Internationally Educated Nurses in U.S. Practice

1. Communication Barriers

Nursing is a highly personal endeavor. To truly understand patient needs, and to effectively treat patients, strong communication skills (verbal and nonverbal) are essential. While IENs are required to pass an English proficiency exam, subtle communication cues, slang terminology, and the use of acronyms can impair communication.

Dr. Padilla’s Communication Tips3
For IENs Ask questions and be proactive in learning about cross-cultural communication Politely ask the speaker to speak slowly when needed, and speak slowly and clearly yourself Read back messages to make sure you understood them correctly	For Team Members Keep word choice simple, avoid slang, and speak clearly and somewhat slowly Be patient, an active listener, and supportive. Don’t laugh or poke fun if they mispronounce or don’t understand common U.S. language Don’t make assumptions (this goes both ways). Clarify that you understood what they meant, and seek clarification from them to make sure they know what you meant

2. Culture

Starting a new job can be difficult, especially when that job is in a different country. Many IENs struggle with loneliness, homesickness, differences in foods and climate, and day-to-day tasks that we take for granted. Virtually everything in their work and home environments may be different.

Dr. Padilla’s Tips for Cultural Understanding3

From Established IENs for New IENs Familiarize yourself with where you want to live beforehand and be resilient. It will be difficult at first, so remember why you decided to make the move Learn the culture (you can take a cultural competency class) and learn how to get along with your co-workers. With that said, be yourself and don’t forget who you are Look for somebody from your home country to guide you, or who might have similar experiences to you. Meet people in your religious community

General Advice for IENs Connect with other IENs, especially those from your home country Learn how to drive in the U.S., as it is necessary to get to most places Research the culture, weather, geography, and other aspects of where you want to live Search for professional organizations or host communities that can help guide you Bring backup cash, as you may experience delays due to your new status

3. CARE Systems - Workplace Differences

The U.S. healthcare system is unique compared to other parts of the world. This presents a steep learning curve that Dr. Padilla explains using the acronym “CARE,” which is summarized as follows:³

• Clients: Client roles and rights
• Access: Barriers to treatment
• Roles & Responsibilities: Nurses' scope of practice
• Equipment: Tools and technology for clinical practice

Dr. Padilla’s Workplace Tips3
For IENs Be proactive by learning about common diseases, treatments, brand names, equipment, protocols, etc. Read about U.S. standards of nursing practice and the code of ethics for nurses Ask specific questions to your mentor, instructor, or a colleague Explore content created by professional nursing organizations (like the AACN)	For Team Members Be patient and accommodating, and learn a little bit about the IEN’s culture Be aware of cultural and workplace differences in the IEN’s home country Create a culturally sensitive educational program for transitioning IENs that focuses on improving patient safety competencies Uphold a healthy workplace environment

Bias in the workplace

A topic that Dr. Padilla does not address is bias in the workplace. Bias can be overt or subtle, but usually derives from preconceived notions associated with IENs. The most common is that IENs may not be as well educated as their U.S. counterparts, which may or may not be accurate depending upon the individual. Recognizing and acknowledging these preconceived attitudes ensures an environment that is free of bias and inclusive of IENs.

Transition Programs for IENs

To ease the transition to living and practicing in the U.S., a number of credential evaluation agencies, staffing agencies, universities, and healthcare providers have improved their recruitment and training programs.

Staffing Agencies

International staffing and recruiting agencies play a crucial role in helping IENs navigate nursing practice in the U.S. Some of the key ways they offer support include:

• Evaluation services: Assistance with CGFNS International education and experience evaluation 
• Visa and immigration assistance: Guidance to obtain a visa (e.g., H-1B or permanent resident documentation) to legally work in the U.S.
• Licensing exam preparation: Resources and support to prepare for the National Council Licensure Examination for Registered Nurses (NCLEX-RN).
• Job Placement: Employment based on skills and experience, visa sponsorship and location; also assistance with negotiating fair compensation and benefits 
• Orientation and mentorship: Onboarding programs and mentors to assist with transition to U.S. culture

Encourage IENs to thoroughly research and compare agencies that best align with their personal and professional goals.

Colleges and Universities

While international staffing and recruiting agencies play a crucial role in assisting IENs, nursing programs at colleges and universities can also offer valuable support:

• Bridge programs: Designed specifically for IENs, they bridge the gap between foreign education and U.S. nursing standards. They often include coursework, clinical experiences, and NCLEX preparation.
• RN-to-BSN programs: These programs facilitate the transition from an associate degree to a bachelor's degree in nursing, which benefits career advancement and leadership opportunities. 
• Scholarship and financial aid programs: Financial assistance can alleviate some of the burden associated with additional education and the licensure process.
• Collaboration with local healthcare systems: Partnerships with healthcare institutions often provide employment opportunities for IENs.

Nursing programs and healthcare institutions support IENs through successful licensure and entry into the U.S. nursing workforce.

Healthcare Providers

Healthcare providers play an important role in welcoming and supporting IENs to practice in the U.S. Post licensure, healthcare providers may deliver support through:

• Mentorship programs: Pairing IENs with experienced nurses provides valuable guidance and support as they navigate cultural nuances and the U.S. healthcare system.
• Culturally sensitive onboarding and orientation: Addressing the specific needs of IENs, including cultural differences and language barriers is essential. This may involve providing translators and cultural sensitivity training for staff.
• Ongoing professional development: Continuing education opportunities focused on U.S. healthcare regulations, specific specialties, and cultural competence help IENs stay up to date and expand their knowledge base.
• Support groups and networking opportunities: Support groups and networking events give IENs an opportunity to connect with colleagues, share experiences, and build a community.

Through sufficient onboarding and professional support programs, healthcare providers can ease the transition of IENs into a new environment and build stronger teams.

The Research on Transition Programs

The results of transition programs for IENs have been promising. This was shown in a 2022 study4 that sought to learn how useful transition programs could be in acculturating IENs to the U.S. IENs who completed the 5-week clinical and cultural transitions program, and received the program’s migration logistical support, were evaluated by nurse leaders after their first 90 days on the job. Overall results were positive, showing that transition programs paired with ongoing support can facilitate the growth of IENs as effective care providers and streamline their pathway to licensure.

This depends on your years of experience. In our case, because we were nurses for over ten years, we were required to be trained for one month only. I would say it really helped since our senior nurses were really accommodating, helpful, understanding, and patient with our learning adjustments.” Leona O, an IEN from the Philippines

Transition programs allow nurse educators and decision-makers at all levels to mitigate the challenges of integrating IENs into their teams. But the research doesn’t stop here.

Another literature review⁶ explored education strategies to support internationally educated registered nursing students with English as a second language in Canada. Once again, challenges related to communication and cultural differences were identified (as well as critical-thinking skills). To address them and build better bridge education programs, the authors suggested incorporating evolving case studies, simulation and role-play, and practice performing multiple-choice tests.

NCLEX-Prep Resources like UWorld Nursing

Limited research exists on how international nursing students (INS) adapt to U.S. educational systems and how IENs transition to U.S. practice. However, there's growing evidence that resources similar to UWorld can be beneficial.

• Our question banks (QBanks) incorporate evolving case studies and practice questions designed to mimic the National Council Licensure Examination (NCLEX-RN®) format, demonstrably improving student performance.⁶
• A similar trend was observed in a cross-sectional survey of Canadian-bound IENs.7 This study found that professional experience combined with guided study resources significantly predicted success on first-attempt licensure exams.

Our QBanks specifically address this need by offering NCLEX-style questions and detailed explanations authored by practicing nurse educators. Internal data suggests that this evidence-based approach using NCLEX-style content enhances students' clinical understanding.