International nurses are an essential part of the U.S. work force—traditionally augmenting the work force during periods of shortage. With the current shortage of nurses, recruitment of international nurses is at an all time high. Buerhaus, Staiger, and Auerbach (2003) found that the number of nurses born outside of the United States who are filling hospital positions is increasing.
From the mid 1990s to 2001, employment of international registered nurses increased 6% annually—faster than for domestic registered nurses as a whole. In 2002, employment of international nurses increased 13.8%. Further analyses by Buerhaus et al. (2003) revealed that 42% of the increase occurred among registered nurses who entered the United States after 1996.
Research conducted by the Commission on Graduates of Foreign Nursing Schools (CGFNS) indicates that, although the majority of nurse executives view the hiring of international nurses as positive, international nurses’ transition into U.S. practice can be challenging for both the nurse and the employer. Employers cited English language competency as the most critical skill international nurses need in their first year of practice, followed by clinical skills, knowledge of medications and medication administration, and knowledge of the U.S. healthcare system (Davis, 2005).
In contrast, internationally educated nurses already employed in the United States retrospectively cited knowledge of the U.S. healthcare system as their top priority when entering the U.S. work force, followed by English language competency, clinical skills, and knowledge of medications and medication administration (Davis, 2005). However, to date no studies have been done on international nurses’ perceptions of either their clinical preparedness or their readiness for nursing practice prior to entering the U.S. work force. Such knowledge might identify the immediate needs of nurses and employers before international nurses enter U.S. practice, encourage the development of learning programs to meet those needs, and facilitate the acclimation of international nurses into the U.S. work force.
Many similarities exist between international nursing education and practice and that in the United States. Globally, nursing is a predominantly female profession. However, several different pathways exist for entry into practice, ranging from secondary school nursing programs to baccalaureate education for nurses. Most countries offer either 3-year programs that lead to a diploma in nursing or 4-year baccalaureate programs.
A major trend in international nursing education during the past three decades is the movement of nursing education into institutions of higher learning, especially in those countries that have a significant number of nurses entering the U.S. work force. In the 1980s, the Philippines adopted the baccalaureate degree for entry into practice. Most Canadian provinces now require a baccalaureate in nursing for entry into the profession, whereas India and Nigeria offer basic nursing education at both the diploma and baccalaureate level (Davis, 2004).
Associate degree programs are rarely seen internationally and are, for the most part, a U.S. phenomenon. However, secondary school nursing programs do exist internationally—primarily in Mexico, China, and Eastern Europe. These programs combine high school education with nursing education. Students enter the program after 9 years of primary school, generally at age 14, take a combination of high school and nursing courses, and graduate with a diploma in nursing (Commission on Graduates of Foreign Nursing Schools, 2001).
As nurses do in the United States, the majority of international nurses enter clinical practice in their home countries as generalists. However, unlike the United States, where specialization occurs at the master’s level, some countries offer nursing specialties at the entry level. For example, the United Kingdom offers entry-level specialties such as children’s nurse, visiting nurse, and mental health nurse in addition to adult, or general, nurse (Nursing and Midwifery Council, 2006).
Generally, the international nurse seeking employment in the United States is female, between 30 and 36 years old, and a graduate with either a diploma or a baccalaureate degree from a nursing program in the Philippines, Canada, India, Nigeria, or the United Kingdom (Commission on Graduates of Foreign Nursing Schools, 2001). Because of the differences in educational preparation and clinical practice worldwide, it is essential to gain an understanding of nurses’ perceptions of their clinical competence prior to entering nursing practice in the United States.
The purpose of this study was to determine the learning needs of internationally educated nurses by having them complete a questionnaire focused on their perceived competence in a specific set of clinical performance areas that reflect nursing program outcomes in the United States. Additionally, data obtained from the international nurses would be used to develop educational and supportive programs to assist the nurses in becoming more effective in their practice and easing their integration into the U.S. healthcare system.
Nurses taking the CGFNS Certification Program examination in countries around the world were asked to participate in a survey to determine how they felt their education prepared them for nursing practice in the United States. The CGFNS Certification Program consists of a three-part process that includes (1) an evaluation of credentials (i.e., analyzing the nurse’s educational transcripts to ensure comparability to U.S. nursing education and the nurse’s license to ensure that it is valid and unencumbered); (2) a 1-day Qualifying Examination that tests the individual’s nursing knowledge and focuses on nursing as it is practiced in the United States; and (3) an English language proficiency examination. The CGFNS Qualifying Examination predicts success on the U.S. licensure examination and also meets the requirements for obtaining an occupational visa to practice nursing in the United States.
Following completion of the CGFNS Qualifying Examination in March 2004, the test site managers recruited a voluntary sample of internationally educated nurses. Managers were informed of the survey prior to the examination date, were instructed to ask for volunteers following completion of the examination, and were provided with instructions for administering the survey.
The survey was administered at all domestic and international CGFNS test sites. To protect participant confidentiality, personal information such as names or CGFNS identification numbers were not required for survey completion. Test site managers collected the completed surveys and forwarded them directly to CGFNS in a package separate from the completed test forms.
The Clinical Competency Survey, an assessment tool developed specifically for this study, was used to measure nurses’ perceptions of their proficiency in several dimensions that are expected for safe and effective nursing practice in the United States. The Clinical Competence Survey was composed of two parts. Part I requested general information such as gender, age, country of education, and type of nursing program. Participants also were asked the following questions:
- Do you think your nursing education and nursing experience prepared you for clinical practice in the United States?
- Would you be interested in an educational program (teleconferences, workshops, on-line courses, etc.) that would help you adapt to U.S. practice?
- In what areas do you think you need assistance to practice competently in the U.S.? Select your first, second, and third choices from the following list: nursing skills, language skills, use of technology, pharmacology and medications, and other (specify).
Part II contained 77 clinical competency statements reflecting multiple aspects of U.S. nursing practice. The statements were arranged into 20 groupings (e.g., administer medications by the following routes, provide pain management, perform physical assessment, provide wound and skin management, manage patients with cardiac disease, and use information technology). Participants were asked to rate their perceived competence using a 7-point Likert scale with anchors at 1 (limited proficiency) and 7 (highly proficient).
Data Analysis and Findings
Surveys were received from 3,205 nurses from more than 30 countries around the world and were grouped into the following categories: Philippines (60%; n = 1,923), India (30%; n = 962), Nigeria (3%; n = 96), and Other (7%; n = 224). Fifty-six percent (n = 1,795) indicated they had received their nursing education in a diploma program and 43% (n = 1,378) in a baccalaureate program. Eighty-nine percent (n = 2,852) were female and 11% (n = 353) were male. Fifty-three percent (n = 1,699) were between 23 and 30 years old and 31% (n = 994) were between 31 and 40 years old.
When asked “Do you think your nursing education and nursing experience prepared you for clinical practice in the United States?” 92.5% (n = 2,964) responded yes, 2.2% (n = 71) responded no, and 5.3% (n = 170) were unsure. When asked, “Would you be interested in an educational program that would help you adapt to U.S. practice?” 93.2% (n = 2,987) responded yes, 2.5% (n = 80) responded no, and 4.3% (n = 138) were unsure. In response to the question “In what areas do you think you need assistance to practice competently in the U.S.?” the overwhelming first choice was use of technology (61%; n = 1,955). The breakdown for the remaining areas (nursing skills, language, and medications) is shown in the figure. Areas identified under Other included needing assistance related to cultural differences, legal aspects of practice, and caring for psychiatric patients.
Perceptions of Clinical Competence
The 77 clinical competency statements were grouped into the following nine dimensions through factor analysis: performing treatments, managing pain, administering medications, performing nursing procedures, managing patient care, performing assessments, using nursing processes for care planning, managing cardiac patients, and using technology. The means and standard deviations for each dimension are listed in Table 1. Some of the specific competency statements and their means for four of the dimensions are listed in Table 2.
Nine Dimensions of Practice Derived From Competency Statements
Sample of Items in Four Dimensions
Each dimension was analyzed in relation to gender, age, and educational program. There were few differences in scores for each dimension by gender or educational preparation. Overall, there was little difference in perceived proficiency by age except for those in the 51+ years group, who scored themselves lower in performing treatments, managing cardiac patients, administering medications, and using the nursing process for care planning. However, they scored themselves higher in using technology.
As the preliminary data were reviewed, it became apparent that all participants perceived they were less proficient in two specific areas of practice: management of cardiac patients and medication administration. Item statements were rearranged to place those dealing with management of cardiac patients in one group and those dealing with medication administration in the other.
The management of cardiac patients group had 12 statements, with a mean of 4.94 and an alpha value of .95. Specific areas with the lowest perceived proficiency were related to recognizing common dysrhythmias (mean = 4.66), using doplers (an ultrasound device used to take a patient’s pulse) (mean = 4.59), and performing a cardiac assessment (mean = 4.82). The medication administration group had 15 statements with an overall mean of 5.37 and an alpha value of .91. The lowest perceived proficiency was in using computerized medication delivery systems (mean = 3.82) and PCA pumps (mean = 4.27).
Table 2 provides a sample of the statements in each of these two areas with their mean scores.
Designing continuing education and staff development programs that take into account the needs of internationally educated nurses as they enter U.S. practice is essential. Clinical needs vary and are dependent on the healthcare system in which the nurse was educated prior to immigrating to the United States. For many international nurses, clinical experiences in their homeland do not prepare them for working in the United States—primarily because of the increasing focus on healthcare technology in this country. However, it is interesting to note that although many international nurses indicated that technology is challenging for them, most went on to work in adult health and critical care units, two of the areas in which knowledge of technology is essential (Commission on Graduates of Foreign Nursing Schools, 2001).
To meet the needs of internationally educated nurses, hospitals will have to increase the amount of time spent on orientation and focus on improving nurses’ physical assessment skills. Based on the findings of this survey, hospitals should ensure that cardiac assessment and technology are an integral part of the orientation process and are included in the unit-based activities with preceptor support.
The use of different types of equipment can be a challenge for any nurse, but cultural and language differences often compound adaptation in the clinical setting. International nurses participating in CGFNS (2001) focus groups felt they were not as skilled at performing physical assessments and documenting their findings independently. Many also reported having a limited understanding of the technology used in U.S. hospitals, particularly technology related to pharmacology, interventions, and treatment procedures. Findings from this survey indicate that internationally educated nurses view technology and medication administration as two areas in which they will need extensive assistance when entering U.S. practice.
Based on the data, the need to develop specific continuing education options to address the areas in which the nurses perceived themselves to be less proficient was identified. Some specific ideas for educational and staff development programs include academic courses, continuing education activities, skills assessment and development workshops, training CD-ROMs and videos, and mentoring programs.
Additionally, collaboration with educators at clinical agencies that have employed large numbers of international nurses in recent years should be explored. The intent would be to develop an assessment tool based on the survey used in the current study to determine the needs of the nurses as they begin practice in the United States. Also, this tool could be used for a period of time to identify progression in proficiency and the benefit of activities implemented during the first year of practice.
With the increase in global nurse migration, clinical competency becomes critical as nurses transition to practice in a host county. Courses and activities that address cardiac assessment and technology will facilitate the transition of internationally educated nurses to U.S. practice by focusing on their perceived clinical needs. Nurses participating in such educational activities should be less intimidated by U.S. nursing practice and demonstrate the ability to function in the U. S. hospital setting in a timely fashion, thereby improving their integration into the U.S. work force.
- Buerhaus, P. I., Staiger, D. O. & Auerbach, D. I. (2003). Is the current shortage of nurses ending?Health Affairs, 22(6), 191–198. doi:10.1377/hlthaff.22.6.191 [CrossRef]
- Commission on Graduates of Foreign Nursing Schools. (2001). Characteristics of foreign nurse graduates in the U.S. workforce, 2000–2001. Philadelphia: Author.
- Davis, C. R. (2004). Crossing borders: International nurses in the U.S. workforce. Imprint, 51(2), 49–51.
- Davis, C. R. (2005). International migration: Easing the transition to practice. In Kritek, P. (Ed.), Building global alliances II: The evolving healthcare migration [Monograph pp. 33–35]. Philadelphia: Commission on Graduates of Foreign Nursing Schools.
- Nursing and Midwifery Council. (2006). Registering as a nurse or midwife in the United Kingdom: Information for applicants from countries outside the European Economic Area. Retrieved September28, 2006, from http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=633.
Nine Dimensions of Practice Derived From Competency Statements
|Performing treatments||6.11 (0.87)|
|Managing pain||5.92 (0.97)|
|Administering medications||5.63 (1.05)|
|Performing nursing procedures||5.56 (1.15)|
|Managing patient care||5.53 (1.05)|
|Performing assessments||5.44 (1.04)|
|Using nursing process for care planning||5.41 (0.89)|
|Managing cardiac patients||4.74 (1.55)|
|Using technology||4.63 (1.26)|
Sample of Items in Four Dimensions
| Reporting (shift report)||5.51 (1.58)|
| PCA pumps||4.27 (1.82)|
| Computerized charting||3.90 (1.91)|
| Computerized medication delivery systems||3.82 (1.94)|
| Intramuscular injection||6.30 (1.14)|
| IV intermittent infusion||5.12 (1.67)|
| IV via central line||4.93 (1.82)|
| Inhalation via peak dose meter||4.80 (1.63)|
| Use PCA pumps||4.27 (1.81)|
|Perform treatments–respiratory management|
| Deep breathing/coughing||6.14 (1.13)|
| Suctioning||5.99 (1.23)|
| Tracheostomy care||5.51 (1.44)|
| Chest percussion||5.34 (1.45)|
| Use mechanical devices||5.10 (1.58)|
|Manage cardiac patients|
| Assess oxygen saturation using pulse oximeter||5.98 (1.42)|
| Perform peripheral vascular assessment||5.82 (1.18)|
| Take electrocardiogram||5.06 (1.78)|
| Use technology—doplers||4.59 (1.77)|
| Recognize dysrhythmias—atrial flutter||4.45 (1.71)|
Need assistance to practice competently.