management in the transition of the IEN, this often leads to frustration and resentment for both the IEN and the local staff (Jeon & Chenoweth, 2007; Xiaoet al., 2014).The team leader's attitude and support toward both the IEN and the domestic nurses’ efforts is important for creating an inclusive, supportive environment for IEN nurses (Jeon & Chenoweth, 2007). Nurses rated higher levels of job satisfaction in workplaces with stronger support from management, and these nurses were also “twice as likely to rate the quality of care as excellent” at their workplace (Cheung et al., 2008, pg. 39). Ohret al. (2016) found that managerial interventions such as performance reviews, corporate orientation, facility-specific transition programs, mentorship, three days of orientation (culture, medications, documentation, local health care system) were considered useful by the IEN in the study. Management should also encourage the staff and IEN to learn from each other and acknowledge both the faculty and IEN's extra effort during the transition period (Xiaoet al., 2014).
There is extensive research regarding the barriers that FBSN encounter in nursing school. I will first present the research regarding setbacks to success in nursing school, then follow this with the research regarding the “solutions” to promote success in nursing school for FBSN.
Language proficiency. Studies specifically emphasize the need to assist these students in achieving Cognitive Academic Language Proficiency (CALP) (Hansen& Beaver, 2012; Crawford&Candlin, 2013; Scheeleet al., 2011). Most FBSN are competent in Basic Language Proficiency (BLP), but may struggle to participate in higher-level discussions during class (Hansen& Beaver, 2012; Scheeleet al., 2011). It takes 2 to 3 years to achieve BLP, but it may take 4 to 7 years to achieve CALP (Hansen& Beaver, 2012; Scheeleet al., 2011). Students not competent in CALP may find it more difficult to deal with experiences in clinical rotations, as well as dealing with patients, families, and healthcare staff requires more CALP (Hansen&Beaver, 2012). During tests, FBSN may translate the English questions into their own language to understand it, and mistranslations can occur frequently with words such as "best" and "least" (Olson, 2012, pg.30). Non-native English-speaking student nurses interviewed in Sanner and Wilson (2008) also reported feeling discriminated against and stereotyped because of their accent alone. This may prevent FBSN from reaching out as they lose confidence and feel more isolated (Malecha et al., 2012).
Cultural barriers. Countries in Asia and Africa emphasize a more authoritarian teaching method in which the students are more accustomed to rote memorization (Scheele et al., 2011; Olson, 2012).Students originating from these countries can be more reluctant to ask questions in class as this is perceived as questioning authority in their home countries and cultures (Olson, 2012). Another large cultural barrier is that the U.S.has a low-context, individualistic culture, while countries in Asia have a high-context, collectivist culture (Scheeleet al., 2011). A low-context culture is one in which communication is more direct and requires little other context besides language to interpret, while a high-context culture is one in which communication is more indirect and the communication can depend on implied meanings (Scheeleet al., 2011). The U.S. is individualistic in nature, while Asian countries are more collectivist (Scheeleet al., 2011); this means that U.S. culture emphasizes the needs of the individual over the community, while Asian culture tends to emphasize the needs of the community over the needs of the individual. These findings are concerning, because therapeutic communication is a necessary skill to acquire during nursing school, but is highly dependent upon understanding the local cultural values and behaviors (Olson, 2012), which can make learning effective therapeutic communication difficult for FBSN. Cultural barriers also affect mental health during nursing school; students interviewed by Sanner and Wilson (2008) reported feeling like they had to prove themselves at school and reported incidences of racial discrimination. This and the loneliness, isolation and frustration experienced by FBNS can reduce confidence and self-esteem, both of which can negatively impact the students’ performance in class and in clinical (Jeong et al., 2011).
NCLEX-RN pass rate. There is a “40% disparity in NCLEX pass rates between ESL and non-ESL students regardless of academic record” (Olson, 2012, pg. 26). This suggests that FBSN are just as capable as domestic students in obtaining a nursing degree, but that the multiple-choiceNCLEX-RN testing style is creating a barrier for them. FBSN often struggle with multiple-choice questions (Hansen& Beaver, 2012), which is common in U.S. nursing schools.Both the multiple-choice formatting and the story-form questions may end up testing the reading comprehension and test-taking skills of FBSN instead of their nursing knowledge (Hansen& Beaver, 2012; Olson, 2012). Most FBSN likely did not receive training for multiple-choice questions like U.S. students during their grade school education; multiple choice questions are a popular method of testing students in the U.S., but the more popular method abroad is the essay-style question (Hansen& Beaver, 2012).
Insufficient support. Several articles identify that faculty attitudes toward students and their teaching strategies for FBSN can help support the students’ academic success (Hansen& Beaver, 2012; Malecha et al., 2012), and many articles indicate that there is a strong need for continuing cultural competency education for staff and students in order to create a more inclusive and supportive environment (Malecha et al., 2012; Jeong et al., 2010; Olson, 2012; Parker & McMillan, 2008; Hansen & Beaver, 2012; Scheeleet al., 2011). There should be a staff member dedicated to coordinating continuing cultural competency education for faculty and also to organizing resources for and attending to the needs of FBSN (Jeong et al., 2011; Malecha et al., 2012). FBSN may have very different family obligations than the U.S. students might have, for example, some African and Asian cultures have a very structured home life and very clear obligations to the family (Scheeleet al., 2011). Hispanic nursing students have been quoted stating that it is difficult for them to juggle the duties of a nursing student and fulfill their cultural obligations at home (especially as female student nurses) (Olson, 2012).
Insufficient resources. Olson (2012) found that some FBSN may be supporting family members in their home countries, and that they may not be receiving enough financial aid. This decreases their financial stability and may force many of them to work during schooling, which can exacerbate their struggle with language and cultural barriers. The American Association of Colleges of Nursing reported on a scholarship that was provided to underrepresented students, 55% of which were from racial/ethnic minority groups; it found that 97.3% of the scholarship recipients had graduated or were still enrolled in their programs, and anecdotally, the recipients verbalized how large of an impact the scholarship had on their academic success (AACN, 2015).
Language competency programs. Donnell (2015) noted that early intervention is important for success. Mixed study groups (with native and non-native English speakers) and role playing of clinical situations were useful for FBSN anecdotally (Crawford&Candlin, 2013).However, English language proficiency is not sufficient to guarantee success for FBSN in nursing school (Zhenget al., 2014), as communication is inextricable from cultural values: a cultural component is needed in these programs.
Cultural sharing. Several studies cite the need to provide opportunities for domestic and international students to learn from each other and increase their cultural competency (Malecha et al., 2012; Scheeleet al., 2011; Bednarz, Schim, &Doorenbos, 2010). Study groups with a mix of domestic and foreign-born nursing students can help increase cultural exchange and create a more supportive environment for FBSN (Olson, 2012; Scheeleet al., 2011; Malecha et al., 2012; Hansen& Beaver, 2012). Individual tutoring is beneficial because of the cultural sharing that takes place – this cultural awareness should be part of the FBSN training for test questions, so that FBSN can learn to recognize when they will need to evaluate their own values and recognize what test questions are asking for with respect to the local culture in the U.S (Hansen& Beaver, 2012).
NCLEX-RN preparation. More support/training is needed for FBSN to help them become proficient at taking multiple choice tests. Faculty must be able to accommodate for FBSN by being aware of what makes multiple choice questions difficult or confusing for non-native English speakers (Olson, 2012). Faculty should be shown how to create multiple choice tests that will not interfere with testing nursing knowledge. Education about how to answer multiple choice test questions (especially NCLEX-RN style) should also be provided to the FBSN (Olson, 2012; Hansen& Beaver, 2012), because it has been shown to be effective (Hansen& Beaver, 2012; Lujan & Little, 2010; Squires, 2017). Changing the test questions to make it easier for FBSN students to understand did not give them an advantage (Hansen& Beaver, 2012).
Faculty support. Several studies cite the need to provide more support for faculty in order to help them meet the needs of FBSN (Parker & McMillan, 2008; Jeong et al., 2010; Malecha et al., 2012). Specifically, these studies emphasize the need for a dedicated faculty member to help instructors advocate for FBSN and find the best strategies to support them (Jeong et al., 2010). Faculty members interviewed by Parker and McMillan (2008) reported feeling that domestic students were not aware of the need to increase their cultural competence, and that faculty were hesitant to advocate for FBSN because they did not want to be perceived as politically incorrect (Parker & McMillan, 2008; Bednarz et al., 2010). A transculturally-trained staff member can provide continuing education to staff (Jeong et al., 2010; Olson, 2012; Scheeleet al., 2011) and become a role model for FBSN and promote cultural competence among the student body (Malecha et al., 2012).
Low-cost initiatives and financial support. Studies show that the financial demands of nursing school for FBSN can be a significant barrier (Zhenget al., 2014; Olson, 2012). Faculty must find low-cost initiatives that they can implement on their own with little difficulty, such as: avoiding story-form test questions, making test questions clear, highlighting key words in test questions, promoting group work in class, audio recording lectures for students, providing lecture handouts, helping students practice reporting off, using case studies, having FBSN share their experiences with domestic nursing students, allowing students to use a bilingual dictionary during exams, allowing students to take exams in a separate room to decrease anxiety, providing resources to students regarding multiple choice test-taking strategies (especially NCLEX-RN style), encouraging inclusive study groups with a mix of native and non-native English speakers, and allowing students to participate in class in “nonthreatening” ways such as having them ask questions via e-mail or in writing after class (Hansen& Beaver, 2012; Malecha et al., 2012; Olsen, 2012; Scheeleet al., 2011).
This literature review has found that there is little information available on the transition of IEN in the U.S.; however, of the literature that exists on transition programs globally, the conclusion is overwhelmingly clear that some kind of transition program is needed for an IEN seeking a career in the United States, especially since patient outcomes are at stake. Despite the clarity of the issue, there are significant barriers to implementation of transition programs: transition programs are not mandatory in the U.S., individual facilities decide whether or not to implement a separate transition program for incoming IEN, individual facilities also decide on the length and content of their transition programs, and without financial support or regulation, facilities generally do not have the resources and knowledge needed to successfully implement transition programs. Of special interest is the finding by both Squires (2017) and Lujan and Little (2010) that the U.S. should consider Mexico a promising source of IEN. Both studies agree that Mexican nurses can indeed be successful in their transition to the U.S. with systematic preparation and training for the NCLEX-RN (Lujan & Little, 2010; Squires, 2017).
There is an abundance of ideas to help FBSN students, but a lack of funding and lack of faculty support seem to be the main barriers to implementing the ideas, strategies, and resources suggested in the literature. Regardless of financial issues, there are still basic interventions that can be used with some effort on behalf of faculty and management. Ideally, a trained faculty member should be in charge of supporting FBSN and promoting an inclusive environment for them while educating staff and domestic students. FBSN may have more invested in their education than domestic students considering the lingual cultural, and financial barriers they have to overcome; it may cost more time and money in the short-term, but from a long-term perspective, giving extra support to FBSN can benefit both the local community and the nursing field. Increasing retention saves the community time and money,because there is limited space for each nursing cohort and limited resources for nursing programs. Since FBSN are less likely to drop out of school in their first year of study, extra funding and resources for FBSN in the first year at least should be considered a safe investment in the future (Zhenget al., 2014).
It is likely that the migration of non-native English-speaking nurses and IEN to America will continue. Therefore, more research needs to be conducted on transition programs specifically in the U.S., especially regarding the barriers to implementation of transition programs in the U.S. and how they can best be overcome. Policy changes should also be considered as several studies strongly recommended making transitional programs for IEN mandatory. It is also likely that the nursing field will continue to see FBSN attending American nursing schools; these schools need to start taking action on their behalf and advocate for their success, because it is to their benefit. Unfortunately, if schools do not have enough funding to implement all the ideal interventions (such as having dedicated transcultural staff supporting both faculty and FBSN), then individual faculty members will have to find ways to implement interventions at low cost to them (both in terms of time and money). Unfortunately, much of the research regarding FBSN or diverse student nurses is anecdotal and considered low-level evidence. Higher-level research is needed with more quantitative evidence supporting the anecdotal findings in the currently available literature and to evaluate the effectiveness of language competency programs.
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by Sabine Knoppke-Wetzel
National Collegiate Honors Council
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University of Nebraska-Lincoln
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