Discrimination against internationally educated nurses (IENs) remains a seldom-explored topic in the United States. Yet, the literature describing experiences of IENs indicates that some do experience workplace discrimination as an additional workplace stressor. IENs view this discrimination as an obstacle to career advancement and professional recognition. Consequences of workplace discrimination affect IENs’ physical and psychological well being, the quality of patient care, and healthcare organizational costs. In anticipation of future nursing shortages, understanding and minimizing workplace discrimination will benefit nurses, patients, and healthcare organizations. In this article the author addresses motivation and challenges associated with international nurse migration and immigration, relates these challenges to Roy’s theoretical framework, describes workplace discrimination, and reviews both consequences of and evidence for workplace discrimination. Next, she considers the significance of this discrimination for healthcare agencies, and approaches for decreasing stress for IENs during their transition process. She concludes that workplace discrimination has a negative, multifaceted effect on both professional nursing and healthcare organizations. Support measures developed to promote mutual respect among all nurses are presented.
Keywords: internationally educated nurses, IENs, Roy, discrimination, racism, psychological stress, overt discrimination, covert discrimination, microaggression
...discrimination in the work environment remains an issue of concern for IENs and healthcare organizations. Internationally educated nurses (IENs) are essential to the United States (U.S.) healthcare system; their contributions to healthcare are noted in direct patient care, administration, research, and education. Despite almost 50 years of IENs’ contributions to the U.S. healthcare system (Masselink & Jones, 2014; Sherwood & Shaffer, 2014), discrimination in the work environment remains an issue of concern for IENs and healthcare organizations.
This article differs from most previously published articles about IENs’ encounters with discrimination in the workplace in that it focuses on discrimination as a specific psychological stressor, a perspective noted in few publications. Many researchers have written about the experiences of internationally educated nurses; however, few have written from the perspective that discrimination in the nursing work environment is a psychological stressor beyond stressors associated with the transition and adaptation processes IENs must master.
Discrimination is a complex, often-contentious issue seeded in irrational and frequently subconscious stereotypical beliefs related to different ethnic, cultural, or religious groups. Discriminatory behaviors may be blatant and overt, or they may be covert and subtle, yet persistent. For IENs, discrimination in the work environment is an occupational stressor that affects well-being, job turnover, and intention to leave an employer (Bergman, Palmieri, Drasgow, & Ormerod, 2012), factors that influence job satisfaction. A negative relationship exists between nurses’ job dissatisfaction and patients’ satisfaction and perceptions of the quality of care they receive (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011). Furthermore, a positive relationship exists between discrimination and adverse health consequences (Krieger, Kosheleva, Waterman, Chen, & Koenen, 2011; Nadimpalli & Hutchinson, 2012).
Statistics from the U.S. Department of Health and Human Services, Health Resources and Services Administration (U.S. DHHS, HRSA, 2010) indicate that IENs compose 5.6% of actively employed registered nurses in the US. Slightly more than 50% of the IEN population comes from the Philippines (See Table 1) and California employs most IENs who work in the United States (See Table 2). The Department of Health and Human Services Health Resources and Services Administration also indicates that more than 68% of IENs hold a baccalaureate degree in nursing (BSN) compared to 49.2% of the U.S. educated nurses (See Table 3).
Table 1: Predominant Countries of Origin of Internationally Educated Nurses Initial Education: 2008
Percentage of Employed IENs in the United States
Other North/South America/Caribbean
Adapted from “Predominant Countries Where Internationally Educated Nurses Received Initial Nursing Education By Employment Status: 2008,” by U.S. DHHS, HRSA, 2010, The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses, Table 65, A-69.
Table 2: Predominant States Employing Internationally Educated Nurses (IENs): 2008
State Employing Nurses
Estimate number IENs employed in nursing (%)
All other states
37, 043 (25.4)
Adapted from The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses by U.S. DHHS, HRSA, 2010.
Table 3: Demographics of Internationally Educated Nurses and U.S. Educated Nurses: 2008
Nursing Home and Extended Care Facilities
Academic Education Program
Adapted from The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses by U.S. DHHS, HRSA, 2010.
Studies of IENs’ work experience provide insight into the effects of discriminatory behaviors on these recipients, as well as methods used by IENs to cope with discrimination and the importance of resilience in the face of such a personal and professional challenge. Recent literature, both empirical and anecdotal, examines initiatives implemented by organizations to facilitate IENs’ transition to employment in the U.S. workforce. These healthcare organizations are increasingly aware of the potential adverse effects of workplace discrimination on patient safety, IENs’ job satisfaction, staff retention, and organizational costs.
In this article, I will address motivations and challenges associated with immigration, relate these challenges to the Roy Adaptation Model, describe work place discrimination, and review consequences of and evidence for workplace discrimination. I will also consider the significance of this discrimination for healthcare agencies, discuss the need to assist IENs in their transitions, and conclude that workplace discrimination has a negative, multifaceted effect on professional nursing, healthcare organizations, and patient care.
Motivators of International Nurse Immigration
Internationally educated nurses are registered nurses who have completed nursing education and received initial professional licensure in countries other than the US, and have immigrated to the US for employment. Internationally educated nurses are registered nurses who have completed nursing education and received initial professional licensure in countries other than the US, and have immigrated to the US for employment. This immigration began in the early twentieth century with marked increases during times of U.S. national nursing shortages (e.g., 1960s, 1980s, 2000s). Before World War I, most IENs immigrated to the US from Western Europe and Canada. Today, IENs immigrate to the US from around the world (Cortes & Pan, 2014; U.S. DHHS, HRSA, 2010).
Dywili, Bonner, and O'Brien (2013) conducted an extensive literature review of articles published between 2004 and 2010 on reasons nurses migrate. They found that numerous economic, social, professional, personal, and political factors motivate IENs to leave their native countries to work abroad. The US offers the potential for personal safety; educational and professional development; and financial security for IENs and for their families (pull factors). American nursing workforce needs and perceived benefits of living and working in the US combine with negative circumstances in native countries (push factors) to create situations that influence nurses’ decisions to leave their native countries and immigrate to the US. The U.S. Department of Labor Bureau of Labor and Statistics (2013) estimates that with growing needs for registered nurses and the need to replace retiring nurses, more than 1.2 million registered nursing job openings will be available by 2020. Impending changes in visa status for healthcare workers combined with a predicted nursing shortage may increase the number of IENs that will work in the U.S. healthcare system.
Challenges Related to Immigration
...numerous economic, social, professional, personal, and political factors motivate IENs to leave their native countries to work abroad. Internationally educated nurses often undergo a lengthy and challenging process to gain entry for employment in the US. Potential candidates must produce documentation of education for review to ensure their nursing education meet the U.S. standard for practice (Jones & Sherwood, 2014; Masselink & Jones, 2014). All potential candidates must pass the NCLEX-RN for U.S. licensure and must also pass the Test of English as a Foreign Language (TOEFL) to demonstrate proficiency in English at a basic level (Jones & Sherwood, 2014). The U.S. government has developed several visas with associated criteria, restrictions, and in some cases benefits, to facilitate entry into the country by IENs in times of workforce shortages and increased need. These visas include the H-1, H-1A, H-1B, H-1C, and TN (Trade NAFTA) visas, as well as the current Employment-Based (EB) visa (Masselink & Jones, 2014).
Some IENs assert that discriminatory-based barriers impede their ability to work at their highest professional skill level, and impede their professional role function and career advancement. Many studies on IENs' work experience in the US have described workplace barriers that affect their ability to meet professional expectations. These barriers included problems with communication, as well as understanding of the U.S. registered nurses’ scope of practice, technology, and healthcare system (Primeau, Champagne, & Lavoie-Tremblay, 2014). Some IENs described interpersonal issues in the work environment that affect work performance including, distrust, rejection, and lack of acceptance by their American colleagues, believed by IENs to be racially and ethnically based (Chege & Garon, 2010; Jose, 2011; Liou & Grobe, 2008; Ma, Griffin, Capitulo, & Fitzpatrick, 2010; Xu, Gutierrez, & Kim, 2008; Yi & Jezewski, 2000). Some IENs assert that discriminatory-based barriers impede their ability to work at their highest professional skill level, and impede their professional role function and career advancement (Chege & Garon, 2010; Yi & Jezewski, 2000) These circumstances can become sources of psychological stress for IENs as they attempt to adapt and transition to working in the U.S. healthcare system (Newton, Pillay, & Higginbottom, 2012). To understand discrimination as a psychological stressor, it is essential to understand both the concept of discrimination and the ideology of racism, and to evaluate their effect on IENs’ professional role function; physical and psychological health; and the financial costs of these effects on already short-handed nursing staffs and healthcare organizations.
Roy's Theoretical Framework
Roy’s Adaptation Model establishes that individuals attain holism, health and well-being by coping effectively with changes and challenges through adaptive behaviors in an effort to maintain social integrity. Social integrity is defined as “…the need to know who one is in relation to others so that one can act appropriately”(Roy, 2009, p. 378). Social integrity is the foundation of role function, the adaptive mode that focuses on an individual meeting the expectations of a given role in society or in an organization (Roy, 2009). An individual fulfills his or her role based on relationships with others. One’s role is the functioning unit of society. Age, gender, and developmental stage determine an individual’s primary role (Roy, 2009).
Secondary roles also fulfill expectations associated with an individual’s developmental stage; however, these expectations are associated with societal values, social generativity, and social responsibilities (Roy, 2009). Nursing is a secondary role. Nurses maintain their social integrity by adapting to the ebb-and-flow of their work environment and the various stimuli they encounter on a daily basis. Interpersonal behaviors influence social integrity and therefore influence role function. Nurses maintain social integrity as they function independently, yet work cohesively within a unit or an organization with the common goal of quality patient care and positive patient outcomes. Nurses who encounter discriminatory behaviors in the work environment may experience diminished social integrity and role ambiguity or impaired role function.
Racism and Discrimination in the Workplace
This section will discuss concepts related to discrimination in the workplace, specifically racism, discrimination, and microaggressive behaviors. Many definitions of racism exist. This article is based on the definition of racism provided by Priest et al. (2013) who defines the ideological concept of racism as:
A phenomena that results in avoidable and unfair inequalities in power, resources and opportunities across racial or ethnic groups: racism can be expressed through beliefs (e.g. negative and inaccurate stereotypes), emotions (e.g. fear/hatred), or behaviors/practices (e.g. unfair treatment) ranging from open threats (including physical violence) and insults to phenomena deeply embedded in social systems and structures (p. 116).
...discriminatory behaviors cause recipients to experience feelings of vulnerability, powerlessness, intimidation, and humiliation. In contrast, discrimination is the process by which members of a group that holds ideological beliefs of superiority treat members of a socially defined group differently, often unequally, to maintain a sense of power (Krieger, 2001, p. 693). Discriminatory behaviors may include favoritism toward a specific group (Priest et al., 2013), usually a group to which the executor of these behaviors belongs (Bergman et al., 2012). Although discrimination often refers to behaviors between different socially defined groups, discrimination also occurs within groups. Be it inter- or intragroup discrimination, discriminatory behaviors cause recipients to experience feelings of vulnerability, powerlessness, intimidation, and humiliation (Agudelo-Suarez et al., 2009). Both overt and covert discriminatory behaviors are cognitively demanding and are considered irrational because they are based on identifiable genetic or cultural characteristics that the recipient cannot alter, the very reason that discrimination is a stressor for recipients of these behaviors (Volpone & Avery, 2013).
Microaggressive behaviors are defined as “the everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, that communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalized group membership” (Sue, 2010b, Chapter 1). Because of close contact between supervisors and subordinates or between colleagues, covert discriminatory behaviors occur more frequently compared with overt discriminatory behaviors. Covert behaviors are subtle and complex and are therefore often difficult for recipients to determine whether or not a behavior is indeed discriminatory. This difficulty in evaluating specific behaviors often causes recipients to question or doubt their perception of these behaviors as misinterpretation or oversensitivity (Noh, Kasper, & Wickrama, 2007). In contrast, recipients of overt discriminatory behaviors evaluate these behaviors with greater ease because the message of discrimination is unquestionable.
An individual’s perception, interpretation, and understanding of discriminatory behaviors determine how he or she will adapt, cope, and respond to this stressor. An individual’s perception, interpretation, and understanding of discriminatory behaviors determine how he or she will adapt, cope, and respond to this stressor (Agudelo-Suarez et al., 2009). Past experiences, self-perception, and self-esteem affect coping and adaptation. Similar to other psychological stressors, discrimination has the potential to erode an individual’s adaptive resources with significant psychological and physiological consequences (Lazarus & Folkman, 1984a).
Consequences of Discrimination in the Workplace
Discriminatory behavior is an occupational stressor for members of non-dominant groups (Light, Roscigno, & Kalev, 2011; Offermann et al., 2014). General organizational tolerance of such behaviors, even when not intentional, is often perceived by members of subordinate groups as institutional support of both racism and discriminatory behaviors (Offermann et al., 2014).
Individuals who execute microaggressive behaviors often do not recognize the significance of their acts on their colleagues and subordinates. Individuals who execute microaggressive behaviors often do not recognize the significance of their acts on their colleagues and subordinates. Because stereotypical beliefs are so deeply seeded, microaggressive behaviors may not be intentional, and therefore may be difficult for recipients of these behaviors to validate, leaving recipients unable to take supervisory, managerial, or legal action (Sue, 2010a). However, these behaviors can create an uncomfortable and sometimes hostile work environment that contributes to a decline in job satisfaction.
Many studies have demonstrated the negative effects of workplace discrimination on employees' emotional and physical health (Benjamins, 2013; Krieger et al., 2013; Meyer, 2014; Molina & Simon, 2014; Nichols & Campbell, 2010; Okechukwu, Souza, Davis, & de Castro, 2014; Pittman, Davis, Shaffer, Herrera, & Bennett, 2014; Tsai & Thompson, 2013; Vogel, 2014). Noh et al. (2007) hypothesized that exposure to discriminatory behaviors, especially microaggressive behaviors, pose greater health risks to members of subordinate groups compared to overt discriminatory behaviors that may be intense but brief and singular. In either case, discriminatory behaviors have a negative effect on physical and psychological well-being of recipients and can affect workplace productivity.
...employees who are recipients of discriminatory behaviors do undergo psychological withdrawal through disengagement, and in some cases burnout, prior to physical withdrawal. Research that explores the relationship between perceived workplace discrimination and physical withdrawal behavior (e.g., tardiness, absenteeism, and intention to leave) has been inconclusive; Volpone and Avery (2013), however, have observed that employees who are recipients of discriminatory behaviors do undergo psychological withdrawal through disengagement, and in some cases burnout, prior to physical withdrawal.
Physical withdrawal is associated with significant organizational costs. Employee tardiness cost U.S. organizations 3 billion dollars in 2012; absenteeism cost approximately 15 percent of organizations’ payrolls; and hiring and replacing vacancies from departing employees cost 50-200 percent of new hires first year’s salaries (Berry, Lelchook, & Clark, 2012). The Equal Employment Opportunity Commission (2014) reported over 46,700 charges of discrimination based on race, color, and country of origin in 2013 with monetary benefits of greater than $112 million dollars paid to victims. This amount does not include monetary benefits gained through litigation (U.S. Equal Employment Opportunity Commission, 2014). Consequences of perceived discrimination to businesses and organizations are significant. Moreover, employee morale and organizational reputations are affected negatively when allegations of discrimination are made against an organization or its members.
Evidence of Discrimination in Nursing
Consequences of perceived discrimination to businesses and organizations are significant. Studies that explore discriminatory behaviors among healthcare workers are limited. The paucity of research on this topic is misleading and supports the false impression that racism and discrimination do not exist in healthcare, and specifically do not exist in nursing (Johnstone & Kanitsaki, 2009; Moceri, 2012). Consequently, the topic of perceived discrimination experienced by IENs has received little attention. Studies that have explored the experiences of IENs working in the US have identified several common challenges for these nurses as they attempt to adapt and transition to the U.S. work environment: perceived discrimination has emerged as one of those experiences. Researchers have evaluated IENs’ experiences with discrimination using both qualitative and quantitative methods. A brief summary of select publications of IENs’ experiences, both qualitative and quantitative, is presented below, along with significant consequence of discrimination to patient care and to the economics of healthcare organizations.
Qualitative studies of IENs' experiences have reported emotional and professional consequences of perceived discriminatory behaviors by nursing colleagues and managers; these studies support discriminatory behaviors as a source of psychological stress (Dicicco-Bloom, 2004; Yi & Jezewski, 2000). Lazarus and Folkman (1984b) defined psychological stress as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (p. 19).
Other studies have confirmed the negative effects of perceived discrimination on IENs’ self-esteem and professional self-perception (Chege & Garon, 2010; Dicicco-Bloom, 2004; Xu et al., 2008). Nurses use phrases such as “crippling of performance,” “erosion of self-confidence,” “doubting own ability to function and solve problems,” “strenuous,” “unwanted,” and “under persistent scrutiny” to describe experiences with workplace discriminatory behaviors and the sense of marginalization, otherness, and in some cases invisibility that results.
...discrimination may be a prevalent problem among nursing professionals independent of international or domestic status. Wheeler, Foster, and Hepburn (2014) conducted an exploratory study on the experience of discrimination with 42 IENs and 40 nurses educated in the US. Findings from this study were similar to findings from other qualitative studies that document IENs’ encounters with discriminatory behaviors. However, several additional finding emerged from this study: specifically, African American registered nurses perceived discriminatory behaviors from white registered and licensed practical nurses; white registered nurses perceived discriminatory behaviors from African American registered nurses; African nurses’ perceived discriminatory behaviors from white nurses; and both African and African American nurses perceived discriminatory behaviors from each respective group. Results of this study demonstrated that discrimination may be a prevalent problem among nursing professionals independent of international or domestic status. A recent exploratory study by Lin (2014) found that IENs developed the perception of discrimination in the late adaptation period, approximately one year after working in the US, and after developing a clearer understanding of American culture, including understanding of subtle nuances in language and in behaviors.
Internationally educated nurses’ descriptions of perceived discriminatory behaviors and descriptions of encounters with some U.S. nursing professionals, colleagues, and managers, along with the subsequent emotions that developed in response to this discrimination, validate theories by Sue and colleagues, (2007); Noh et al., (2007); and Pearson, Dovidio, and Gaertner (2009). These theories suggest that discriminatory behaviors diminish self-esteem and have the potential to affect work performance.
Quantitative studies of IENs’ work experiences also demonstrated discriminatory behaviors in the workplace. Pittman, Davis, et al. (2014) found that 40.1 percent of IEN participants in their study (n=392) perceived at least one workplace discriminatory behavior. This study also reported that IENs believe they do not receive equal wages, benefits, or shift assignments compared to their U.S. nursing colleagues.
Quantitative studies of IENs’ experiences with discrimination using ‘Aroian’s Demands of Immigration’ scale reported inconsistent findings. Aroian’s Demands of Immigration (D.I.) scale is a 23-item, 6 sub-scale instrument that measures an individual’s perception of the demands associated with immigration. The subscales assess loss, novelty, occupational adjustment, language accommodation, not feeling at home in the resettlement country, and discrimination. The D.I. scale measures demands of immigration as an operational measurement of distress. Aroian, Norris, Tran, and Schappler-Morris (1998) proposed that demands associated with immigration, including discrimination, decrease as length of time residing and working in the US increases.
Ma et al. (2010) used Aroian’s D.I. scale in a study of Chinese registered nurses who had lived and worked in the US for at least five years. In this study, participants’ perception of discrimination decreased after five years of residing and working in the US. Although the score for discrimination decreased after five years, the D.I. sub-scale score that measured the perception of discrimination remained the highest of the six sub-scales. In another study that utilized Aroian’s D.I. scale (Jose, Quinn Griffin, Click, & Fitzpatrick, 2008), Indian registered nurses who had lived and worked in the US for more than three years had higher scores associated with discrimination compared with Indian registered nurses who had worked in the US for less than three years.
Some of these studies contradicted Aroian’s hypothesis that nurses’ perception of discrimination is linear and decreases as length of time living and working in the US increases. These results also contradicted the assumption that perceived discrimination is attributable to the novelty of living and working in a new country. Some studies (Jose et al., 2008; Lin, 2014) indicated that IENs’ perception of discrimination increases as communication skills and familiarity with cultural norms progress.
Beechinor and Fitzpatrick (2008) used Aroian’s Demands of Immigration scale to compare demands associated with immigration between Canadian and Filipino nurses. No statistically significant findings were discovered with either Canadian or Filipino nurses with respect to demands associated with discrimination. Participants’ scores, however, indicated that both Canadian and Filipino nurses were exposed to discriminatory behaviors.
...some IENs’ perception of discriminatory behaviors increases with length of time living and working in the US . Quantitative studies have demonstrated that discrimination remains among the most demanding issues associated with immigration even after living and working in the US for a number of years (Ma et al., 2010). Paradoxically, some IENs’ perception of discriminatory behaviors increases with length of time living and working in the US (Jose et al., 2008). The consistency with which discrimination appears in the IEN literature should cause professional nursing to consider that these experiences are not merely perceived, but are indeed based on different and unfair treatment of IENs (Pittman, Frogner, Bass, & Dunham, 2014).
Significance of Discrimination for Healthcare Organizations
The above discussion has illustrated that discrimination against IENs continues in nursing in the US. The following section will present consequences associated with discrimination in U.S. healthcare organizations. These consequences include nurse turnover, financial costs and negative effects on patient care.
When IENs are faced with what they perceive as inescapable and consistent expressions of discrimination in an environment in which they are not supported, psychological withdrawal (e.g., disengagement and burnout) begins; this is often followed by physical withdrawal, including tardiness, absenteeism, and deliberation regarding intention to leave (the predecessor of actual turnover) (Berry et al., 2012; Volpone & Avery, 2013). When nurses vacate their positions, units are often left short-staffed, sometimes with less-skilled nurses in a given specialty area. Remaining staff may be burdened with increased workload, and for some, this increased workload may also lead to psychological and eventually physical withdrawal from the employer (Wheeler et al., 2014).
Hayes et al. (2012) also found that external turnover (i.e., leaving the organization) is associated with organizational factors including the psychosocial work environment, lack of team support, and the determination by employees that physical and psychological demands associated with work are overwhelming and negatively affect their well-being to an unacceptable degree. Role ambiguity or lack of role clarity is also a contributor in nurses’ decision to leave their employer (Hayes et al., 2012; Osuji, Uzoka, Aladi, & El-Hussein, 2014).
Financial Costs of Turnover
Significant costs are associated with hiring IENs. Healthcare organizations recruit IENs based on one or a combination of business models: direct recruitment model, placement model, or staffing model. Direct recruitment by healthcare organizations costs $5,000-$12,000 per registered nurses (Pittman, Folsom, & Bass, 2010). Healthcare organizations pay $15,000-$20,000 per registered nurse to placement agencies, with most of the cost toward agency fees (Pittman et al., 2010). Healthcare organizations that utilize the staffing model pay $60.00-$80.00 per hour to staffing agencies: The IEN receives between $25.00-$35.00 per hour (Pittman et al., 2010). Estimates indicate that hiring one IEN with a 2-year contract could save a healthcare institution $40,00-$50,00 compared to utilizing per-diem staff for the same length of time (Pittman et al., 2010).
The costs of hiring IENs are easily obtained and extrapolated, yet the costs associated IEN turnover are not equally attainable. Currently no studies or reports exist of healthcare organization financial losses specific to IEN turnover. Estimates of healthcare organizations’ costs to replace one full-time registered nurse vary in the US. A literature review of nurse turnover costs from 1990 to 2009 estimated costs at $11,740-$88,000 per single registered nurse, with varying percentages of costs allocated to orientation and training a newly hired nurse and other associated post-hire costs. The review further indicated that for institutions with higher turnover costs, as much as $8.5 million may have been spent on turnover costs in one year (Li & Jones, 2013).
Effects on Patient Care
The cost of external staff turnover to patient care continues to garner significant interest. In a review of 68 publications from 2006 to 2011, Hayes et al. (2012) found that external nurse turnover has adverse effects on patient care including increase in nurse-patient ratios, increase in medication errors, and increase in patient falls. In addition, some studies in the review indicate that a negative relationship exists between nurse-turnover staffing repercussions (i.e., new hires, use of temporary staff and agency staff) and patients’ satisfaction with their care (Hayes et al., 2012). Unit tenure has a positive relationship with desired patient outcomes and with patient satisfaction (Osuji et al., 2014). Osuji et al. (2014) also affirm that healthcare consumers are negatively affected when nurses’ work environments do not foster respect, justice, and nurses’ well-being.
Decreasing IEN Stress During the Transition Process
Some healthcare organizations in the US and other countries that employ large numbers of IENs realize the challenges associated with the transition and adaptation process. These organizations have undertaken initiatives to ease the transition with the hope of increasing IEN retention. Retention of IENs is paramount given the organizational financial investment in each IEN. Some research indicates that a positive relationship exists between nursing tenure and patient outcomes (Osuji et al., 2014). Low nurse turnover benefits healthcare organizations and thus the patients they serve.
The US does not have a standardized transition program for IENs... The US does not have a standardized transition program for IENs; rather each healthcare organization develops its own education and transition program. Xu and He (2012) assert that the US is the nation that employs the most IENs, but fails to recognize benefits of standardized IEN transition programs. In comparison, Great Britain, Canada, and Australia, other countries that employ large numbers of IENs have developed mandatory transition, bridge, and integration programs ranging from 3 to 6 months. Although these programs ensure that IENs and employers understand and meet each other’s expectations, the length and content of orientation are at the discretion of each organization. Internationally educated nurses in these countries must complete transition programs prior to licensure or registration. In the United States, IENs undergo transition programs after gaining employment in healthcare organizations. However, current transition programs are not without constraints. In the United Kingdom and Australia, for example, nurses must first work as nursing assistants and cannot work as registered nurses while taking part in transition programs.
Numerous sources recommend implementing IEN transition programs in the US (Lin, 2014; Smith & Ho, 2014; Wolcott, Llamado, & Mace, 2013; Xu & He, 2012). Xu and He (2012) recommend developing IEN transition programs similar to nursing residency programs to facilitate IEN transition in to the U.S. work environment, and also suggest cultivating partnerships between the U.S. government, agencies, and healthcare organizations to develop and implement IEN transition programs. Similarly, Wolcott et al. (2013) advocate the need for a well-developed curriculum of study for IENs that includes both diversity training and assertiveness training. Wolcott et al. (2013) further explain that IENs who undergo successful transition and adaptation to working and living in the US demonstrate greater job satisfaction that may be associated with increased job tenure.
Cultural sensitivity and cultural education were of particular importance to IENs and the nurse educators and nurse managers who facilitated the transition process. Wolcott et al. (2013) explored the transition of five IENs to the U.S. work environment. For these IENs, the need for comprehensive orientation and social support, along with the need to understand U.S. scope of practice, policies, and procedures, and communication emerged as challenging issues during their transition. Cultural sensitivity and cultural education were of particular importance to IENs and the nurse educators and nurse managers who facilitated the transition process. In this study, U.S. nursing educators and managers were educated in differences in cultural learning styles and educated in the cultures of new IENs. Internationally educated nurses expressed their need to change their communication style to foster better interpersonal communication among nursing colleagues, patients, and staff.
It is unclear if, by providing IENs with more structured workplace integration, they will be able to cope more effectively with discriminatory behaviors. Lin (2014) conducted a qualitative study of the transition of 31 Filipina nurses as they adapted to working in the US and found three distinctive phases in the adaptation process: pre-arrival, early adaptation, and late adaptation phases. In each phase, interventions emerged that IENs believed facilitated or improved the integration and transition process with respect to both living and working in the US. These interventions included: education on medical equipment; training in effective communication; patient confidentiality and legal issues; cultural education for all staff; and clear role expectations. Participants also suggested that organizations provide education about conflict and stress management, and offer managerial support, spiritual support, and appropriate rewards. These participants suggested that organizational personnel involved in the transition process round on unit staff regularly. Lin recommended that organizations provide culture-specific training to IENs as well as continuous evaluation of job satisfaction, a theme echoed in another study by Wolcott et al. (2013). Although the expectation is that by implementing these strategies, turnover rates for IENs will be low, Lin (2014) stated that little evidence exists that such implementations will increase retention and job satisfaction among IENs. It is unclear if, by providing IENs with more structured workplace integration, they will be able to cope more effectively with discriminatory behaviors.
Despite significant challenges and obstacles in the workplace, most IENs remain determined to persevere and to succeed in the new work environment and express a sense of accomplishment in use of effective coping methods to overcome challenges (Yi & Jezewski, 2000). Some study participants expressed processes such as: transformation while clinging to hope, unlearning nursing from their native countries and relearning American nursing, fostering resilience in the face of change, and using problem-focused coping to succeed or in some cases improve workplace situations (Xu et al., 2008).
Many nurses attribute their ability to overcome challenges associated with transitioning and adapting to work in the US to those who provide professional and social support. These supporters often include nurses from their native countries who preceded them and shared their experiences; American nursing colleagues, nurse managers and educators; and family in the US and in their native countries. Some nurses credit themselves for recognizing their self-worth, focusing on positive patient outcomes, and building positive relationships (Lin, 2014; Wolcott et al., 2013).
Summary and Conclusion
Discrimination affects patient safety in two ways. First, the presence or perception of discrimination by IENs can potentially affect an IEN’s self-esteem, self-perception and role function if he or she cannot cope with stress related to discriminatory behaviors effectively (Roy, 2009). Safe patient care requires group cohesion formed through mutual respect among colleagues. Workplace environments in which behaviors cause isolation, exclusion, and in some cases hostility, result in dissension and poor patient outcomes (Bailey, 2013, p. 41). Additionally, when nurses separate from their employer, as in cases of external turnover, the potential for adverse patient outcomes on units increases due to short-staffing, less than adequate nursing skill mix, or the use of agency staff. Patient safety, the priority of healthcare organizations and professional nurses, increases on units and in organizations with positive work environments for nurses. Positive work environments promote job satisfaction and retention.
Internationally educated nurses are integral members of and contributors to the U.S. healthcare system. For IENs, the transition and adaptation associated with integrating into the US nursing workforce is difficult, and more so for those who perceive themselves as recipients of discriminatory behaviors by their nursing colleagues. The perception of discrimination is an additional workplace stressor that requires effective coping and adaptation both to persevere and succeed personally and professionally, and to limit adverse patient-related outcomes associated with job dissatisfaction and nurse turnover.
To recognize and manage discrimination in the workplace, it is necessary to educate all healthcare staff and providers on discriminatory behaviors, the psychological and professional consequences of these behaviors on intended recipients, and the effects discrimination in the workplace can have on patient care. Franklin A. Shaffer, Chief Executive Officer of the Commission on Graduates of Foreign Nursing Schools International (CGFNS), and co-authors of a study that addressed perceived discrimination among IENs, has raised questions regarding ethical treatment of IENs. He has called on nurse leaders to promote positive work environments while diminishing factors that lead IENs to perceive a lack of equitable treatment (Commission on Graduate Foreign Nursing Schools International, 2013).
The US remains an attractive and desirable workplace for IENs whose skills are needed to supplement the nursing workforce, especially in times of nursing shortages. Research that examines and expands understanding of the work stressors, including discrimination, that IENs encounter is needed to facilitate the transition and adaption process in to the U.S. workplace.
Although diversity advocates have promoted initiatives to improve understanding the multicultural populations of U.S. healthcare consumers and expand the cultural diversity of healthcare workers, the paucity of scholarly articles addressing racism and discrimination in the nursing literature may give the misperception that racism and discrimination do not exist within the profession (Barbee, 1993; Johnstone & Kanitsaki, 2009). Only recently have several publications explored the subjects of racism and discrimination in nursing, as well as potential effects on the profession and subgroups of nurses (Hall & Fields, 2012; 2013; Hassouneh, 2013; Johnstone & Kanitsaki, 2009; Steed, 2014; Stone & Ajayi, 2013).
Effects of discrimination reach far beyond the intended recipients, often extending to other healthcare staff and to our patients. In conclusion, the effects of discriminatory behaviors on IENs fall into two categories. The first is personal: the psychological impact of coping with discriminatory behaviors becomes an additional stressor while adapting to a new work environment. The second is professional and multi-dimensional: IENs experience the negative effects of discriminatory acts on their professional role and on their careers, with subsequent potential effects on patient safety, patient satisfaction, and patient outcomes. Effects of discrimination reach far beyond the intended recipients, often extending to other healthcare staff and to our patients.
Maria M. Baptiste, MSN, APRN-BC, NP-C, CCRN-CMC
Maria Baptiste is an American Nurses Credentialing Center (ANCC)-Certified Acute Care Nurse Practitioner (ACNP-BC) and an American Association of Nurse Practitioners (AANP)-Certified Adult Health Nurse Practitioner (NP-C). She is also certified by AACN in critical care nursing (CCRN) with subspecialty certification in cardiology medicine (CMC). She received her MSN degree from Seton Hall University in South Orange, NJ; her BSN from New Jersey City University in Jersey City, NJ; and her Diploma in Nursing and Associate Degree in Science concurrently from Trinitas School of Nursing in Elizabeth, NJ, and Union County College in Cranford, NJ. Ms. Baptiste worked in the Emergency Department and Trauma Center at University Hospital in Newark, New Jersey, for seven years while pursuing her BSN and MSN degrees. Since completing her MSN, she has worked as an Advanced Practice Nurse in primary care and cardiology, and for the past 13 years has served as the nurse practitioner for cardiothoracic surgery at University Hospital in Newark, NJ. In addition to clinical work, Ms. Baptiste has been an adjunct professor of nursing in both online and traditional institutions of higher education and a mentor and preceptor to baccalaureate and master’s level nursing students. She has been a speaker and presenter at professional conferences and consumer health fairs. Her interest in this topic of internationally educated nurses stems from her interest in global health, her experiences of working in multicultural environments, and her interest in the nursing work environment.
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