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More Internationally-Trained Nurses Can Boost Patient Safety, Quality of Care

The need for more diversity and inclusion among nurses and PAs is well-established, and the benefits proven by research. But the relative value of immigrant and nursing professionals trained in other countries has often been questioned. A new study by researchers at NYU Rory Meyers College of Nursing addresses this controversy and finds that having more nurses trained outside of the United States working in a hospital may result in a more educated and stable nursing workforce.

“While there have been concerns that internationally educated nurses may not perform at the same level as U.S.-trained nurses, including collaborating with colleagues, our study suggests that such concerns may not be necessary,” said Chenjuan Ma, PhD, an assistant professor at NYU Meyers and the study’s lead author.

Covid-19, diabetes care, maternal and child health care, cancer screening and access to care are just a few examples in which persistent disparities exist for people of color, minority and low-income populations. Studies prove a strong connection between a culturally diverse nursing workforce and the ability to provide quality, culturally competent patient care. The need to attract professionals from underrepresented groups in nursing is a high priority for the healthcare profession.

Internationally educated nurses–who receive their primary nursing education outside of the country where they currently work–have also become an important part of the nursing workforce. In the U.S., recruiting these professionals can address nursing shortages. It is estimated that 5.6 to 16 percent–or 168,000 to 480,000–of the country’s more than 3 million nurses were educated in another country.

Internationally educated nurses often face challenges when transitioning to practice in the U.S. because of cultural, language and healthcare system differences. While internationally educated nurses can help mitigate nursing workforce shortages, there is little research on their impact on quality of care and patient outcomes, and the findings have been mixed.

In this study, the researchers looked at the proportion of internationally educated nurses on hospital units and evaluated whether this affects collaboration among health professionals and other factors of hospital units. They used 2013 survey data from the National Database of Nursing Quality Indicators, analyzing responses from 24,045 nurses (2,156 of whom were trained outside the U.S.) working on 958 units across 160 U.S. acute care hospitals. Collaboration on a unit was measured using a nurse-nurse interaction scale and a nurse-physician interaction scale.

The researchers found having more internationally educated nurses did not lead to decreased collaboration among nurses and between nurses and physicians. This is important because collaboration among healthcare professionals is a fundamental aspect of quality work environments and can result in positive patient outcomes and satisfaction.

Units with higher proportions of internationally educated nurses had notable differences, including factors that could both help and hurt patient care. For example, units with more internationally trained nurses had nurses with higher levels of education, which may be because these nurses are more likely to have a baccalaureate degree in order to qualify for and pass the U.S. nursing licensure exam.

Units with more internationally trained nurses also had less turnover, as these nurses are likely to stay in a job longer than their U.S.-educated peers.

“In other words, units with more internationally educated nurses have a more stable nursing workforce. Not only can lower turnover rates reduce recruiting and hiring expenses, but they are also linked to fostering collaborative environments among nurses,” said Ma.

In contrast, units with more internationally trained nurses had worse nurse staffing levels or higher patient-to-nurse ratios, despite these nurses being recruited to address shortages. Worse staffing levels have been shown to hurt collaboration and could potentially worsen patient outcomes.

The researchers note that hospitals and nurse recruitment agencies can play important roles helping to integrate internationally educated nurses into the U.S. workforce–for instance, providing training on the basics of the U.S. healthcare system, creating peer mentoring programs and running workshops on culture, communication and teamwork.

“Given the ongoing nursing workforce shortage, especially in rural areas, nurse managers and hospital administrators should not be reluctant to hire qualified internationally educated nurses to fill vacancies,” said Ma. “In addition, nurse managers and peer nurses should recognize the contributions of their internationally educated colleagues, who are part of more stable, educated nursing teams. Recognizing the value of individual nurses can lead to a healthy work environment and workforce, which contributes to high quality patient care and outcomes.”

Though nursing has made great strides in recruiting and graduating nurses that mirror the patient population, experts agree more must be done before adequate representation becomes a reality. According to the American Nurses Association, diversity awareness is the “acknowledgement and appreciation of the existence of differences in attitudes, beliefs, thoughts, and priorities in the health-seeking behaviors of different patient populations. It reflects the nursing profession’s contract with society and our responsibility to act according to a strong code of ethics, which means to be aware of our own attitudes, beliefs, thoughts, and priorities in providing care to individual patients, families, communities, and populations.” Bottom line: Healthcare providers can maximize this potential by learning more about patients’ cultures and by hiring professionals who bring more cultural awareness and sensitivity.