Internationally Educated Nurses’ Experiences Working in the U.S.

The nursing shortage is a global concern. Internationally educated nurses (IENs) have been an integral part of mitigating this issue. IENs, also known as foreign educated nurses, are those who completed their nursing degree outside of the country where they currently work.

Based on "Commission on Graduates for Foreign Nursing Schools' (CGFNS) Nurse Migration Report 2022," labor migration of nurses to the U.S. is rising. Visa applications rose 109% since 2018 for healthcare workers from 116 countries. In 2022, 81% of new visa applicants were registered nurses. Helping these culturally and linguistically diverse IENs become successful team members in the U.S. healthcare system starts with learning about their experiences. Prior to working in their host countries, IENs endure many challenges such as visa screening processes, credentialing evaluations and examination services, and recruitment and work authorization approvals that may take up to 16 years.

International Nurses Day

To celebrate International Nurses Day (May 12), I explored the experiences of other IENs now working in the U.S. and interviewed a number of them. In learning about their stories, I realized that, as an IEN myself from the Philippines, I faced many of the same challenges and similar experiences.

Demographics

My interviewees:

• Migrated from India, the Philippines, South Africa, and the United Kingdom
• Had up to 29 years of nursing experience prior to migration
• Experienced two to 16 years of visa application processing
• Worked in California, Indiana and Ohio
• Worked in different specialties: critical care, emergency department, medical-surgical, operating room and progressive care
• Have been working in the U.S. for six months to 46 years

Let's learn what they have to say.

Challenges Faced by IENs: 3 Common Themes

Based on my discussions with the IENs and my own experiences, three themes emerged as the IENs' top challenges. I call it the 3Cs - Communication, Culture and Care Systems.

Challenge #1: Communication Barriers

Communication barriers, both verbal and nonverbal, top the list. Although they must pass an English language proficiency exam as a requirement to work in the U.S., most IENs are challenged by nuances of language such as accents, slang words, acronyms, colloquialisms, differences in interpersonal communication and cultural norms of interaction. It's crucial to promote effective cross-cultural communication in the healthcare setting, not only to support satisfaction between IENs and their colleagues, but also to improve quality of care and patient outcomes.

• Communication Tips for IENs:
  • Ask questions. Do not shy away from asking questions. The only bad question is one not asked.
  • Ask the speaker to speak slowly.
  • Be proactive; learn about effective cross-cultural communication.
  • Read back messages to ensure you understood them correctly.
  • Speak slowly and clearly - the issue can go both ways. Don't be concerned about letting the speaker know you have a difficult time understanding.
  • Learn tips for communicating while wearing a face mask.
• Communication Tips for Healthcare Team Members When Speaking With IENs:
  • Keep it simple.
  • Speak clearly and somewhat slowly.
  • Be an active listener.
  • Be patient and supportive.
  • Avoid nuanced language such as slang, difficult-to-understand humor, colloquialisms, etc.
  • Do not assume that IENs understood you correctly. Clarify if they need further explanation by doing a read back. If you're teaching a skill, ask them to teach back.
  • Similarly, try not to assume that you understood them correctly. Clarification is key.
  • Never laugh at an IEN's pronunciation of a word. This reaction can be interpreted as insensitive.
  • Consider nonverbal communication.

Challenge #2: Culture

Culture is the second most common theme of challenges for IENs. Settling in a new workplace can be difficult for anyone, even more for someone who is also in a new country. Following are some reported socio-cultural challenges for IENs:

• Homesickness and Loneliness: Most IENs have families they left behind in their home country.
• Weather: Climates vary from country to country and region to region. For example, IENs from a tropical country and moving to the Midwest are used to warm weather, only have warm clothes, and then need to adjust to a place where there is distinctly colder winter weather.
• Food/Dining: Finding familiar ingredients for cooking or finding restaurants that serve traditional meals can be difficult in a new country.
• Housing and Transportation: Housing and transportation for the first four to six weeks are sometimes provided by the staffing agency or employer organizations. The transition to permanent housing can be difficult. There are many factors to consider such as proximity to work or to good schools if there are children in the household. If you are working with IENs, consider sharing resources if they express difficulties that you can help with.
• Access to familiar amenities and necessities:
  • Religious/spiritual affiliations or places of worship: An IEN may have a large support network in their home country related to their spiritual affiliations that may be difficult to find in their host city or region.
  • Banking: The financial system in the U.S. may be completely different from an IEN's home country. Opening a bank account and/or getting a credit card can be a very limiting challenge and pose a significant barrier to day-to-day living.
  • Healthcare services: IENs may or may not be able to access the healthcare services that they're accustomed to in their home country.
  • Driving: The rules of the road are different everywhere and can pose a big challenge for IENs.
  • Human Resources (HR) Related Topics: Understanding American taxation, retirement and Social Security are just a few topics that IENs may not fully understand.

Advice From Established IENs for New IENs

When I interviewed IENs already living and working in the United States, they offered advice for others considering or making the transition:

• "Familiarize yourself with where you want to live. Do a search. Learn how to drive before coming over to the U.S., bring some backup money in case you need it. Further your studies even outside of nursing once you get here. Be resilient. Keep in mind that it's going to be difficult to navigate the system at the beginning and it will get better. Learn how to get along with your co-workers, it makes a huge difference" - Fathma U.
• "Learn the culture for yourself. Take a cultural competency class. Learn as you go. Choose who you trust. Learn how to speak up when necessary." - Demi
• "Make up your mind before you move because life is totally different. It can help reduce stress. Remember the reason why you moved if you feel overwhelmed and stressed." - Jincy G.
• "Be as you are. You do not change yourself. Learn the environment. Learn to adjust with the environment. Meet new people." - Jini Susan J.
• "Look for somebody who is from your country who can help guide you, show you around, who will be happy to explain things or listen to your challenges. Somebody that might have had the same experiences as yours, and they can share how they navigated through it. - Rachel R.
• "Find someone from your country who can help you, even with small needs, such as where to buy the spices that you are used to. Connecting with religious or spiritual groups or church services is an important part of your support system. Learn the culture. Attend a cultural diversity class." - Shiny B.

More Cultural Tips for IENs

1. Connect with other IENs, especially those who come from your country, and nurture those relationships. They can share experiences, advice or practical tips.
2. Learn to drive if you don't know how. It is a necessity in the U.S., especially if you will live in an area that doesn't have a robust public transportation system.
3. Learn about other cultures that you might encounter in your community or workplace.
4. Research where you want to live. Explore the different cultures, weather, etc.
5. Check your host community for any resources, especially for associations of community members or nurses from your country of origin.
6. Look for professional organizations that support professional practice such as the American Association of Critical-Care Nurses (AACN), Philippine Nurses Association of America (PNAA), Inc., National Black Nurses Association, Inc., National Association of Hispanic Nurses, etc.
7. Connect with your HR partner.
8. Bringing some backup cash. It will help if there are delays in establishing bank or credit accounts.

Remember: You are in a new country with a new culture and new work environment. Prepare for challenges. Have a strong support system. Let your family know about your challenges and also your positive experiences. As I mentioned earlier, connect with nursing or social organizations or with other IENs with similar experiences.

Challenge #3: Care Systems - Workplace Differences

The American healthcare system and workplace are unique, posing challenges to IENs. Based on the conversations I had with IENs and from my own experiences, I have summarized these obstacles in the acronym CARE:

• C - Clients: Differences in the clients or the patients and their loved ones, their roles and involvement in the delivery of care, decision-making, patient rights and other patient care standards
• A - Access to care plus medications and treatments: The structure of the U.S. healthcare system often presents different barriers to accessing care than other countries. There are also vast differences in medications from brand names to route of delivery, and nursing scope of practice related to medication administration. Treatments and procedures in the U.S. can also be very different.
• R - RN/Ancillary staff scope of practice, roles and responsibilities: Nursing scope and standards of practice, policies and procedures, roles and responsibilities, and code of ethics vary from country to country. In some places, nursing autonomy is not a common practice. While comparing experiences, one IEN mentioned that in the U.S., nurses have more ability to dictate their practice in terms of safety and process improvement. Another IEN pointed out that you might need a physician's order here in the U.S. for basic care, when an order is not needed in your country of origin.
  
  There could be major differences in legal concerns from country to country. Additionally, hospitals or clinics in some countries may not have interprofessional collaborations with other healthcare professionals.
• E - Equipment, healthcare information systems (HIS) and technology: This category includes not only technology and equipment but also information technology, including electronic medical record systems and standards related to documentation. Learning new technology or equipment can lead to steep learning curves and increased occupational stress for newly arrived IENs.

Tips for IENs in the Workplace:

• Be proactive with your learning:
  • Learn about medication brand names, IV infusions, most common diseases, treatments, equipment, HIS, protocols, standards of nursing practice and the code of ethics.
  • Consider getting certified in your specialty area to advance your professional and personal growth.
• Ask questions. Direct questions to your preceptor/mentor, a trusted colleague, educator or nurse leader. Participate in interprofessional collaboration activities.
• Use materials and services from professional nursing organizations. Many professional nursing organizations, such as AACN, have a wealth of clinical resources that can support your patient care learning needs. Explore what is freely available online, or ask your colleagues what resources they recommend.

Do not give up! Remember that you are not alone. If you feel overwhelmed, talk to somebody. Connect with another IEN who might be having similar challenges and who might have some advice based on their experiences. Following are more tips and advice from IENs on managing workplace challenges:

• "Life begins at the end of your comfort zone. Take risks. Trust God. Maintain a good work ethic. If you have problems, consult your manager." - Hilda BN.
• "There is no difference in the level of care that you need to provide your patients; it is just that you are in a different country. You still have to provide the best care possible. At the end of the day, all we care about is to provide that one day of best patient care for that patient you took care of who will remember it and/or the family will remember for the rest of their lives." - Fe B.
• "If you don't know something, research it or ask questions. Never assume you know it." - Kim S.
• Throw yourself into the education system - learn things. Get certified; certification helps validate your education that it is at par with what is expected of you to provide patient care. No matter where you are in the world, approach every patient with compassion." - Belinda SB.
• "You might have a feeling that they don't like you or your patients do not like you. They might not feel comfortable being taken care of by a foreign nurse. You also must understand where they are coming from. Remember that you cannot please everyone. Not all patients or co-workers will like you. This happens to everyone." -Jay B.

Tips for Healthcare Team Members Working With IENs:

• Be patient and accommodating. Remember that a newly arrived IEN is going through a lot of challenges not only at work but outside of work. Consider learning about their culture to better understand them.
• Be aware that the care systems where the IENs came from are different from those in the U.S.
• Create a culturally sensitive educational program for IENs transitioning to practice in your organization with a focus on strengthening their patient safety competencies.
• Maintain a Healthy Working Environment (HWE), which can impact nursing retention, a sense of inclusion, satisfaction and improved patient outcomes.
• Use your equity, diversity, and inclusion (EDI) lens when analyzing situations and resolving concerns. Be open-minded.
• Tips for preceptors, educators/NPDS, nurse leaders:
  • Assess the potential knowledge gaps of IENs.
  • Set practical expectations with the IEN early in the orientation process.
  • Set up consistent, meaningful meetings to check their progress.
  • Provide support structures such as a mentorship program.
  • Do not consider an IEN's difficulties as incompetence, but rather consider them as a learning opportunity.
  • Be aware of their potential challenges and how that may affect their work.

Empathy Is Key

The key to the success of helping an IEN, or any new nurse, in an organization is to provide a holistic approach to the nurse as an individual, just like we provide individualized, holistic care to our patients. Everyone benefits from empathy because it helps improve human connection, supports effective communication and fosters positive outcomes.

Special Acknowledgements

I acknowledge and thank the following IENs who shared their time, experiences and advice to make this blog possible: Jay B, BSN, RN, critical care clinical nurse leader; Fe Beduya, BSN, RN, critical care, previously a clinical instructor; Shiny Biju, BSN, RN, critical care; Demi, BSN, RN, medical-surgical; Jincy George, BSN, RN, intermediate care; Jini Susan John, BSN, RN, MA, sociology, critical care; Fathma U, MSN, RN, CEN, cardiothoracic ICU; Hilda Bolivar-Narra, BSN, RN, medical-surgical; RachelR., MBA, BSN, RN, CNOR, RNFA, clinical nurse educator; Belinda Stewart-Burger, SCRN, CNRN, CRRN, movement disorders nurse navigator; Kim Straszheim, MSN(c), BSN, RN, emergency department

How have you helped an IEN fit in and feel supported?