The role of nurses in the global healthcare landscape continues to expand, demanding a diverse and talented workforce to meet the challenges of a rapidly changing world. For many internationally educated nurses (IENs), the path to success may present unique obstacles, but it also offers vast opportunities. As they navigate through the intricacies of adapting to a new healthcare system, culture, and sometimes even a new language, IENs bring a wealth of knowledge, skills and experiences that enrich the fabric of healthcare communities worldwide.
Hiring IENs can be a valuable strategy for organizations, particularly in countries facing nursing shortages or seeking to diversify their healthcare workforce. However, the process of hiring and integrating IENs into the healthcare system presents both benefits and challenges.
I interviewed several nurse leaders who developed and implemented a robust program for IENs who are transitioning to the healthcare field in the U.S. This program seeks to help them not only overcome the hurdles but also harness their potential to thrive as exceptional caregivers and leaders. With their permission, I am sharing one healthcare network's journey to integrating IENs successfully into their organization.
Where It All Started: History of IEN Integration Into the Healthcare System
In 2020, the healthcare network faced a significant demand for nurses. To address the nursing shortage, the network explored the option of hiring IENs. The network assembled a group of leaders, including vice presidents representing each campus, the network's chief nursing officer (CNO), CNOs from individual campuses, a physician champion, the director for the Center for Nursing Excellence, the IEN nursing professional development specialist (NPDS), and key representatives from Human Resources (HR), immigration and the legal department.
This diverse team developed a comprehensive "Bridge to Success" program for IENs, ensuring that the network could meet its nursing needs. Their efforts proved successful, as they managed to fill all the nursing vacancies and even expanded their pipeline to include other healthcare specialists, such as medical technologists and physical therapists. This growth demonstrated the network's commitment to providing quality healthcare services while adapting to the evolving demands of the industry.
The Bridge to Success for IENs Transitioning to the US-Based Clinical Practice Program
The program was designed with three tracks to ensure nurses receive appropriate training based on their learning needs:
Track 1: This track is designed for IENs who have successfully completed an undergraduate program in the U.S. and/or have previous professional experience in the U.S.
Track 2: This track is for IENs who have been residing in the U.S. but haven't had prior professional experience here.
Track 3: This track is tailored for IENs who have neither lived nor practiced in the U.S. before.
The IEN training program has two phases:
Phase 1: Recruitment and Community Integration
Specialized recruitment agencies in the U.S. help IENs find employment opportunities. The health network developed partnerships to recruit qualified IENs through employment agencies and an immigration lawyer.
The Bridge to Success program commences approximately two to three weeks after the IENs' arrivals in the U.S. During the initial two to three weeks, the HR department helps the IENs settle down, providing support in the following areas:
- a. Airport pickup
- b. Accommodations, transportation and meals
- c. Contract arrangements
- d. Background checks
- e. Pre-employment appointments
- f. Obtaining a social security number, driver's license, bank account and car if needed
- g. Community tours, visits to churches, cultural groups and local nursing organizations, and other opportunities to make new friends
Phase 2: Training Program – Transitioning to US-Based Clinical Practice
a. IENs' clinical training:
- Training for IENs includes a comprehensive blend of educational lectures, realistic simulations, valuable shadowing opportunities, immersive hands-on experiences or on-site training at the IEN's workplace.
- Throughout the training, individuals receive guidance and mentorship from experienced professionals such as a preceptor, NPDS, nurse educator or nurse leader.
- Topics include but are not limited to:
- U.S. nursing practice standards and the U.S. healthcare system
- Orientation to general hospital and nursing practices
- Interpersonal skills and effective communication
- Cultural-based values and beliefs influencing healthcare
- Familiarity with policies and procedures
- Patient rights and responsibilities
- Fundamentals of electrocardiogram (ECG)
- Critical thinking skills
- Clinical training for the specific unit
Tips for Preceptors
- Apply the Married State Preceptorship Model. If possible, limit the number of preceptors throughout the orientation period to two.
- Working together throughout shifts, the preceptor should provide continual feedback to the preceptee, gradually transitioning from a teaching role to assisting the preceptee, allowing them to take fuller responsibility for patient care.
- Be flexible. As a preceptor, adapt your teaching style to suit the preceptee's learning needs. Tailor the education plan according to their individual learning style and requirements.
- Advocate for IENs to ensure their success in the new work environment.
- Foster insightful conversations by asking questions such as, "Walk me through your approach to a physical assessment," or "Explain your process for conducting a bedside shift report."
- Delve deeper into the fundamental principles of communication. If you ask, "How are you?" and receive a response such as "I am overwhelmed," acknowledge that adapting to a new work environment is a process. Having to adjust is not unique to IENs. Explore the details of their responses to gain a better understanding.
- Assure IENs that it is acceptable to ask questions and seek clarification.
- When providing instructional teaching, speak carefully and request a return demonstration or read-back. Use simple, straightforward language.
- Be aware of different medical terminologies across countries; provide a list of common abbreviations used in your facility.
- Understand and respect the IEN's background without expecting them to change.
- Create a safe environment for IENs to unlearn practices that are not aligned with U.S. nursing standards.
- Take the time to get to know the IENs personally to foster a supportive and inclusive work environment.
- Follow these tips to assess the learning needs of IENs:
- Ask, "What skills and competencies do you possess?"
- Understand that situations such as managing arterial lines may differ significantly in terms of processes, skills, competencies and expectations across countries. Ask, "Have you encountered similar situations where you have worked?"
- Encourage reflective thinking by asking questions such as, "Tell me how you've approached this skill in your experience."
- Ask what types of medications they administered in their previous experience. For example, in some countries, nurses may only be allowed to administer fixed doses of drips, whereas in the U.S., nurses are often permitted to titrate drips.
- Establish regular meetings in both one-on-one settings and larger forums. In Bridge to Success, the IENs meet weekly with the unit nurse leader, preceptor, the unit NPDS and the NPDS in charge to address any concerns, provide feedback and ensure the IENs' ongoing development. Encourage collaboration among IENs to foster a culture of sharing experiences and knowledge.
"Ask lots and lots of questions. Be open-minded, be open to lots of questions. Seek. Talk to different people and employees. Go out and ask about their experiences and dreams – connect with them. Ask what they want in our organization. Connect them with your local chapter of nurses' organization that can help them with their needs." Marie, Center for Nursing Excellence Director
"The ultimate objective of the Bridge to Success Program for IENs is to facilitate a seamless and successful integration of IENs into the U.S. healthcare system, enabling them to embark confidently on their professional journey." Jillian, Bridge to Success Program NPDS Lead
"Be patient. Know that you have to change your teaching style. When teaching a skill, confirm first if they have done it before. If so, ask them to show you so you have an idea where the gap is. Validation is key! Speak carefully and ask them to do a read-back." Kelley, ICU RN, preceptor
Training the Healthcare Team
To build understanding, train the rest of the healthcare team to focus on collaboration. Raise awareness about cultural differences, promote open communication and encourage teamwork. Include important topics such as equity, diversity and inclusion, fostering a healthy work environment (HWE), and promoting understanding of both the new staff's culture and other cultures.
Here are some potential valuable data collection points that could enhance the program:
- Training Duration: What is the timeframe of the orientation/training process?
- Employee Engagement: Gather baseline data from Press Ganey surveys
- Retention Rate
- This organization boasts an impressive retention rate of 98%, with only one employee leaving in the course of one year.
- Feedback for Continual Improvement: Continually enhance your program by incorporating feedback from IENs, nurse leaders, preceptors and colleagues. Conduct town halls where directors and CNOs interact with nurses at the bedside.
According to CNO Jen, the successful integration of IENs into healthcare teams requires deliberate efforts from healthcare organizations to provide adequate training and support. She emphasized her responsibility to ensure that teams comprehend the significance of this pipeline and are aware of their roles in contributing to the program's success and the success of new team members.
Advice shared by CNO Jen:
- Thoroughly map out every step of the implementation process to ensure a smooth and organized experience.
- Review potential obstacles to establishing a smooth process, starting from immigration and extending to the integration of individuals into their respective units.
- Ensure that you allocate enough time with your leaders to define and introduce strategies for implementing the program effectively. Underestimating this crucial aspect can hinder the program's success.
- Extend the program's reach to encompass all teams involved, including physicians. Be sure to include them in the planning and implementation processes.
- Emphasize not only the clinical and cultural aspects, but also the well-being of the IENs' families. Provide assistance in settling their families, which will further help them integrate into the new work environment.
- Establish a support system by connecting them with a community of IENs or internationally trained staff already working in your facilities.
- Establish regular touchpoints with the participants, both one-on-one and in larger forums. Encourage collaboration among IENs to foster a culture of sharing experiences and knowledge.
- Help equip your teams with information and competencies related to different cultures to enhance their awareness and sensitivity.
"With good training and awareness, the ability to help, shape, influence and guide will be endless." Jen, CNO
I acknowledge and thank the following nurse leaders who shared their program, experiences and advice to make this blog possible: Jen Shull, DNP, MHA, RN, CNO; Marie Leist-Smith, PhD, RN, Center for Nursing Excellence director; Jillian Wills, MSN, RN, NPDS; Kelley Polley, BSN, RN, critical care preceptor and relief charge nurse.
How have you helped an IEN successfully transition into practice?