Post-Hire Transitional Programs for International Nurses: A Systematic Review

Abstract

Both the numbers and the proportions of international nurses in some Western countries are rapidly growing. There are numerous post-hire transitional programs designed to facilitate the transition of these nurses; however, little information is available on the evaluation of the "state-of-the-art" of these programs. A systematic review of 20 post-hire transitional programs for international nurses was conducted to evaluate the status of these programs regarding country of origin, research- versus non-research-based articles, proposed versus implemented programs, program structure and content (i.e., mentorship, formal language or communication training, length, single vs. multiple component, logistics support, and theoretical or conceptual framework), and indicators for program success. Data from this review indicate that most programs were not evidence-based. In addition, there is minimal research on transitional programs, especially their effectiveness. Implications and recommendations for practice and future research are elaborated here in light of the review findings. [PUBLICATION ABSTRACT]

Headnote

abstract

Both the numbers and the proportions of international nurses in some Western countries are rapidly growing. There are numerous post-hire transitional programs designed to facilitate the transition of these nurses; however, little information is available on the evaluation of the "state-of-the-art" of these programs. A systematic review of 20 post-hire transitional programs for international nurses was conducted to evaluate the status of these programs regarding country of origin, research- versus non-research-based articles, proposed versus implemented programs, program structure and content (i.e., mentorship, formal language or communication training, length, single vs. multiple component, logistics support, and theoretical or conceptual framework), and indicators for program success. Data from this review indicate that most programs were not evidence-based. In addition, there is minimal research on transitional programs, especially their effectiveness. Implications and recommendations for practice and future research are elaborated here in light of the review findings.

J Contin Educ Nurs 2009;40(2):57-64.

Migration of nurses is an international phenomenon (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004; Buchan & Calman, 2004; Kingma, 2006). Hundreds, if not thousands, of nurses cross national borders each year for professional and personal opportunities, although the exact numbers remain unknown. However, there are some reliable regional and national data. For instance, internationally educated nurses constituted 3.5% of the estimated 2.9 million U.S. nurse work force in 2004 (Health Resources and Services Administration, 2005), whereas another study suggested that as much as 15.2% of the U.S. nurse work force was foreign born (Polsky, Ross, Brush, & Sochalski, 2007). In the United Kingdom, 1 in 12 nurses came from another country; in fact, during 2001 to 2002, there were more international nurses than United Kingdom nurses added to the nursing registry (Buchan & Calman). Omeri and Atkins (2002) profiled the Australian nurse work force, indicating that 23.6% (78,700) were foreign born. In 2005, 34.1% of the newly registered nurses in Ontario, Canada, were international nurses (Baumann, Blythe, Rheaume, & McIntosh, 2006).

It is unequivocal that international nurses have become an important and integral part of the nurse work force in many Western countries. However, international nurses encounter numerous challenges during their transition in host countries (Xu, 2007). These challenges include, but are not limited to, language and communication difficulty; clinical differences such as different role expectations of the nurse; marginalization, racism, and discrimination; and cultural displacement (Xu). Growing evidence suggests that these challenges could affect patient safety and quality of care, as well as the health and job satisfaction of international nurses (Davis & Nichols, 2002; Xu; Xu, Gutierrez, & Kim, 2008; Yi, 1993). In fact, retention of international nurses has become an issue as some of them seek other career options or return to their home countries after failing to adapt. Currently, most U.S. employers require international nurses to participate in the orientation program for new nurse graduates or other domestically educated nurse hires because they have neither the resources nor the expertise to develop specific transition programs for international nurses.

It is important to consider whether a transitional program is mandatory for international nurses by the host country government. In the United Kingdom, transitional programs have been established as a result of the governmental regulatory requirements for health care standards. Each international nurse recruited to the United Kingdom is required to complete an "adaptation course," also called "supervised practice," which is defined as working with a preceptor for a given period of time (Horner, 2004). This supervised practice lasts a minimum of 3 months and a maximum of 6 months. On its successful completion, international nurses can receive their registration from the government to work as an independent nurse. The goal of supervised practice is to ensure the successful achievement of statutory outcomes and competencies for professional registry by enabling candidates to gain appropriate skills for safe and effective practice (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1998).

This systematic review examines available post-hire transitional programs for international nurses in an attempt to evaluate their status. To the authors' knowledge, this scholarly endeavor is the first of its kind. For the purpose of this article, international nurses are defined as nurses who received their basic nursing education or were born outside their destination countries. The term international nurse is used instead of foreign nurse because "foreign" denotes "otherness" or "alien" and many of these nurses have become permanent residents or citizens of their host countries.

METHODS

To evaluate transitional programs for international nurses available in the literature, a systematic literature search was conducted. The databases used in the review were CINAHL, Medline, Academic Search Premier, ProQuest, and Scopus. Key search words used were "foreign," "oversea," "international," "nurse," "adaptation," "transition," "integration," and "acculturation." Combinations of these terms were searched within the title, abstract, and subject. The inclusion criterion was empirical studies or scholarly articles published in English that describe, evaluate, or propose a post-hire transitional program for international nurses. Articles of expert opinions or "should be" were separated from those that included empirical data. There were no cut-off dates for the literature search. The last research was conducted in December 2007. In addition, available conference presentations and publications from other published sources with limited circulation were also included in the search.

To make the review process more objective and manageable, the reviewers developed a list of interested categories of variables pertaining to transitional programs for international nurses. These categories included country of origin, research-versus non-research-based articles, proposed versus implemented programs, program structure and content (i.e., mentorship, formal language or communication training, length, single vs. multiple component, logistics support, and theoretical or conceptual framework), and indicators for program success. Research-based articles referred to publications on transitional programs that presented empirical data regarding these programs, such as statistics pertaining to the program evaluation. Non-research-based articles were those that provided expert opinions or proposed ideas regarding transitional programs without empirical data. Each article was read and re-read to extract the needed data. During this process, the initial list of variable categories was amended through an iterative process after constant discussion between the two researchers. Once the variable categories were finalized, tables were constructed for each variable to provide the data from each retrieved and reviewed article to allow aggregation and summary of findings.

RESULTS

Twenty-four articles on transitional programs for international nurses were retrieved, including non-research-based articles. Four programs were excluded from the review: two were developed for pre-hire international nurses to prepare them for licensure (Baj, 1997; Chapman, 2007); one involved only preceptors mentoring international nurses without activities for these nurses (Shivnan, 2007); and another was primarily concerned about educators training international nurses in academic settings (Mott, Shortridge, & Sheppard, 2005). Twenty programs were exclusively designed for post-hire international nurses and were the focus of this review. The majority (n = 13) of the 20 post-hire programs focused on multifaceted transitional and adaptation issues of international nurses. The United Kingdom appeared to be the only country where transitional programs were involuntary or required by the government.

Country of Origin

Only 2 of the 10 research-based transitional programs were United States based (Adeniran, Moore, Sullivan, & Gabriel, 2007; Yahes & Dunn, 1996), whereas 5 United Kingdom programs (Gerrish & Griffith, 2004; Horner, 2004; Parry & Lipp, 2006; Winkelmann-Gleed & Seeley, 2005; Witchell & Osuch, 2002) and three Australian programs (International Institute for Policy and Administrative Studies [IIPAS], 1990; Menon, 1992; Palmer, 1989) fell into this category. The fact that transitional programs for international nurses were required by the United Kingdom government may have accounted for the predominance of United Kingdom programs in the literature. On the other hand, there were seven non-research articles on U.S. programs (Commission on Graduates of Foreign Nursing Schools [CGFNS], 2005; Davis, 2003; Dijkhuizen, 1995; Long, 2005; McBroom, Davis, Mostaghimi, & Holtschneider, 2006; Pilette, 1989; Ryan, 2003) and three non-research articles on United Kingdom programs (Cowan & Norman, 2006; Hydes-Greenwood, Nellestein, & Leach, 2002; Thomas, 2007).

Research-Versus Non-Research-Based Articles

Ten of the 20 included articles were research based (Adeniran et al., 2007; Gerrish & Griffith, 2004; Horner, 2004; IIPAS, 1990; Menon, 1992; Palmer, 1989; Parry & Lipp, 2006; Winkelmann-Gleed & Seeley, 2005; Witchell & Osuch, 2002; Yahes & Dunn, 1996). It appears that government requirement for mandatory transitional programs may play a role in the proliferation of research-based articles from the United Kingdom.

Proposed Programs Versus Implemented Programs

Of the 20 articles, 6 included only expert opinion or proposals for future programs (CGFNS, 2005; Cowan & Norman, 2006; Davis, 2003; Dijkhuizen, 1995; Pilette, 1989; Ryan, 2003). However, these opinion pieces or program proposals were written by authors who derived theoretical underpinning for their ideas from such theories or conceptual frameworks as Maslow's hierarchy of needs. None of these articles were research based. Of the 20 articles, 14 described implemented programs for international nurses. Of these 14, 3 did not have empirical data on their implementation at the time of publication.

Program Structure and Contents

The following subheadings highlight and summarize the components of the 20 included transitional programs. These program components were extracted from the obtained literature on current transitional programs. The Table presents a profile of 10 transitional programs in research-based articles included in this study.

Mentorship. Any article employing a buddy, preceptor, or mentor or any other equivalent figures to provide personal guidance for international nurses was deemed as having a mentorship component. The authors were interested in mentorship because it was cited (Horner, 2004) and generally recognized as one of the critical factors for the successful adaptation (or maladaptation or failure) of international nurses (Xu, 2007; Xu et al., 2008). Of the 20 articles, 9 mentioned the use of some form of mentorship, such as a preceptor or buddy (Adeniran et al., 2007; CGFNS, 2005; Gerrish & Griffith, 2004; Horner, 2004; Menon, 1992; Parry & Lipp, 2006; Ryan, 2003; Thomas, 2007; Witchell & Osuch, 2002). Programs were further divided into those that voluntarily had a mentorship component and those required to include this element. Of the nine programs with a mentorship component, four were voluntary and the remaining five were required or involuntary with a near even distribution between the United Kingdom and the United States. This near equal division suggested that mentorship was common and therefore important in transitional programs regardless of whether it was required by the government.

Formal Language or Communication Training. Of the 20 included programs, 10 mentioned the importance of or the use of formal language or communication courses to aid the transition of international nurses, suggesting that communication competence was one of the priority needs of international nurses (Adeniran et al., 2007; CGNFS, 2005; Cowan & Norman, 2006; Hydes-Greenwood et al., 2002; IIPAS, 1990; Menon, 1992; Palmer, 1989; Parry & Lipp, 2006; Witchell & Osuch, 2002; Yahes & Dunn, 1996). Nine merely mentioned language as an important part of transitional programs (Adeniran et al.; CGFNS; Cowan & Norman; Long, 2005; Menon; Palmer; Parry & Lipp; Witchell & Osuch; Yahes & Dunn). However, only five programs actually included a language course, indicating a dissonance between the identified need and the reality (Adeniran et al.; Menon; Palmer; Parry, & Lipp; Yahes & Dunn).

Length of Transitional Program. Lengths of transitional programs varied widely. The longest running post-hire transitional program was 1 year, which included follow-up and evaluation of the program by participating international nurses at the 1-year mark (Adeniran et al., 2007). The shortest program lasted 1 week and mainly consisted of reviewing hospital policies and procedures. This course was referred to as "induction week" and was considered part of a formal transitional program required for international nurses as part of their registration process in the United Kingdom (Hydes-Greenwood et al., 2002). Most programs were 12 to 16 weeks. Three of the articles did not specify their program length.

Single-Versus Multiple-Component Program. Of the 20 transitional programs, 15 incorporated multiple components (Adeniran et al., 2007; CGFNS, 2005; Cowan & Norman, 2006; Davis, 2003; Dijkhuizen, 1995; Gerrish & Griffith, 2004; Horner, 2004; IIPAS, 1990; Long, 2005; Palmer, 1989; Parry & Lipp, 2006; Pilette, 1989; Thomas, 2007; Winkelmann-Gleed & Seeley, 2005; Witchell & Osuch, 2002). The components incorporated into these programs included language skills, communication, mentorship, safety issues, agency policy and procedures, health care technology, and cultural issues such as diversity. The remaining five programs focused on only one area, such as communication or mentorship (Hydes-Greenwood et al., 2002; McBroom et al., 2006; Menon, 1992; Ryan, 2003; Yahes & Dunn, 1996).

Logistics Support. Logistics support was perceived as very important by international nurses, especially during the "settling down" phase following arrival in host countries. Meeting international nurses at the airport, assisting them with lodging arrangements, and helping them find ethnic grocery stores, set up bank accounts, and locate pastoral services affected their immediate quality of life and their perception of employers. Of the 20 programs, 7 included some form of logistics support for international nurses to become familiar with their new living and working environments, including 5 programs actually providing the support (Adeniran et al., 2007; Dijkhuizen, 1995; Hydes-Greenwood et al., 2002; Parry & Lipp, 2006; Pilette, 1989; Ryan, 2003; Witchell & Osuch, 2002).

Theoretical or Conceptual Framework. The authors were also interested in evaluating whether any theoretical or conceptual frameworks were used in guiding the development of the transitional programs and, if so, what theoretical or conceptual frameworks were adopted. Of the 20 programs, only 3 used theoretical frameworks, one of which was research based. These frameworks were Pilette's (1989) four phases of adjustment, Maslow's (1954) hierarchy of needs, Herzburg, Mausner, and Snyderman's (1959) theory of employee motivation, and Knowles' (1988) theory of adult learning. For instance, interventions were designed to match the four phases of adjustment proposed by the non-research-based article by Pilette. Acquaintance, indignation, conflict resolution, and integration concepts are addressed in the research completed by Winkelmann-Gleed and Seeley (2005). A non-research-based program grounded in Maslow's hierarchy of needs was foremost concerned about meeting the basic needs of international nurses, such as shelter, food, and transportation, instead of focusing on work-related issues initially (Dijkhuizen, 1995). In addition to Maslow's hierarchy of needs (1954), Herzberg et al.'s theory was of major focus in the non-research-based article completed by Dijkhuizen. This theory focuses on international nurses' intrinsic needs by promoting a positive work environment. Finally, implications for nurse educators regarding international nurses were addressed by Dijkhuizen using Knowles' concepts of adult learning.

Indicators for Program Success. The authors were also interested in the indicators of the transitional programs. A majority of the programs used some form of evaluation to assess program outcomes. The most common evaluation measures included surveys and interviews. Among the 10 research-based articles, the majority of the participating international nurses rated their adaptation programs as "useful." Another outcome measure was registration rate on completion of the adaptation program that was typically employed by United Kingdom-based programs (Witchell & Osuch, 2002). Other programs used qualitative feedback data from participating international nurses. For instance, international nurses stated the courses they took prepared them for U.S. nursing practice (Adeniran et al., 2007). Yahes and Dunn (1996) reported higher job satisfaction and fewer communication complaints related to international nurses on the unit after taking a communication course.

IMPLICATIONS AND RECOMMENDATIONS

Despite the limited research on transitional programs for international nurses, important insight can be gained from this review of the state-of-the-art of these programs. Employers of international nurses who are plagued by the nurse shortage cannot expect to fix it by merely recruiting international nurses and expecting them to "hit the ground running" without adequate transition programs. In addition, it takes time for international nurses to adapt to work environments in new host country cultures. As demonstrated from the results of this systematic review, transitional programs help international nurses with their transition.

However, if these programs are critical to the transition of international nurses and, therefore, patient safety and quality of care, why is research on this topic limited? Why are transitional programs designed specifically for international nurses lacking? Is this a result of limited funding or expertise, an indication of a lack of institutional and managerial commitment, or the result of the misconception that international nurses do not have unique transitional and adaptation needs? Although this review provides no specific answers to these questions, they need to be investigated further, especially given the national strategic plan and agenda for patient safety research after the landmark Institute of Medicine report, To Err is Human (Kohn, Corrigan, & Donaldson, 1999), and subsequently established National Patient Safety Goals by The Joint Commission (2008).

Implications for Practice

Language or Communication Training. It is noted from the reviewed program literature that international nurses benefited substantially from language or communication training. Although this review found only 5 of the 20 programs incorporated this component into transitional programs, research indicates that language or communication deserves more attention because lack of communicative competence is recognized as the most commonly identified problem for international nurses by their employers (Miraflor, 1976; Yahes & Dunn, 1996), credentialing agencies (Davis & Nichols, 2002), and international nurses themselves (Davison, 1993; Miraflor; Xu, 2007; Xu et al., 2008; Yi, 1993). This growing body of evidence suggests that a considerable share of the negative situations and undesirable patient-related outcomes involving international nurses would have been improved or even prevented if language and communicative skills had been adequate. Therefore, language or communication skills training must be an integral part of an evidence-based transitional program.

Logistics Support. Providing logistics support was reported in only 5 of the 20 reviewed programs. As inferred from theorists such as Maslow (1954), meeting the basic human needs of international nurses is essential to their successful transition into new work environments in host countries. It appeared that many United Kingdom programs focused on the hospital requirements rather than international nurses' holistic needs, including logistics support. In this regard, it appears that the United Kingdom adaptation programs need to pay more attention to this vital part of international nurses' experiences in addition to job-related requirements if job satisfaction, retention, and organizational commitment and loyalty are the desired outcomes.

Mandatory Program. The United Kingdom was the only country in the reviewed literature where transitional programs were mandated by the government. Given the growing literature on the unique needs and challenges of international nurses, especially those that posed real and potential risks for patient safety and quality of care (Davis & Nichols, 2002; Xu, 2007; Xu et al., 2008; Yi, 1993), and available initial research evidence from this review, the recommendation to make transitional programs for international nurses mandatory, at least on a trial basis, is warranted. For example, after completing mandatory programs in the United Kingdom, international nurses began practicing independently sooner; they also stated the programs were "useful" and "helped transition into practice" (Horner, 2004, p. 40). However, more research needs to be conducted to evaluate this recommendation. Moreover, these programs should be separately developed and tailored to meet the unique needs of international nurses, although there may be some content overlap with programs designed for domestic nurse hires.

Recommendations for Future Research

This systematic review indicates that few transitional programs were based on available research on international nurses. In other words, available research on international nurses has been used marginally to inform transitional programs for international nurses, thus resulting in a paucity of evidence-based programs in the current literature. The lack of evidence-based transitional programs is incompatible with the increasing numbers and proportions of international nurses in the national nurse work force in many Western countries, especially the United States.

Based on this systematic review of the existing literature, the core recommendation is to develop and test evidence-based transitional programs and translate the research findings into practice. First, research on the development of evidence-based transitional programs needs to be encouraged. Such research will inform the development of effective programs that will increase retention of international nurses and ultimately enhance patient safety and quality of care.

Second, more interventional research is needed to test measures designed to facilitate the transition and adaptation of international nurses. Currently, studies on post-hire interventions are still in the infancy stage. However, their value to contribute to improved clinical (patients and international nurses) and organizational outcomes (retention and savings from a reduced turnover rate) cannot be overestimated. For instance, the need to conduct an interventional study on a comprehensive communicative competence training program to address both the linguistic and the sociocultural dimensions of communication is well documented (Xu, 2007).

One gap in the reviewed transitional programs was the lack of measures to address fundamental social issues international nurses face in host countries, including racism, discrimination, and interpersonal conflicts. It is noted in the general literature on international nurses that there is widespread racism and discrimination against international nurses (Xu, 2007). In one case, a nurse from a Muslim country caring for a British patient was told, "I don't want to be treated by a terrorist" (Winkelmann-Gleed & Seeley, 2005, p. 957). However, existing transitional programs have not provided nurses with any tools to deal with prejudice and injustice in the workplace. Similarly, existing transitional programs largely failed to address workplace incivilities such as verbal and physical assaults and sexual harassment from patents, peers, and physicians and interpersonal conflicts arising from different beliefs, values, norms, and personalities.

Finally, once these interventions are tested, it is pivotal to translate the research findings into practice to benefit international nurses themselves, their employers, and their patients. Ultimately, translation of research findings into practice should be the goal of any research endeavors to demonstrate the social value, responsibility, and accountability of researchers. Further, funding agencies would like to see the social benefits of their investments made after recruiting international nurses.

CONCLUSION

The influx of international nurses is likely to increase because of the worsening global nurse shortage and ever growing demand for health services. This review indicates that there is limited research on transitional programs for international nurses and a lack of evidence-based transitional programs. However, growing literature suggests that evidence-based transitional programs for international nurses are urgently needed. These programs will benefit not only international nurses, but also their employers and, most importantly, their patients.

Sidebar

key points

International Nurses

Zizzo, K. A., Xu, Y. (2009). Post-Hire Transitional Programs for International Nurses: A Systematic Review. The Journal of Continuing Education in Nursing, 40(2), 57-64.

1 International nurses make a huge impact on the host countries they immigrate to and their numbers continue to rise each year to minimize the current nursing shortage.

2 According to research data, international nurses have great difficulty transitioning to another country.

3 There are few programs aiding international nurses as they make this transition.

References

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