The United States Department of Health and Human Services (United States Department of Health and Human Services [USDHHS], 2002) has projected that by year 2020, unless the present trend is not reversed, there will be a shortage of more than 800,000 registered nurses (RNs) in the United States (US). This is a catastrophic scenario since it is anticipated that as life expectancy of Americans with chronic and acute diseases increases, the need for more specialized nursing care will also increase (Heller & Nichols, 2001). Although controversial, the hiring of foreign-educated nurses (FENs) has been identified by some organizations and agencies as one of the practical and realistic solutions to help alleviate the current nursing shortage crisis (Davis & Nichols, 2002; International Council of Nursing [ICN], 2005).

Current trends worldwide indicate that the hiring of foreign-educated nurses will continue indefinitely especially in the US which faces a health care crisis if the current nursing shortage is not addressed. Undeniably, FENs will continue to be a part of the nursing workforce of this country. Although small in number compared to U.S.-prepared nurses, FENs not only contribute to the diversity of the U.S. health care workforce but they also help alleviate the current nursing shortage crisis. Most importantly, Foreign-educated nurses are integral members of the nursing workforce tasked to promote, maintain, and restore the health of the U.S. citizenry. FENs are integral members of the nursing workforce tasked to promote, maintain, and restore the health of the U.S. citizenry.

Review of the literature suggests that FENs who have successfully acculturated to their host cultures are more satisfied with their jobs and have a better quality of life (Ea, 2006; Magnusdottir, 2005; Yi & Jezewski, 2000). Further, the literature also reveals that registered nurses, U.S. or foreign-educated, who are satisfied in their jobs and personal lives stay longer in their jobs and contribute to better patient outcomes (Aiken, Clarke, & Sloane, 2002; Cimete, Gencalp, & Keskin, 2003; Flanagan & Flanagan, 2002; Hayhurst, Saylor, & Stuenkel, 2005; Lee, Hwang, Kim, & Daly, B., 2004; Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2005). Therefore, there is a need to assist FENs to successfully acculturate to the U.S. health care system and mainstream society so as to improve their perceptions of job and life satisfaction that could lead to increased retention of the immigrant nursing staff, better nursing care, and improved patient, health-related outcomes.

The primary purpose of this article is to identify and discuss strategies that health care agencies and administrators can implement to assist FENs to transition smoothly into the U.S. health care system and mainstream society. These strategies and recommendations are derived from the reported experiences and challenges of FENs as they acculturate to host cultures. To provide a better understanding of how FENs became vital members of the nursing workforce in the US and other countries, a brief history of the hiring of FENs in the US and a brief discussion of the factors that encourage global migration of nurses will first be explored.

Hiring of Foreign-Educated Nurses: Then and Now

Hiring of foreign-educated nurses in the US is not new. Hiring of FENs in the US is not new. Prior to 1965, nurse migration to the US was limited and was primarily associated with the Exchange Visitor's Program (EVP) which was designed to offer education and practice training to FENs. The majority of these FENs came from Scandinavia and the British Isles and temporarily worked at various sponsoring American hospitals to further their nursing knowledge and skills. These nurses were expected to return to their countries of origin at the end of their contracts to enrich the nursing profession in their homeland (Brush & Berger, 2002).

The enactment of the Immigration Act of 1965 saw one of the most dramatic changes in U.S. immigration policies. This more liberal immigration policy encouraged the immigration of skilled workers to the US in areas of labor shortages, such as nursing, and was instrumental in increasing the number and changing the demographic make up of FENs coming to this country (Brush & Berger, 2002). European-educated nurses were slowly replaced by immigrant nurses from the Asia-Pacific region (Brush & Berger). By 1975, the number of FENs increased from 6,000 to more than 50,000 with the majority of these nurses coming from the Philippines. By mid-1970's, a typical FEN was female, in her late 20's to early 30's, married, diploma-prepared, and had less than 10 years of nursing experience (Brush & Berger, 1993). In 2000, of the almost 3 million registered nurses in the US, 3.7% (99,456) were foreign-educated (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000). Five years later, a typical FEN was predominantly female, married, between the ages of 30 to 40 years old, lived and worked in urban areas, was a graduate of diploma or baccalaureate program, and worked full time in either long term care or in specialized acute care areas such as intensive care units (Xu & Kwak, 2005). Currently, the majority of these foreign nurses (75%) come from the Philippines, Canada, India, and the United Kingdom (Xu & Kwak, 2005).

Hiring of FENs to alleviate nursing shortages is not unique to the US. A number of economically-advantaged countries have used this practice to remedy their own nursing shortage crises. Nurses have become global professionals, and this global mobility of nurses impacts the health care systems of their countries of origin and destination.

Global Migration of Nurses

The global migration of nurses is a multi-factorial phenomenon. Mejia, Pizurki, and Royston (1979) described the personal, social, political, and economic conditions that drive this phenomenon as "push and pull" factors. Push factors are those conditions that are present in donor countries that drive nurses to find employment abroad while pull factors are those conditions that exist in receiving countries that entice nurses to leave their homeland.

Kingma (2001) categorized these push and pull factors into the following: inherent individual desire for educational and professional growth, search for improved economic and working conditions present in receiving countries, and the need to secure personal safety either within the health sector or the external environment. The great economic disparity in world economies is a major influence in the global migration of nurses.The great economic disparity in world economies is a major influence in the global migration of nurses. To cite an example, nurses working in the Philippines make a little more than $2,000 a year compared to those nurses based in the US who earn an average of $48,090 a year (Dugger, 2006). Aside from the obvious economic and professional gains that attract nurses to foreign countries, the desire to maintain personal safety either in the workplace or place of residence is becoming a strong motivational factor in the migration of nurses worldwide. Nurses move to countries that are safe and have stable political systems and decreased incidences of violence (Kingma, 2001).

The US is a major importer of FENs. Other countries that actively recruit FENs include the UK and some countries in the Middle East. While these countries are benefiting from this hiring practice, this labor shift has resulted in a negative impact in the health care delivery systems of donor countries. Countries such as the Philippines, Nigeria, Zimbabwe, and Ghana, which are afflicted by health care problems themselves, are feeling the strain of this labor shift due to the migration of their nursing professionals to more developed countries (Buchan, 2002). To address the issues of nurse migration and uneven labor shifts, some host and donor countries of these nursing professionals, local and international nursing organizations, and private agencies have mapped out sustainable and equitable initiatives and have established ethical guidelines in the hiring and recruitment of FENs (Davis & Nichols, 2002; International Council of Nurses [ICN], 2006; Kingma, 2001).

Although ethical and moral implications of this hiring practice are beyond the scope of this article, one thing remains certain: the global migration of nursing professionals will continue. FENs will continue to affect the delivery of health care services and impact patient outcomes in their adopted countries. Therefore, the countries that hire FENs, including the US, have a responsibility to assist them transition to their health care systems and mainstream societies. But how do FENs acculturate to their host countries? What are the challenges and obstacles they face in their process of acculturation? What are the outcomes of a successful acculturation among FENs? Answering these important questions and understanding the dimensions of acculturation are crucial to facilitate FENs' successful acculturation to host countries.

Acculturation of FENs to Host Societies

Acculturation is a complex, multidimensional, and bidirectional process that involves the adopting and relinquishing of the behaviors and attitudes of both the host and original cultures (Alba & Nee, 1997; Berry, 1980; Schiller, Basch, & Blanc, 1995). Nursing studies that explore and investigate how FENs acculturate to host societies support the theoretical underpinnings of acculturation developed by Alba and Nee (1997), Berry (1980), and Schiller, Basch, and Blanc (1995). Berry (1980) views acculturation as a three-phase process that includes initial contact, conflict, and adaptation. The initial contact phase begins when an individual is initially exposed to a different culture, i.e., when migrating to a different country. The next phase, conflict, occurs when immigrants and residents of host cultures attempt to accept or reject each other; and the final phase of acculturation occurs when immigrants either positively or negatively adapt to host cultures. Positive adaptation occurs when immigrants and residents of the host culture mutually accept one another, and immigrants become integrated and assimilated to the culture of the host country; negative adaptation implies rejection and alienation of the immigrants by the residents of the host culture or vice versa.

Alba and Nee (1997) also view acculturation as a process that immigrants must undergo before they assimilate to the host culture. Alba and Nee (1997) envision an assimilated immigrant as someone who has assumed the traits, behaviors, and attitudes of the host culture. On the other hand, Schiller, Basch, and Blanc (1995) suggest that some immigrants do not fully assimilate to their host cultures but become what they call "transmigrants." Transmigrants are those immigrants who settle and live productive lives in their host countries of residence, but continue to keep and maintain some parts of their original cultures. This form of cultural adaptation among transmigrants is possible because they have learned how to successfully navigate some of the cultural differences between their original and host cultures and have adopted some of the essential traits, attitudes, and behaviors of the host culture, such as proficiency in language and communication skills. As a result, transmigrants are able to successfully maintain dual cultural identities and achieve and maintain a sense of balance and harmony between their original and host cultures.

Varying viewpoints by Alba and Nee (2002), Berry (1980), and Schiller, Basch, and Blanc (1995) regarding the concept of acculturation illustrate the complexity of how immigrants become integrated into a new culture. These viewpoints also suggest that the process of acculturation is made up of several dynamic and interrelated phases that could be fluid and non-linear in nature.

Building on the work of Alba and Nee, Berry, and also Schiller, Basch, and Blanc, nursing studies on acculturation, and personal experiences, this author has identified three phases that FENs experience in their process of acculturation. They are cultural contact, cultural negotiation or bargaining, and cultural adjustment.

Cultural Contact

This phase begins when FENs immigrate to their host countries and is analogous to Berry' s phase of initial contact between two different cultures (Berry, 1980). This phase is characterized by feelings of excitement, a sense of exhilaration and discovery, and a roller-coaster of emotions that are common among newly-immigrated FENs. Most FENs become fascinated by the change of environment, the people, the climate, and the different way of life. However, these feelings of excitement and euphoria are quickly replaced by feelings of panic and anxiety when FENs realize that they are expected to learn unfamiliar nursing roles and work-related tasks as quickly as possible. Also during this phase, FENs have to learn to navigate the complexities associated with living in an unfamiliar environment and performing out-of-work routines. Most notably, FENs identify difficulty in communicating as one of the major challenges during this phase. They struggle to understand and learn the idioms, jargon, and accents of native speakers. FENs also quickly realize that in order to communicate effectively, they also need to understand the culture, values, and the people who speak the language. Concurrently, FENs are disappointed to learn that their pre-immigration work and living expectations were unrealistic. The literature has suggested that the discrepancy between expectations and actual work and life experiences of newly-immigrated FENs could lead to job dissatisfaction and frustrations (Daniel, Chamberlain, & Gordon, 2001; Withers & Snowball, 2003).

Cultural Negotiation or Bargaining

FENs who have achieved a sense of stability in their work and out-of-work routines move into the phase of cultural negotiation or bargaining. This phase is similar to Berry's (1980) phase of conflict where FENs become acutely aware and struggle to reconcile the differences between their personal beliefs with the values of their host society. Because of these cultural differences, some FENs may report perceived alienation and discrimination from coworkers and patients during this stage (DiCicco-Bloom, 2004). Most FENs may also report feelings of ambivalence, anxiety, and indifference at this phase and describe this awkward phase as like living in two different dimensions and being in two places at the same time (DiCicco-Bloom, 2004). FENs realize that they have to navigate these differences in order to successfully function in the workplace and mainstream society. Most notably during this phase, FENs have to make an important life-changing decision: either to adopt and learn the behaviors, attitudes, and skills of their host culture or retreat and withdraw. Those FENs who chose to adopt some of the behaviors and attitudes of their host cultures but find it difficult to fully integrate at this time may become what Schiller et al (1995) describe as transmigrants. Those FENs who find it undesirable to assimilate to their host culture may leave their jobs and return to their countries of origin typifying Berry' s negative adaptation (Berry, 1980). Emotional and psychological support from family members, friends, and social networks such as cultural and faith-based support groups are crucial to overcome the internal and external stresses that characterize this phase.

Cultural Adaptation

FENs who have successfully navigated and reconciled the differences between their original and host cultures move into the cultural adaptation phase. Similar to Berry' s (1980) positive adaptation phase, FENs during this phase, embrace their adopted culture and consider themselves as part of their work and out-of-work communities. Most notably during this phase, FENs undergo transformations in their personalities, behaviors, and attitudes similar to the changes described by Alba and Nee (1987) when immigrants have fully assimilated to their host cultures. For example, FENs who have successfully acculturated develop and adopt the individualistic value that defines the U.S. culture and become assertive in the workplace (Yi & Jezewski, 2000). These nurses also reported developing a sense of belonging at work and their communities-at-large and expressed a sense of personal and work satisfaction (Ea, 2006; Magnusdottir, 2005; Yi & Jezewski, 2000).

As review of the literature has shown, the process by which FENs acculturate to host cultures is difficult, complex, and multidimensional. However, successful acculturation among FENs leads to positive personal and work-related outcomes (Ea, 2006; Magnusdottir, 2005;Yi & Jezewski, 2000). This information should encourage health care administrators and employers to ensure that they implement effective acculturation programs that will assist FENs to transition smoothly to the U.S. health care system and mainstream society.

How to Help Foreign-Educated Nurses Acculturate

This section will discuss recommendations and strategies that health care administrators can implement to assist FENs in their process of acculturation. These recommendations and strategies are based on the challenges and experiences identified in the different phases of acculturation of FENs.

Difficulty in Communicating

Difficulty in communicating is identified in the literature as one of the major challenges that FENs face especially right after immigration. Initially, foreign-educated nurses become intimidated by the accents, use of idioms, and speed of speech of native speakers.Initially, FENs become intimidated by the accents, use of idioms, and speed of speech of native speakers. Because of this, most FENs become very conscious of how they sound; and they tend to remain silent during interactions with patients and coworkers for fear of being ridiculed. Further, they are unaware of the accepted, culture-specific behaviors that accompany verbal communication. To assist FENs to develop effective communication skills, health care administrators should implement a carefully-designed communication course as an integral part of orientation. This communication course should include language classes that are regularly scheduled during the entire orientation phase or longer, if necessary. As part of the language classes, FENs should be introduced to the common idiomatic expressions, colloquial terms, jargon, and accents of native speakers. To decrease feelings of insecurity and to develop familiarity with the accents of native speakers, FENs should be encouraged to watch television shows, listen to radio programs, and practice speaking the host country's language even at home. Oftentimes, FENs are so preoccupied in mastering the verbal aspects of communication that they miss important components of the message especially in their interactions with coworkers and patients. Furthermore, FENs need to be educated regarding common, culture-specific behaviors that accompany verbal communication and the different techniques of therapeutic communication. For example, FENs should be taught that looking directly at someone while speaking is acceptable and does not imply being rude. They should also be made aware that it is acceptable to request someone to speak slowly and to repeat what was said especially during phone conversations or if the message was not clear. To encourage active participation among FENs, role plays that include at-work and out-of-work scenarios could be employed as a teaching strategy. It is important that everyone in the class be given ample opportunity to speak and be listened to during each session.

Change in Professional Roles and Responsibilities

FENs are often confused and unclear about their professional roles and responsibilities in their new work environment. Most often, newly-immigrated FENs are unaware and misinformed of their legal and immigration rights and how the nursing profession is regulated in their host countries. ...administrators should ensure that foreign-educated nurses are taught about their new roles and responsibilities and how the profession of nursing is regulated...Because of this, they may become insecure and fearful at work, especially when taking care of their patients. This misinformation and lack of education can affect how FENs adjust to their new work environment (Daniel, Chamberlain, & Gordon, 2001; Withers & Snowball, 2003). During orientation, health care administrators should ensure that FENs are taught about their new roles and responsibilities and how the profession of nursing is regulated in their new work environment. FENs also should be informed about the institution' s organizational structure and the host culture' s health care delivery system. To decrease feelings of insecurity and helplessness, FENs also should be educated about their immigration and legal rights in their host countries.

Complicated Work-Related Routines

Easing into their new work schedule and routines is a major challenge facing most FENs. Many express difficulty in learning the pace, organizing their work, and trying to finish on time. They often are uncomfortable "handing over" unfinished nursing tasks to incoming shifts, get confused with unfamiliar medical terminologies, and become scared and overwhelmed by complicated medical equipment, use of technology, and amount of paperwork and documentation. FENs' adjustments to their work routines have a major impact in their successful acculturation to their host culture (Daniel, Chamberlain, & Gordon, 2001; Withers & Snowball, 2003; Yi and Jezewski, 2002). To assist FENs develop a sense of control and familiarity in their new work environment, health care administrators are encouraged to design a structured and individualized mentorship program as part of orientation. Preferably, this mentorship program should be initiated during the day shift where most of the opportunities for patient care, interdisciplinary staff interaction, and skills development and refinement occur. FENs' should be assigned willing mentors who will introduce, facilitate, and encourage them to assume their new roles and responsibilities. These mentors do not have to be the same ethnicity as the FENs but should be carefully selected to match the interests, clinical skills, and experience of their mentees. It is important that FENs and their mentors initially establish a mutually agreed contract that includes goals, expectations, accountability, and a time frame for this professional partnership. This contract should include specific information as to what happens when goals and outcomes are not met. Further, administrators also should provide FENs refresher courses on basic pharmacology, nutrition, and physical assessment and also introduce them to the use of technology in health care.

Unfamiliar Life Outside of Work

Foreign-educated nurses' adjustment to life outside of work is as important as becoming comfortable at work. FENs' adjustment to life outside of work is as important as becoming comfortable at work. Adjusting to out-of-work routines is considered by some FENs to be one of the major obstacles in their process of acculturation (Daniel, Chamberlain, & Gordon, 2001; Withers & Snowball, 2003; Yi and Jezewski, 2002). Shortly after immigration, most FENs become both fascinated and overwhelmed by the sudden change of their immediate environment, the climate, the people, and a different way of life. Daily activities considered mundane by residents of host countries, such as shopping for basic needs, going to and from work, and opening a bank account, can cause great stress and anxiety to new immigrants. To assist FENs develop some type of consistency in their new environment as they learn a new system of living, employers can create a support system made up of willing and interested volunteers who will assist FENs in the following activities: finding affordable living spaces, navigating the local transportation system, setting up connections with professional and cultural organizations, obtaining driver's licenses and social security cards, and locating the nearest ethnic-specific food stores, banks, and places of worship. These volunteers may or may not be the FENs' clinical mentors.

Feelings of Alienation and Being Devalued

New immigrants, including FENs, are vulnerable to feel isolated, unwanted, and devalued. Some FENs had to leave their families and comfortable lives behind as they moved to work in a different environment. Although they may not be familiar with complicated medical equipment, use of technology, and hectic work routines, FENs may be highly educated and possess excellent clinical skills. They are thrust into an unfamiliar environment and most often do not know to whom and where to turn for help. Although they may not be familiar with complicated medical equipment, use of technology, and hectic work routines, foreign-educated nurses may be highly educated and possess excellent clinical skills. To preclude the nurses feeling devalued or deskilled at work, administrators are encouraged to evaluate and assess each FENs' experiences, education, and clinical skills prior to or at the beginning of employment and use the information to create a "tailor made" orientation approach based on FEN' s level of nursing skills, experiences, and knowledge (Matiti & Taylor, 2005). Educational sessions that highlight the common behaviors and accepted norms of both cultures can be planned to prevent misunderstandings that could lead to feelings of mutual isolation and alienation between FENs and their U.S. counterparts. Planned social events and informal get-togethers among nurses can foster an atmosphere of acceptance, mutual understanding, and collegiality.

Differences between Personal and Societal Values

Newly immigrated FENs usually lack the interpersonal skills to interact with their Western counterparts because of cultural differences (Xu, 2005). Most FENs, especially nurses from Asian countries, come from collectivistic cultures that value harmony and a deep respect for their elders and persons of authority. Because of this, they may be hesitant to question a physician' s order or reason with a supervisor's unrealistic directives. They may have difficulty accepting the Western style of nursing practice that encourages assertiveness, equality, advocacy, and fairness. FENs may also have difficulty in delegating tasks to ancillary health care workers due to fear of possible conflict; they would rather complete the task themselves than approach someone who might argue or refuse. Although the literature indicates that role transformation and the eventual change in behaviors and attitudes among FENs take time to develop, health care administrators, cognizant of these culture-specific behaviors, can use the information to focus on the long term needs of FENs at work and out-of-work. With this in mind, health care employers should introduce FENs to the individualistic values that define U.S. health care and mainstream society and plan to create future continuing education sessions that focus on effective coping strategies and leadership and management training specifically targeted for FENs.

Adjusting to new professional roles, responsibilities, and unfamiliar work and out-of-work routines can be difficult for FENs. The recommendations and strategies discussed can be used by health care leaders to anticipate the short-term and long-term needs of an important sector of the nursing workforce of this country and to assist them to settle comfortably in their adopted cultures. As the number of FENs continues to increase in this country, there is a growing need to investigate and explore the process of acculturation among FENs. The following section will discuss areas of potential research for nurse researchers and administrators who are interested in exploring the different dimensions and outcomes of acculturation among FENs.

Implications for Future Research

There is a great need to examine the impact of acculturation on the quality of nursing and patient care. There is a great need to examine the impact of acculturation on the quality of nursing and patient care. There is also a need to evaluate via research the effects of the strategies and recommendations discussed previously as to how they facilitate acculturation among FENs. More studies are needed to strengthen and establish the relationships between acculturation and personal and work-related variables such as FENs' perceptions of life and work satisfaction. These studies should test theories on acculturation and immigration developed by Transcultural nursing scholars and other social scientists.

As hiring of FENs is anticipated to continue indefinitely in the US and abroad, there is a pressing need to examine the effects of global nurse migration on host and donor countries. Studies should be directed to finding solutions that address the negative effects resulting from global nurse migration such as uneven labor shifts and maldistribution of nursing personnel worldwide. Studies addressing the implications of global migration of nurses and the impact of FENs acculturation on personal and patient outcomes would not only expand the current body of nursing knowledge but could also improve nursing practice.

Conclusion

Many countries worldwide are experiencing shortages of nurses, including the US. Hiring of FENs is identified in the literature as one of the practical and short term solutions to this nursing crisis that is anticipated to continue indefinitely. The literature suggests that FENs who have successfully acculturated to their host cultures are satisfied with their jobs and have a better quality of ife. Further, there is also evidence in the literature suggesting that registered nurses, U.S. or foreign-educated, who are satisfied with their jobs and personal lives stay longer in their current jobs and contribute to better patient outcomes. Suggestions and recommendations were discussed to assist health care institutions and administrators to develop effective acculturation programs that would facilitate FENs' smooth transition to the U.S. health care system and mainstream society. It is hoped that these recommendations and suggestions would strengthen nursing and patient care, enhance collegiality among nurses from diverse backgrounds, improve patient outcomes, and increase retention of FENs in the workplace.

Acknowledgment

The author would like to thank Dr. Nora L’Eplattenier, PhD, RN, Professor of Nursing at Long Island University Brooklyn Campus and Mr. Joseph Victory-Stewart, RN, MBA, Night Hospital Administrator, St. Vincent’s Midtown Hospital, New York, for their encouragement and assistance in the preparation and review of this manuscript.

Author

Emerson E. Ea, DNP, APRN, BC, CEN
E-mail: Emerson.Ea@liu.edu

Emerson E. Ea is currently Assistant Professor of Nursing at Long Island University Brooklyn Campus. Dr. Ea obtained his Bachelor of Science in Nursing at the University of St. La Salle, Bacolod City, Philippines, and his Master of Science with a major in Adult Health at Long Island University School of Nursing Brooklyn Campus. He recently obtained his Doctor of Nursing Practice (DNP) degree from Case Western Reserve University Frances Payne Bolton School of Nursing in Cleveland, Ohio. His doctoral thesis was on acculturation and job satisfaction among Filipino Registered Nurses. He is certified in medical-surgical and emergency nursing and as an adult nurse practitioner.