Internationally Educated Nurses must adapt their clinical practice and communication patterns to that of the new environment in order to successfully deliver safe, quality care to patients. Philippine nurses over the years have migrated to practice nursing in a variety of the developed countries of the world, including the United States (US). The recognition that the international migration of Philippine nurses benefits the national economy of the Philippines, because migrated nurses send money earned back to the Philippines, has resulted in an exponential increase in nursing schools in the Philippines to produce nurses for labor expert since 1950. Although Philippine nurses currently comprise the largest single ethnic group of nurses migrating into the US, the proportion of nurses migrating to the US from other countries continues in increasing. This occurs as nurses migrate from Asian countries to the European countries (east to west migration), and from the developing countries to the developed countries (south to north migration). Nurses also migrate among developed countries, such as the United Kingdom, Canada, or the US. Regardless of where migration is taking place, Internationally Educated Nurses (IENs) must adapt their clinical practice and communication patterns to that of the new environment in order to successfully deliver safe, quality care to patients. They must also familiarize themselves with the cultural nuances of the new practice and geographical environments and ensure that their current national, state, and institutional policies guide their professional practice. Before proceeding, it is important to clarify the use of different terminology in the literature referring to IENs. Various writers may refer to them as “Foreign Educated Nurses” (FENs), “Foreign Nurses”(FNs), “Foreign-Born Nurses” (FBNs), and/or “Internationally Recruited Nurses” (IRNs). In this article, the term Internationally Educated Nurses (IENs) will be used to refer to nurses who received their basic nursing education in a country other than the US and who later migrated to the US to practice nursing. These nurses may have come to the US after being recruited by a healthcare organization or recruitment agency, or they may have come to the US on their own.

Increasing numbers of nurses are migrating to the US because the U.S. schools of nursing currently are unable to educate a sufficient number of healthcare professionals to care for the U.S. public. The discrepancy between the projected numbers of nurses needed to care for the U.S. citizens and the capacity to educate the projected numbers of nursing professionals (Cooper & Aiken, 2006) is compelling the US to recruit IENs. Healthcare organizations across the US are recruiting internationally educated healthcare professionals, primarily nurses and physicians, to meet the healthcare needs of its citizens. Although the certification and licensure process assures competency in educational training and language skills of IENs recruited to the US, it is not known whether the quality of nursing care provided by IENs differs from the nursing care provided by U.S. educated nurses (Brush & Sochalski, 2007). Some healthcare organizations are now developing programs to support the transition of IENs to their new practice environments. Yet these transition programs differ across organizations, and there has been minimal research to document that the desired outcomes of these programs are being achieved.

This article will explain why IENs are a key component of the current and future U.S. nursing workforce, present a rationale for transition programs that support successful integration of IENs to the U.S. practice environment, describe a model Transition Program developed by the Hospital of the University of Pennsylvania in Philadelphia, and advocate for the development of a national policy to standardize transition programs for IENs in the US.

Current and Future Role of Internationally Educated Nurses in the Healthcare System

Even if the US...becomes capable of educating sufficient numbers of nurses...nurses will continue to migrate to the US because this migration is an inevitable product of globalization and a reality of the 21st century. Migration of healthcare professionals around the world is not a new phenomenon. However, the 21st century has witnessed an unprecedented increase in the migration of healthcare providers. In 1972, approximately 6% (140,000) of the world’s physicians were found in countries other than their country of origin. At that time, an estimated 5% of all practicing nurses practiced outside of their own countries (Mejia, Pizurki, & Royston, 1979). According to statistics reported by the Organization for Economic Cooperation and Development (OECD) in 2003, internationally educated health professionals accounted for more than 25% of the medical and nursing workforces of Australia, Canada, the United Kingdom, and the United States. Statistical data from the Registered Nurse Licensure database shows that IENs have increased steadily over the past few years, moving from about 6,000 in 1998 to over 8,000 in 2001 (Health Resources and Services Administration [HRSA], 2004). The main source countries identified in this HRSA report are Nigeria, South Africa, Canada, and the Philippines. Employment of IENs in the US grew 13.8% between mid 1990 and 2002, (Buerhaus , Staiger, & Auerbach, 2004).

It is expected that the presence of IENs in the U.S. workforce will continue to grow for the following reasons. The US is identified as the ultimate destination of all migrating professionals (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004; Khadria, 2004; Van Eyck, 2004). The U.S. healthcare delivery system employs an unusually large nursing and physician workforce, including almost 3 million nurses (more than any other healthcare system in the world) and over 8000,000 physicians, who represent almost half of all nurses and physicians among English-speaking countries (Cooper & Aiken, 2006). This need for nurses in the large, U.S. healthcare system and the desire of many migrating nurses to come to the US will continue to increase IENs in the US. Even if the US at some point becomes capable of educating sufficient numbers of nurses to care for its citizens, nurses will continue to migrate to the US because this migration is an inevitable product of globalization and a reality of the 21st century.

Compelling Rationale for Transition Programs for Internationally Educated Nurses

...little or no attention has been paid to requiring or even encouraging healthcare organizations that recruit IENs to institute transition programs designed to support successful integration...to the U.S. practice environment. A review of the literature underscores the need to develop transition programs to prepare IENs to offer clinically and culturally safe and effective practice. The literature discusses the opportunities and challenges presented by migrating nurses, as well as the moral and ethical obligations of recruiting agencies and the healthcare organizations who hire IENs (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004; Bieski, 2007; Blakeney, 2006). Edwards and Davis (2006) and Ryan (2003) have identified practice gaps between the IENs and U.S. educated nurses that include use of technology, management of pain, performance of assessments and nursing procedures, and administration of medication. The identified gaps between the IENs’ previous practice and U.S. practices have implications that may affect the quality, safety, and costs of healthcare services. It is important for IENs to quickly learn standard nursing practices in the US and integrate into the U.S. healthcare system. Society is only able to benefit fully from migration when migration is accompanied by successful integration. Without integration, migration gives rise to social issues that can disrupt a society (International Organization on Migration, 2003). Ryan has identified four overlapping areas that must be addressed if international nurses are to adjust successfully to their new work place. These areas include: (a) socialization to the professional nursing role, (b) acquisition of language and other communication skills, (c) development of clinical and organizational workplace competence, and (d) availability of resources within the system to support IENs.

Kwak (2005) and Polsky, Ross, Brush, and Sochalski (2007) have compared the characteristics of  IENs  to U.S. educated nurses and found IENs to be more likely than U.S. educated nurses to work in direct patient care in urban areas and less likely to be in higher management and leadership positions. Because most IENs interface on a daily basis with the patients, it is a risk to society if these nurses are not supported in practicing at their full potential. It is imperative that these frontline IENs be successfully transitioned to the U.S. practice environment. Yet  little or no attention has been paid to requiring or even encouraging healthcare organizations that recruit IENs to institute transition programs designed to support successful integration of IENs to the U.S. practice environment. Properly developed and evaluated transition programs could ensure that IENs who come to the United States are able to successfully bridge the identified practice and cultural gaps. It is a loss for nursing and for all of society if IENs are not able to successfully transition to their new practice environment and decide instead to abandon nursing entirely. Furthermore ensuring that IENs bridge the gap is essential to ensuring safe, effective, quality nursing care. This article will now describe a model transitional program. Ultimately, there is no more compelling reason for transitioning programs for IENs than protecting the public!

Transitioning Internationally Educated Nurses for Success

A Model Transition Program

...a supportive environment and the provision of resources to bridge the practice differences...are also important keys to transition success. Transitioning Internationally Educated Nurses for Success (TIENS) is a four-phase, transitional program developed by the Hospital of the University of Pennsylvania (HUP) in Philadelphia to help IENs make the transition to nursing practice in a new culture. Change, a constant variable in a globalizing world and in healthcare, is at the core of the phenomenon of transition. In 1994 Schumacher and Meleis noted the importance of understanding transition as a concept of change in nursing. Recognizing the different dimensions of transition that affect nursing practice can serve to guide effective transition and program developments. IENs’ transition needs can be likened to many processes involving change in nursing, such as moving from one specialty of nursing practice to another specialty, i.e. moving from women’s health nursing to critical care nursing or home health nursing, or transitioning from a student nurse role to the registered nurse role.

A common thread for transition success is the degree of interest and motivation of the individual who wants to transition from one status to another. We believe high motivation and great interest is inherent to all IENs in the US, considering the numbers of separate and distinct processes they must complete before legally being permitted to practice in the US. Maneuvering past these steps and hurdles requires motivation, determination, and resilience. Thus, one can safely assume that any IEN who arrives in the US has demonstrated the motivation needed to succeed. However, a supportive environment and the provision of resources to bridge the practice differences, as found in the TIENS Program, are also important keys to transition success. The background of the HUP TIEN Program and the four phases of the Program will be discussed below.

Background of the TIENS Program

The TIENS program arose as a product of the Global Nurse Program (GNP) of the HUP, established in November 2003. The GNP was established under the leadership and vision of Victoria Rich (a co-author of this article) with support from Afaf Meleis, Dean of the University of Pennsylvania School of Nursing (UPSN), Barbara Nichols, Chief Executive Officer of the Commission on Graduates of Foreign Nursing Schools (CGFNS) International, and Norma Lang, who at the time was the Director of the World Health Organization Collaborating Center of the UPSN. The purpose of the GNP was for HUP Nursing to build initiatives that would be responsive to the global nursing community. It was with the establishment of the GNP that the position of Global Nurse Ambassador (GNA) was created to lead the GNP initiatives. It was the responsibility of the GNA to help identify priority programs based on the vision of these nurse leaders. TIENS is one of the many outcomes of the GNP.  

As the hospital began to receive more IENs, the GNA was increasingly contacted to provide support for IENs, and sometimes to help assess the challenges confronting these IENs. Complaints of inefficiency, poor learning ability, and poor communication skills were issues reported by U.S. educated nurses. After a thorough investigation of the issues, three main concerns were identified. First, there was a difference in nursing practice style between the IENs and the U.S. nurses, specifically regarding the use of technology and availability of multiple resources that IENs were not accustomed to having. There were also communication differences in choice of, and pronunciation of words. The U.S. nurses used many idioms, slang expressions, and euphemisms that differed from the IENs’ book of choice words. IENs also took idiomatic expressions literally. Thirdly, there were cultural differences that infused the practice style and priority identification of both groups.

After these issues were reported to the HUP leadership team, it was agreed that an educational program was needed to support the IENs. Initially the GNA conducted a literature review of the general issues and solutions to help the IENs’ successful transition. In addition, the GNA contacted different academic medical centers and community hospitals who recruited IENs to learn about successful methods and programs they had in place. Of the 40 organizations contacted, there were no formal programs in place. At best, programs were informal and fragmented. Findings suggested two important themes/behaviors that organizations used to help integrate IENs, specifically an extended nursing orientation for IENs to address communication and cultural skills and the provision by recruitment agencies of the knowledge and skills IENs needed to transition. These inquires identified the need for a comprehensive program that addressed the differences in nursing practice, communications styles, and cultures; and the HUP Department of Nursing became a pioneer in developing a program for transitioning internationally educated nurses. After the literature review had been completed, and the HUP leadership and IENs had had a series of meetings focusing on to the IENs’ personal experiences, the early program structure including four phrases was developed. It was developed with the understanding that the four phases of the transitional program’s initial structure (described below) would be strengthened as needed over time.

Phases of the TIENS Program

Phase 1 (Pre-Arrival). Phase 1 focuses on the needs of IENs who have received a job offer from the Hospital of the University of Pennsylvania and are making arrangements to leave their previous country to come to the US. The goal of this phase is to begin the process of helping each IEN to successfully settle in a new environment. Activities in this phase include a notification email from the HUP Nursing Recruitment Department informing all stakeholders that an IEN will soon be arriving. These stakeholders include the GNA, the nurse manger of the nursing unit where the IEN will be working, and a selected “buddy,” preferably someone from the same culture as the IEN. A welcome letter is sent to the IEN in order to provide information about these stakeholders and other information needed upon arrival in the US. In addition, a book titled  “Hello USA,”  a map of  the city of  Philadelphia, a schedule of activities for the first few weeks upon arrival.  Human resources paper work, guidelines for meeting occupational medicine requirements, and an application for social security are  provided to the IEN in the welcome letter. If time does not permit, the IEN may receive this information as soon as they arrive in the US. Upon arrival in the US a representative from the University of Pennsylvania Healthcare System (UPHS), the health system of which HUP is one entity, meets the IEN at the airport. Depending on the situation, a limousine ride may be arranged to pick up and deliver the IEN to a ready apartment, having two months paid rent and located 15 minutes or less by bus ride from the hospital. In securing apartments, three things are always put into consideration: (a) safety, (b) proximity to hospital, and (c) proximity to shopping areas.

Phase 2 (On-Boarding Phase). This phase is concerned with familiarizing IENs with certain information and resources that are necessary for survival in the US. The activities include: help for the IENs to learn the city transportation system, support for the IENs to open a bank account, an orientation to their community, a visit to the grocer to see the variety of foods, which may not be available in their country of origin, and completion of required paper work for both the hospital and the U.S. government.

The GNA and the buddy assigned to the IEN contact the IEN within a few days after arrival to introduce themselves and offer the IEN a social event. The IENs also meet quarterly with nursing’s leadership in a breakfast discussion forum at a nearby hotel. Newly arrived IENs are invited to attend this meeting on a voluntary basis, even if they have not started their employment. At this forum IENs discuss their transition with nursing leadership and the GNA and learn a specific educational concept identified as important by the group. Speakers are invited as needed to explain important activities, such as reading one’s pay check. 

The “buddy” may take the IEN to local grocery stores, and/or social gatherings within or outside of the IEN community. Some IENs have reported meeting with old friends or colleagues at these different gatherings. The GNA schedules a one-on-one lunch meeting with the IEN, informing the IEN about her role as a consultant and support person for the IEN, as well as taking the IEN to tour the hospital. There is also an assigned recruiter who works with the IEN to support the completion of all necessary hiring paperwork. At this point, the nurse recruiter also schedules the IEN to meet with the nurse manager of the unit where the IEN will be working. Nurse managers give the IEN a tour of the unit and sometimes have a lunch gathering with some unit staff to meet and greet the IEN. This on-boarding phase occurs before actual orientation begins. 

Phase 3 (Formal Classes). This is the phase where the IEN is given formal education about the U.S. healthcare system as well as the U.S. clinical practices. The five main objectives of this preparation are listed in the Table. Depending on the number of people in a class, Phase 3 training may take up to 16 hours, or less than a day for just one IEN.  Organizations interested in this educational program may choose to focus on each objective listed in the Table for 1-2 hours per educational session. The ultimate goal of this formal education is to raise the IENs’ awareness of key players of the U.S. healthcare  system, who may not have been available or who may have functioned differently in their previous healthcare system, and to equip the IEN with knowledge of the U.S nursing-practice style.

Phase 4 (Clinical Orientation). This phase focuses on the clinical orientation and integration of the IEN to the HUP practice environment. At the HUP, each clinical unit has a Clinical Nurse Specialist (CNS) who is a Master’s prepared nurse and an expert in the specific patient population or disease process of the clinical unit they work. The CNS works with each nurse, either U.S. prepared or IEN, to ensure that they have the clinical expertise to function on the unit. The CNS and the nurse manager of each nursing unit work collaboratively with the GNA to understand the unique transitional needs of each IEN, and work with each IEN to support successful integration by identifying and preparing preceptors to be sensitive to the orientation and transition needs of each IEN. In order for a nurse to be chosen as a preceptor for an IEN, the individual must be willing to do some self-reflection and be open to different learning and teaching techniques, and also to be a preceptor who “wants to” precept, not one who “has to” precept an IEN. A positive attitude is key! The CNS and nurse manger work to match preceptor to IEN, define clear and measurable orientation goals, facilitate both observational and educational experiences of the IEN, supervise the IEN’s orientation progress, and grant extended time as needed  to complete clinical orientation. The GNA is consulted and kept abreast of progress both by the IEN and the unit leadership which includes the CNS and Nurse Manger.

Adaptation for IENs who entered the US prior to hiring at HUP. The four phases of TIENS have been effective in helping those IENs who have been hired at HUP upon entering the US to successfully integrate into the U.S. healthcare system. IENs that are hired at HUP after living for some time in the US, do not qualify for Phase 1 and 2 of the TIENS program, because it is likely they already have an established social network and living situation. They do, however, qualify for Phase 3 and 4. HUP encourages those IENs who have been in the US for a period of time, and who may already have successfully transitioned to the U.S. culture, to advise the organization of their interest in participating in Phases 3 and 4 of TIENS program.

Education in this phase will focus on how nurses...can work at effectively understanding, appreciating, and leveraging the inherent creativity that exits in diverse groups. A fifth phase. Concerted efforts are made to continuously enhance the TIENS program. Currently, we are in the process of adding the fifth phase of TIENS. This phase will focus on raising awareness of U.S. prepared nurses at HUP to better understand the challenges that confront IENs and themselves during the IENs transition period, and to learn how best to deal with each situation. Education in this phase will focus on how nurses, regardless of origin, can work at effectively understanding, appreciating, and leveraging the inherent creativity that exits in diverse groups. There is a plan to add special preceptor training as part of this phase. As the U.S. nursing workforce continues to diversify, it is imperative that all parties work together to provide the best nursing care for the public.

Creating a Policy to Standardize Transition Programs for IENs in the United States

Initiating a national policy that would mandate healthcare organizations to have transitional programs requires an appreciation of the complexity of the problems and the answers needed to support the creation of such a program. National and  local governmental agencies, professional groups and organizations, policy makers, and healthcare organizations need to sit at the table to discuss how they can work together to create a positive practice environment for IENs. If this is not done for any other reason, it should be done for ensuring the safety of those who receive nursing services from IENs. Specific groups that need to sit at the table include: The American Nurses Association (ANA), the International Center on Nurse Migration (ICNM), nurse researchers and academicians, healthcare organizations, recruiting agencies, and internationally educated nurses. The contributions each group can make to this important discussion are noted below.

The American Nurses Association

The ANA, the strongest, largest voice of nursing in the US, has an important role to play in this discussion. As the nurses’ voice, the ANA could echo the voices of both domestic nurses and IENs to facilitate the formation of policy to standardize transition programs for IENs.

International Center on Nurse Migration

The ICNM, a joint venture between the CGFNS International and the International Council of Nurses (ICN), understands the road traveled by IENs and their unique positions and challenges. Their presence at the table would allow the other stakeholders to learn first-hand information about IENs, thus providing more light on the issues at stake.

Nurse Researchers and Academicians

Nurse researchers and academicians in the field of nurse migration and global health can work with the group to carry out further research. This research could validate the need for such programs, as well as perform follow-up studies to assess the impact of these programs on ensuring safe, quality healthcare for the public.

Healthcare Organizations

...the IENs themselves...are the nurses who have walked the lonely path of transitioning from one country’s practice style to another.Healthcare organizations’ leadership, both administrators and managers who utilize the services of IENs, would also need to sit at the table. The collective wisdom of each organization’s experiences, as well as lessons learned in the process of helping IENs integrate into their organization’s practice environment, could serve to guide others in designing policies that would have the most positive impact. Additionally, their participation in influencing and enacting the policies would promote commitment to and compliance with the policies.

Recruiting Agencies

U.S. recruiting agencies are often the first people with whom IENs interface in the process of coming to the US to practice nursing, and their representatives would make ideal participants  at the table. They could offer important information with regards to IENs' expectations, as well as take important information about the planned policy to the IENs in their home countries so these IENs would be aware of the policies before coming to the US. Their participation in developing and influencing the policy could increase their commitment to ensuring that such policy is enacted.

Internationally Educated Nurses

Lastly, the most important participants to sit at this table are the IENs themselves. These are the nurses who have walked the lonely path of transitioning from one country’s practice style to another, and who could provide insight through their actual experiences to enrich the knowledge of the stakeholders group.

Potential Benefits of a Stakeholder Coalition

Building a coalition of the above stakeholders could facilitate the development of a standardized IEN transition policy. The synergy of the collective “buy-ins” and resources from the stakeholder groups, as well as their commitment to ensuring that IENs successfully transition to the U.S. healthcare practice environment, could make the difference between the failure or success of such a policy, and more importantly, ensure safe, quality healthcare for the public.

Conclusion

Migration is an inevitable product of the 21st century. Nurses migrate in order to meet their professional and personal goals, thus allowing nurses to respond to their changing needs and interests and those of society in general. It is a fundamental human right for anyone, including nurses, to use their professional or educational qualifications to better themselves or their families. It is the responsibility of a country who recruits migrating professionals to ensure that adequate resources are in place to support their transition. Migration is an inevitable product of the 21st century. Regardless of one’s take about migrating nurses, migration will continue to take place as globalization evolves in the 21st century. In the end, it is not what we don’t know that will destroy us, but rather the failure to respond appropriately to what we do know. The authors of this article hope that we will act now on what we do know before it is too late!

Authors

Rita K. Adeniran, MSN, RN, CMAC, CNAA, BC
E-mail: rita.adeniran@uphs.upenn.edu

Rita K. Adeniran is the Global Nurse Ambassador of the Hospital of the University of Pennsylvania (HUP). She received her diploma in nursing from Lagos University Teaching Hospital, Nigeria, in 1988, and  her BSN from Widener University in 2000.  In 2002, through a joint program between the University of Pennsylvania’s School of Nursing and Wharton Business School, she earned her Master’s in Nursing Science and Health Care Administration. She is also a student of the Drexel College of Nursing and Health Professions Doctor of Nursing Practice (DrNP) program in Philadelphia, PA. Rita is known for her work in the areas of international leadership and cultural competence and has published and  spoken nationally and internationally on these matters. With the support of the HUP nursing leadership and internationally educated nurses, she developed the Transitioning Internationally Educated Nurses (TIENS) Program at the HUP.

Victoria L. Rich, PhD, RN, FAAN
E-mail: Victoria.rich@uphs.upenn.edu

Victoria L. Rich is the Chief Nurse Executive of the University of Pennsylvania Medical Center, Associate Executive Director of the Hospital of the University of Pennsylvania (HUP), and Assistant Dean of Clinical Practice, at the University of Pennsylvania, School of Nursing. Dr. Rich’s career has focused on operational effectiveness, patient safety, and inclusive leadership strategies. In 2003, with the support of  Dean Afaf  Meleis of the School of Nursing,  and  Dr. Barbara Nichols, Chief Executive Officer of the Commission on Graduates of Foreigh Nursing Schools, she established the Global  Nurse Program (GNP) of the HUP. One of her visions for the GNP is that the HUP will develop a program that will be responsive to the global nursing community. An international consultant, teacher, and speaker,  Dr. Rich is currently working with Botswana nursing leadership to further the reach of the Global Nurse Program through organized nursing exchange programs.  She also created the first Global Nurse Ambassador role in the United States (US) and charged the Global Nurse Ambassador to design a program to support, empower and ease Internationally Educated Nurses (IENs) into the HUP nursing environment.  

Elizabeth W. Gonzalez, PhD, APRN-BC
E-mail: ewg22@drexel.edu

Elizabeth W. Gonzalez is an Associate Professor in Nursing at Drexel University College of Nursing & Health Professions. As an educator and researcher, Dr. Gonzalez has served as mentor to internationally educated nurses who are pursuing graduate education in nursing. Her research has focused on depression among the elderly, minority health issues, and cross-cultural research among family caregivers of relatives with Alzheimer’s disease; and she has been a  frequent participant in scientific forums. Her current research, funded by the National Institute in Nursing Research at National Institutes of Health, seeks to enhance resourceful skills in family caregivers of persons with Alzheimer's disease.

Cheryl A. Peterson, MSN, RN
E-mail: Cheryl.Peterson@ana.org

Cheryl A. Peterson is the Senior Policy Fellow, American Nurses Association (ANA). She received her BSN from the University of Cincinnati, School of Nursing and Health, and her MSN, from Georgetown University, School of Nursing. Ms. Peterson has been involved in developing ANA policy related to foreign educated nurses and U.S. immigration policy since 1995.

Sandra Jost, MSN, RN
E-mail: Sandra.Jost@uphs.upenn.edu

Sandra Jost is the Associate Chief Nursing Officer (ACNO) at the Hospital of the University of Pennsylvania (HUP), a 704 acute, quaternary-level hospital located in Philadelphia, PA.  In her role, Sandra provides operational oversight for the 35 inpatient and procedural areas at HUP. Sandra received a BSN from the University of Delaware in 1988 and earned a MSN in 2000 from the University of Pennsylvania in Nursing Administration.  Ms. Jost started her career at HUP as a clinical nurse where she worked closely with Internationally Educated Nurses (IENs) and also cared for the culturally diverse patients that visit the hospital. Ms. Jost has had several years of healthcare operational and consulting experience.  She meets regularly with IENs at HUP to learn their unique needs, and approves the necessary resources to help meet their needs.  She was instrumental in helping to fine tune the TIENS program to respond to the unique needs of these nurses.

Melanie Gabriel, RN, BSN
E-mail: melanie.gabriel@uphs.upenn.edu

Melanie Gabriel is a level II-Clinical Nurse in the Intensive Care Nursery  at the Hospital of the University of Pennsylvania (HUP). She received her BSN degree from University of the East Ramon Magsaysay Memorial Medical Center in the Philippines in 1992, and practiced in the Philippines for eight years before moving to the United Kingdom where she also practiced in intensive care as an Internationally Educated Nurse (IEN) for four years.  She came to HUP as an IEN in April 2006.  She is the clinical co-chair of the TIENS program and has worked very closely with other IENs and the Global Nurse Ambassador in developing the TIENS program.  Ms. Gabriel co-presented the TIENS program at the American Nurses Association/International Center on Nurse Migration conference in August 2007 in Chicago.