ONBOARDING COMPETENCY

DEVELOPMENT FOR FOREIGN-

EDUCATED NURSES (FENs) WITHIN THE

UNITED STATES HEALTH CARE SYSTEM

Lobel A. Lurie, MA, RN-BCAmerican Sentinel UniversityDoctor of Nursing Practice in Executive Leadership

Final Capstone Defense May 10, 2016

COMMITTEE MEMBERS

Kristine Skalsky, MSNEd, EdD, RN

Capstone Chair

Eddie Beard, Jr., DNP, RN, NEA-BC

Committee Member

PROBLEM STATEMENT• Nursing Competence• Workforce demand - retirement• Nursing shortage is a cycle• 526,800 RNs = Yearly Replacement Need

(Department of Labor, 2013)

• Institute of Medicine (IOM) (2010)

BACKGROUND• Nursing Shortages

• 1930 - 1940s – Demand-driven

• 1943 Bolton Act - Wartime Nursing Demands $160M

• 1960s – Triad approach

• Foreign-educated nurses• 1948 – U.S./Philippine Exchange Visitor Program

• 1965 – Hart – Celler Act – abolished quota

BACKGROUND• Commission on Graduates of Foreign Nursing Schools

(CGFNS International) (1977)• CGFNS qualifying examination

• English language proficiency exam

• NCLEX examination

FORCES CAUSING NURSING MIGRATION• U.S. Reliance on importation (Auerbach,

Buerhaus, & Staiger, 2011)

• Stunted Economic Progress (Siyam & Dal Poz, 2014)

• Nurse Motivators • Better wages • Better living conditions• Professional Advancement

PURPOSE• Transition attributes• Nurturance of the human capital investment• Competency for safe, effective, and efficient

practice.

RESEARCH QUESTION• What are the onboarding experiences of the

foreign-educated nurses in the U.S. healthcare system?

THEORETICAL FRAMEWORK

• Transitions Theory In Nursing (Afaf Meleis, 2010)

• Three Stages• Entry• Passage • Exit

• Recognition of transition is key

SCOPE AND LIMITATIONS

• Qualitative descriptive phenomenological design

• Filtration of information of the interviewees• Bias due to investigator presence• Elapsed time may hinder recollection

LITERATURE REVIEW

• Historical• Current

• Competency a priority• Transition Experiences• Places with higher wages

• Lacking• Transition experiences in onboarding

LITERATURE REVIEW CONTINUED

• Challenges in Onboarding (Edwards & Davis, 2006; IOM, 2011; Adeniran et al., 2008; Xu, 2007)

• Education Preparation Variations• Language and Communication • Medication Management• Advanced Technologies and New Equipment

LITERATURE REVIEW CONTINUED

• Best Practices in Onboarding• United Kingdom (Post graduate program)• Australia (National Adaptation Program)• Canada (Bridging Program)

• The U.S. has no standardized program

METHODOLOGY

The Flow of Inductive Logic of Research in Qualitative Study on the Development of Onboarding Competencies for Foreign-Educated Nurses

Researcher poses generalizations or theories from past experiences and literature

Researcher looks for broad patterns, generalizations, or theories from themes or categories

Reseacher analyzes data to form themes or categories

Researcher asks open-ended questions of participants or records field notes

Researcher gathers information using interview questions as the instrument

ETHICAL CONSIDERATIONS

• Collaborative Institution Training Initiative completed• Institutional Review Board approval secured

• American Sentinel University• Cone Health

• Informed Consent obtained• Guaranty of participant confidentially

VALIDITY/RELIABILITY• Qualitative Validity Strategies (Creswell, 2014)

• Triangulation • Person, Time, and Place

• Member Checking• External Auditors• Bracketing

INSTRUMENT

• Semi-Structured Interview Guide• Open-ended, non-leading• Grand Tour Question• Clarifying questions• Follow Up questions

RECRUITMENT

• 6 participants for qualitative study• First email survey - screening • Second email - demographic survey• Snowball recruitment

DATA COLLECTION AND MANAGEMENT

• Semi-structured recorded interview• Free of identifying information• Participant reviews transcript• Transcription – TranscribeMe! (Version 2.2.3)• Coding – NVivo for Mac (Version 11.1.1)• Data storage/five years

SAMPLE SELECTION

• Obtained nursing education outside the U.S.• 1 male and 5 females• 23 to 65 years old• Currently practicing nurses in acute care

COUNTRIES OF ORIGIN

North America 2 = Canada

Asia 2 = Philippines

Africa1 = Ghana1 = Nigeria

N = 6

FIRST U.S. JOB SETTING

RESULTS

FINDINGS

• 83 Codes (Nodes)• 504 References• Five Major Interrelating Themes

INTERRELATING THEMES

• Socialization• Orientation Structure• Nursing Structure• Cultural Competence• Personal Growth

SOCIALIZATION

• Communication• Community• Difficulties• Financial• Language• Support

ORIENTATION STRUCTURE

• Accountability• Difficulties/Support• Patient Population• Nursing Practice• Orientation Process• Technology• Work Environment and Work Experience

NURSING STRUCTURE

• Hiring Process• Legal• New Employee Engagement• Professional Development• State of Nursing

CULTURAL COMPETENCE

• Countries of Origin• Community Resources• Diversity• Difficulties• Food • Language• Workplace Learning

PERSONAL GROWTH

• Educational Advancement• Leadership• Organizational Support • Professional Accountability

DISCUSSION OF FINDINGS

ONBOARDING COMPETENCIES

• Interview Data• Current Best Practices• Nursing Professional Development Standards

New Foreign-Educated Nurse (FEN)Competencies

Leadership Competencies

Organization Competencies

COMPETENCIES

FEN Competencies Leadership Competencies

Organizational Competencies

• Community Integration and Socialization at all levels.

• Community Introduction

• Collaboration with various ethnic groups

• Workplace Learner Socialization

• Religious Communities

• Define the structure for internal and external community integration

• Identify the main structure to support FENs

COMPETENCIES

FEN Competencies Leadership Competencies

Organizational Competencies

• Clinical Competencies Nursing practice

standards Language and

communication Medication Technology

• New Nurse Academy• Clinical Language

Proficiency• Medication

Management• Technology

Management• Nurse Practice Act

• Components of quality care in reported data

• Defined organizational Intention and Purpose

COMPETENCIES

FEN Competencies Leadership Competencies

Organizational Competencies

• Post-assessment Evaluation Advancement Extension Repeat

• Moving Up to Independent Practice

• Extension of the Orientation Period

• Change Specialty or Department

• Defined HR policies for actions to be taken

• Structure for Professional Advancement

SIGNIFICANCE OF THE PROJECT

Return on Investment on FENs Competency• Quality – better patient outcomes• Cost – efficient care delivery• Service – supports patient satisfaction

scores

SIGNIFICANCE TO NURSING PROFESSION

• Expansion of nursing knowledge• Literature, Presentations• Policy Development

• Leadership accountability• Patient-focused care

• Staff Competency• Safe, effective, and efficient care

RECOMMENDATIONS FOR FUTURE RESEARCH

• Through review of FEN onboarding competencies• Quantitative assessment of the effectiveness of competencies• Organizational and nursing structures to support FENs• Policy development• Preparation for internal migration

SUMMARY

• Historic nursing shortages cycles back• Imbalance between caregiver and patient care

demands• Caregiver competency• Effective transition process for FENs• Quality of care and public safety

Thank you. Ready for questions.

April,1992. Lobel’s departure day for the U.S. Ninoy Aquino International Airport, Philippines

REFERENCESAdeniran, R., Rich, V., Gonzalez, E., Peterson, C., Jost, S., & Gabriel, M. (2008, May 31). Transitioning internationally educated nurses for success: A model program. OJIN: The Online Journal of Issues in Nursing, 13(2).

Aiken, L., Buchan, J., Sochalski, B., Nichols, B., & Powell, M. (2004). Trends in international nurse migration: The world’s wealthy countries must be aware of how the “pull” of nurses from developing countries affect global health. Health Affairs, 23(3), 69-77. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=url,cookie,ip,uid&db=c8h&AN=2004192520&site=ehost-live&scope=site\

Bureau of Labor Statistics. (2014). Registered Nurses. Retrieved from http://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-1

CGFNS International. (2014). VisaScreen: Visa Credentials Assessment. Retrieved from http://www.cgfns.org/services/visascreen/

Cortes, P., & Pan, J. (2012, December). Relative quality of foreign nurses in the United States. In Fifth International Conference on Migration and Development , 28-29.

REFERENCES (CONT.)Department of Homeland Security. (1994). North American Free Trade Agreement. Retrieved from http://www.cbp.gov/trade/nafta

Department of Homeland Security. (2013). H-1C registered nurse working in a health professional shortage area as determined by the Department of Labor. Retrieved from

Ea, E. E. (2008). Facilitating acculturation of foreign-educated nurses. Online Journal of Issues in Nursing, 13(1), 5-5. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=url,cookie,ip,uid&db=c8h&AN=2009987699&site=ehost-live&scope=site

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health . Washington, D.C.: National Academies Press.

Meleis, A. I. (2010). Transitions Theory: Middle-range and situation-specific theories in nursing research and practice. New York: Springer Publishing Company.

Moran, K., Burson, R., & Conrad, D. (2014). The Doctor of Nursing Practice scholarly project: A framework for success. Burlington, MA: Jones & Bartlett Learning.

REFERENCES (CONT.)Nichols, B. L., Davis, C. R., Richardson, & D. R., (2010). International models of nursing. In The future of nursing: Leading change, advancing health (pp. 565-642). Washington, D.C.: The National Academies Press.

QRS International. (2015). What is qualitative research? Retrieved from http://www.qsrinternational.com/what-is-qualitative-research.aspx

Tregunno, D., Peters, S., Campbell, H., & Gordon, S. (2009). International nurse migration: U-turn for safe workplace transition. Nursing Inquiry, 16(3), 182-190. http://dx.doi.org/10.1111/j.1440-1800.2009.00448.x

U.S. Citizenship and Immigration Services. (2011). Visa retrogression. Retrieved from http://www.uscis.gov/green-card/green-card-processes-and-procedures/visa-availability-priority-dates/visa-retrogression

United States Department of Labor. (2013, December 19). Employment projections: Occupations with the most job growth. Retrieved from http://www.bls.gov/emp/ep_table_104.htm

Wheeler, R. M., Foster, J. W., & Hepburn, K. W. (2013). The experiences of internationally educated nurses in the southeastern United States of America. International Nursing Review, 60(3), 397-404.

REFERENCES (CONT.)Whelan, J. C. (2015). “Where did all the nurses go?”: Mid twentieth century nurse shortages, causes, solutions, and continuing problems. Retrieved from http://www.nursing.upenn.edu/nhhc/Pages/WhereDoAlltheNurseGoMid-TwentiethCenturyNurseShortagesCausesSolutionsandContinuingProblems.aspx

Witchell, L., & Ousch, A. (2002). Managing international recruits: Managing an adaptation programme for overseas registered nurses. Nursing Management - UK, 9(3), 10-14. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=url,cookie,ip,uid&db=c8h&AN=2002080756&site=ehost-live&scope=site

World Health Organization. (2010). User’s guide: The WHO global code of practice on the international recruitment of health personnel. Retrieved from http://whqlibdoc.who.int/hq/2010/WHO_HSS_HRH_HMR_2010.2_eng.pdf

Xu, Y., & He, F. (2012). Transition programs for internationally educated nurses: What can the United States learn from the United Kingdom, Australia, and Canada? Nursing Economic$, 30(4), 215-239.

Zizzo, K. A., & Xu, Y. (2009). Post-hire transition programs for international nurses: A systematic review. The Journal of Continuing Education in Nursing , 40(2), 57-64. http://dx.doi.org/10.3928/00220124-20090201-02