tomlinson.ua.edu 8/Responses/AmeliaDelosRey… · Web viewThis study addresses the issue of the lack of transition programs for internationally educated nurses (IENs) migrating to

Running head: TRANSITION PROGRAM FOR INTERNATIONALLY EDUCATED NURSES

Transition Program for Internationally Educated Nurses

In partial fulfillment of Comprehensive Examination

Amelia de los Reyes

The University of Alabama

May 17, 2017

TRANSITION PROGRAM FOR INTERNATIONALLY EDUCATED NURSES

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Transition Program for Internationally Educated Nurses

Abstract

This study addresses the issue of the lack of transition programs for internationally

educated nurses (IENs) migrating to the United States to join the U.S. nursing workforce to fill

vacant nursing positions. To address this problem, the purpose of this qualitative study is to

explore the experiences of internationally educated nurses with Nurse Residency Programs in

facilitating their transition related to socio-cultural differences, language barriers, and adaptation

to their new working environment. Transition programs can serve to bridge the practice gaps

between IENs previous and new experiences (Adeniran, Rich, Gonzalez, Peterson, Jost, Gabriel,

May, 31, 2008). To gather data, face to face interviews of eight internationally educated nurses

working in community hospitals located in the Southeastern part of the U.S. will be conducted.

The interview data will be transcribed and analyzed using the constant comparative method

(Glazer & Strauss, 1967). The themes emerging from the data analysis will be useful in

understanding the difficulties in transitioning to the U.S. nursing workforce experienced by

internationally educated nurses.

Introduction

Background and Significance

Nurses educated in other countries represent a vital part of the U.S. nursing workforce

(Giegerich, M. 2006). Nursing shortages impact not only the United States but also countries

around the world like Australia, Canada, and the United Kingdom (Withers & Snowball, 2003).

As a result, many health care agencies in the US and around the world are recruiting and hiring

nurses educated in other countries to fill the vacant positions. Increasing numbers of nurses are

migrating to the US because U.S. schools of nursing currently are unable to educate a sufficient


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number of healthcare professionals to care for the U.S. public (Cooper & Aiken, 2006). Despite

the increased utilization of foreign-educated nurses in the US, there is a lack of knowledge of

how these nurses transition into the US nursing workforce. Nursing has become a more

transferable career due to increased global communication and travel. Many Internationally

Educated Nurses (IENs) are drawn to the US due to opportunities available for increased pay,

better education, career advancement, and career development (Giegerich, M, 2006). The rate of

IENs entering the US workforce has been increasing faster than the rate of new nurses educated

in the US since 1998 (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004).

The US Department of Health and Human Services (2005), using a large probability

sample, reported that there were 2,909,467 nurses in the United States in March, 2004. Three and

half percent of registered nurses (RNs) received their education in another country, amounting to

100,800 nurses (US Department of Health and Human Services [DHHS], 2005). There were an

estimated 146,097 internationally educated RNs employed in the United States in 2008, 23.6% of

whom were licensed between 2004 and 2008 (U.S. Bureau of Health Professions, 2010).

According to the Bureau of Labor Statistics’ Employment Projections 2012-2022 released in

December, 2013, Registered Nurses (RN) is listed among the top occupations in terms of job

growth through 2022. The RN workforce is expected to grow from 2.71 million in 2012 to 3.24

million in 2022, an increase of 526,800 or 19%. The Bureau also projects the need for 525,000

replacement nurses in the workforce bringing the total number of job openings for nurses due to

growth and replacement to 1.05 million by 2022. Retrieved May 15, 2017 from

http://www.bls.gov/news.release/ecopro.t08.htm.

Literature Review


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As the demand for nurses and the utilization of foreign-trained nurses’ increases, it will

become progressively more important to have a thorough understanding of these processes and

outcomes faced by these individuals. Greater understanding will allow employers and nurses to

better assist the foreign-trained nurse. The transition challenges of IENs are not due to lack of

knowledge or clinical skills, but rather linked to socio-cultural differences, including the

structure of the health care systems, language subtleties such as the use of idioms, acronyms, and

abbreviations, and unfamiliarity with their new surroundings (Adeniran, Rich, Gonzales,

Peterson, Josh & Gabriel, 2008). IENs must adapt their clinical practice and communication

patterns to that of the new environment in order to successfully deliver safe and quality care to

patients. They must also familiarize themselves with the cultural nuances of the new practice and

geographic environment and ensure that their current national, state, and institutional policies

guide their professional practice (Adeniran, Rich, Gonzalez, Peterson, Josh & Gabriel, 2008).

Marginalization in the work place remains an issue of concern for IENs and health care

organizations (Baptiste, M. 2015).

Marginalization affects patient safety in two ways. First, the presence of perceived

marginalization by Internationally Educated Nurses (IENs) can potentially affect IENs self-

esteem, self-perception and the role function if he or she cannot cope with stress related to

discriminatory behaviors (Roy, 2009). Safe patient care requires group cohesion among nurses,

physicians, and health care team formed through mutual respect among colleagues. Workplace

environments in which behaviors cause isolation, exclusion, and in some cases hostility, results

in safety issues, resentment and job dissatisfaction. For IENs, the transition and adaptation

associated with integrating into the US nursing workforce is difficult, and more so for those who

perceive themselves as recipients of discriminatory behaviors by their nursing colleagues,


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physicians, and the health care team. The experience of marginalization is an additional

workplace stressor that requires effective coping and adaptation both to persevere and succeed

personally and professionally, and to limit adverse patient-related outcomes associated with job

dissatisfaction and nurse turnover. Recruitment of IENs is costly and nursing turnover causes

low staffing and low patient satisfaction. (Berry et al., 2012; Volpone & Avery, 2013).

When IENs are faced with what they perceive as inescapable and consistent expressions

of discrimination and marginalization in an environment in which they are not supported,

psychological withdrawal (e.g., disengagement and burnout) begins; this is often followed by

physical withdrawal, including tardiness, absenteeism, and deliberation regarding intention to

leave (the predecessor of actual turnover) (Berry et al., 2012; Volpone & Avery, 2013). When

nurses vacate their position, nursing units are often left short-staffed, sometimes with less-skilled

nurses in a given specialty area. Remaining staff may be burdened with increased workload, and

for some, the increased workload may also lead to psychological and eventually physical

withdrawal from their employer (Wheeler et al., 2014). While research regarding foreign-

educated nurses is limited in the US, there are many studies in the global nursing community that

address this subject (Baptiste, M. 2015).

Internationally Educated Nurses bring a variety of knowledge, skills and experience to

the new practice areas. Although the benefits of their knowledge, skills and experience can be

enhanced by successfully integrating them in the healthcare system of their new country, this

may be a challenging process (Adeniran, Rich, Gonzalez, Peterson, Jost & Gabriel, 2008). The

role of the nurse varies from culture to culture, particularly with regard to the delivery of patient

care and professional responsibilities. For example, it is common practice in China, Nigeria, and

the Philippines for the family, not the nurse, to assume the primary role in caring for the elderly


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in both the home and hospital setting (Matiti & Taylor, 2005; Taylor, 2005). This is not the case

in the UK and US, where the nurse has the primary role in caring for the elderly. Hence, IENs

are asked to assume a role that is not only contrary to their culture, but one they have not been

educated to perform. IENs also experience difficulty adjusting to their increased levels of

autonomy and responsibility nurses have in the UK and the US when compared to their native

country. IENs found they needed to develop new skills such as discharge planning and increased

involvement of the patient and family in the plan of care (Taylor, 2005). Because IENs differ

from US trained nurse demographically and within their roles in the workforce, the possibility of

not receiving the desired level of respect increases. Some IENs experienced alienation, racism,

sexism, and oppression (Di-Cicco-Bloom, 2004). In the UK and in the US, Taylor (2005) found

that IENs who were educated in a total of six countries felt their professional qualifications were

not respected. These nurses felt they were awarded positions lower than they were qualified for,

resulting in perceived need for the IENs to prove themselves to their colleagues to gain respect

and trust. Non-white or non-native English speaking nurses experienced more difficulty with

respect and discrimination (Taylor, 2005).

The US does not have standardized transition programs for IENs; rather each healthcare

organization develops its own education and transition program; Xu and He (2012) assert that the

US is the nation that employs the most IENs, but fails to recognize benefits of standardized IENs

transition programs. A survey of over 650 US nurse executives by David and Kritex (2003)

revealed common methods for assisting the IENs to adapt to his and her new environment. The

mentors and preceptors were by far the most common tools used, followed by a more extensive

orientation, clinical assessments, and English classes. Other tools used were cultural workshops

for the staff, an introduction to US healthcare, housing assistance, assertiveness training,


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computer and social training. These same executives reported that the most critical skill for IENs

is English competency. Use of US technology, knowledge of US nursing practice, US

medications, and clinical skills were also found to be critical by the executives which correlate to

their intervention (Davis & Kritek, 2003).

A review of literature underscores the need to develop transition programs to prepare

IENs to offer clinically and culturally safe and effective practice. The literature discusses the

opportunities and challenges presented by migrating nurses, as well as the moral and ethical

obligations of recruiting agencies and the healthcare organizations who hire IENs (Aiken,

Buchan, Sochalski, Nichols, & Powell, 2004; Bieski, 2007; Blakeney, 2006). Edwards and Davis

(2006) and Ryan (2003) have identified gaps between the IENs and U.S. educated nurses that

include use of technology, management of pain, performance assessments and nursing

procedures, and administration of medications. The identified gaps between the IENs’ previous

practice and U.S practices have implications that may affect the quality, safety, and costs of

healthcare services. It is important for IENs to quickly learn standard nursing practices in the US

and integrate these practices into the U.S. healthcare system. Society is only able to benefit fully

from migration when migration is accompanied by successful integration. Without integration,

migration gives rise to social issues that can disrupt a society (International Organization on

Migration, 2003).

Theoretical/Conceptual Framework

Roy’s Theoretical Framework

Roy’s Adaptation Model establishes that individuals attain holism, health, and well-being

by coping effectively with changes and challenges through adaptive behavior in an effort to

maintain social integrity. Social integrity is defined as the need to know who one is in relation to


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others so that one can act appropriately (Roy, 2009, p. 378). Social integrity is the foundation of

role function, the adaptive mode that focuses on an individual meeting the expectations of a

given role in society or in an organization (Roy, 2009). An individual fulfills his or her role

based on relationships with others. One’s role is the functioning unit of society. Age, gender, and

developmental stages determine an individual’s primary role (Roy, 2009).

According to Baptiste, M. (2015), discrimination against IENs remains a seldom-

explored topic in the United States. The literature describing experiences of IENs indicates that

some do experience workplace discrimination as an additional workplace stressor. IENs view

this discrimination as an obstacle to career advancement and professional recognition.

Consequences of workplace discrimination affect IENs physical and psychological well-being,

the quality of patient care, and healthcare organizational costs. In anticipation of future nursing

shortages, understanding and minimizing workplace discrimination will benefit nurses, patients,

and healthcare organizations. The author addresses motivation and challenges associated with

international nurse migration and immigration, relates these challenges to Roy’s theoretical

framework, describes workplace discrimination, and reviews both consequences of and evidence

for workplace discrimination. She considers the significance of this discrimination for healthcare

agencies, and approaches for decreasing stress for IENs during their transition process. She

concludes that workplace discrimination has a negative, multifaceted effect on both professional

nursing and healthcare organizations. Many researchers have written about the experiences of

IENs; however, few have written from the perspective that discrimination in the work

environment remains an issue of concern for IENs and healthcare organization (Baptiste, 2015).

Feminist Ethics of Caring


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This study will utilize feminist ethics of caring (Gilligan, 1982/1994). In Gilligan’s word

feminism is one of the great liberation movements in human history. It is the movement to free

everyone from the gender binary and the hierarchy of patriarchy in the interest of women and

men, and in the interest of love. It is a way of dealing with human conflicts other than through

the use of force and the imposition of hierarchy. Gilligan suggests that women use an ethic of

caring, and their morality was based around caring for others rather than appealing to some

universal code of behavior. It is a theory about what makes an action morally right or wrong. It

involves treating everyone fairly and equally, having respect for who you are and for what you

know, experiencing the freedom to express one’s ideas, freedom to make independent nursing

decisions, and freedom to participate in hospital-wide training in leadership and management.

Feminism maintains that women are oppressed and that systemic injustices based on gender must

be eliminated.

Generally, nurses experience discrimination and marginalization based on their gender,

race, age, sexuality, and physical disability. In nursing, discrimination and marginalization have

led to lower salaries, hostility from co-workers, physicians, managers and other health care teams

in the workplace, and unequal access to professional training programs and career advancement

opportunities (Minority Nurse Staff, March, 2013). For IENs, the transition and adaptation

associated with integrating into the U.S. nursing workforce is difficult, and more so for those

who perceive themselves as recipients of discriminatory behaviors which lead to experiences of

marginalization (Berry et al., 2012; Volpone & Avery, 2013).

Qualitative research often uses frameworks to provide guidance for a starting point in the

field, as a lens or perspective from which to view the world, and at times to assist with the

organization of data in a broad sense. Frameworks can be utilized in research in a number of


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ways, such as to guide the study, to assist with the organization of thought and inquiry, and to

help with data analysis (Creswell, 2009). Phenomenology serves a dual purpose as both a

philosophy and methodology. It frames a specific type qualitative inquiry useful for

understanding lived experiences.

Phenomenology seeks to describe the world as experienced by subjects (Kvale &

Brinkman, 2009, p. 26). Phenomenological inquiry is rooted in the lived experiences of humans.

As described by van Manen (1990) it is a study of the life world (p. 9). Humans living each day

experience phenomena within the world and have multiple understandings. The

phenomenological researcher is intrigued by humans and wants to understand fully who they are

and what life experiences mean to them. Taking on a phenomenological attitude involves

focusing and reflecting on the natural attitude and all the intentionalities that occur within it

(Sokolowski, 2000, p.42).

Humans express life experiences through language such as speaking and writing. This is

why interviewing participants is essential for the phenomenological researcher to gather data.

The science of phenomenology is, therefore, retrospective, because to study an experience it

must have already occurred. Phenomenology depends upon first-person accounts of experiences

(Roberts, 2013; Rossman & Rallis, 2012; Sokolowski, 2000). Participants revisit the experience

in their minds in order to dialog about what it meant to them (Randles, 2012). Phenomenology

guides the researcher to edify the personal insights of humans who are study participants (van

Manen, 1990). By using these theories as framework for this study, the lived experiences of

Internationally Educated Nurses can be thoroughly explored.


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Research Questions

1. How do Internationally Educated Nurses (IENs) describe their lived experiences as they

transition into the U.S. nursing workforce?

2. How do Internationally Educated Nurses (IENs) describe their lived experiences related to

gender, race, ethnicity, sexuality, and disability?

3. How do Internationally Educated Nurses (IENs) describe their lived experiences related to

marginalization in the workplace, adaptation to socio-cultural differences, and language barriers?

4. How do Internationally Educated Nurses (IENs) describe their lived experiences with their

new working environment? (See Appendix A for Interview Question)

The data and its analysis will seek to provide responses to these questions in order to

understand the phenomenon of the lived experiences of IENs transitioning into the U.S. nursing

workforce and inform the development of transition programs put in place in U.S. hospitals.

Methodology

A qualitative phenomenological methodology will be utilized to collect data on the lived

experiences of internationally educated nurses. The researcher selected phenomenology because

it will give the participants an opportunity to describe their individual lived experiences

regarding their transition into the US nursing workforce. Phenomenology is a powerful tool

when studying lived experiences and is appropriate for this study. The essence of

phenomenology is the description of lived experience. Realizing that experimental research is

not useful to studying human phenomena, Edmund Husserl wanted to develop a rigorous human

science that would assist researchers in learning about meanings of everyday experiences

(Roberts, 2013; Sokolowski, 2000). Originally developed as a philosophy by Husserl, and later

expanded upon by Martin Heidegger and others, phenomenology offers a way to study the life


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experiences of humans in a vivid and contextual way. The researcher chose phenomenological

methodology because it gives voice to human experience and therefore is appropriate to give

voice to IENs.

When investigating by means of a phenomenological study, the researcher is on a mission

to gather and analyze lived experience data in order to find and describe meaning. This allows

the researcher and others to become informed, enriched, and shaped by understanding the

essence of a phenomenon. Interviewing is the primary means of data collection for this study

because it will allow the researcher to explore and gather narrative data. To explore the nature of

the IENs transition to the US nursing workforce, firsthand accounts will be collected. Because

the IENs experienced this phenomenon, their accounts and perceptions are vital to exploration

and understanding. I will ask participants to share with the researcher any written artifacts related

to the lived experience such as diaries or notes discussing their journey.

Site and Participants

The researcher will conduct the research study in the community hospitals located in the

Southeastern part of the United States. One of the researcher’s primary responsibilities is to

always act in an ethical manner, which includes having an independent review committee review

the researcher’s proposed research study for its adherence to ethical standards (Sieber & Tolich,

2012). The researcher will follow the code of ethics and will abide by the rules and regulations of

The University of Alabama Institutional Review Board (IRB) and each community hospital’s

IRB. The eight participants in this study are all IENs working in the community hospitals, two of

which use Nurse Residency Programs for new graduates and for IENs.


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The IENs are not members of a vulnerable population and there is minimal risk for

them to participate in the study. It is the researcher’s responsibility to obtain the necessary

documentation before collecting data. The researcher needs to write letter of invitation and

provide information about the study and to explain why their involvement is very important if

they decide to take part in the study. The researcher will explain to the IENs that they are best

suited to speak about their lived experiences with marginalization and with their transition

process as a way of examining the effectiveness of the Nurse Residency Program. The researcher

will explain to each participant that participation is voluntary, they can decline to answer any

interview questions, and they can withdraw from the study at any time without negative

consequences by advising the researcher. The researcher will also inform the participants that

there will be no compensation included for participation. (See Appendix B for Ethical

Consideration, Appendix C for Letter of Invitation and Appendix D for names and descriptions

of each participant. The researcher used pseudonyms for each participant).

Data Collection

In qualitative phenomenology study, data collection involves conducting face to face

interviews with participants. Interviewing is a powerful and intimate way to collect subjective,

narrative data on experiences of others related to the phenomenon of interest. “The qualitative

research interview attempts to understand the world from the subject’s point of view, to unfold

the meaning of their experiences, to uncover their lived world prior to scientific explanations”

(Kvale & Brinkmann, 2009, p. 1). In qualitative inquiry the researcher is the instrument for data

collection (Creswell, 2009). I will explain to each participant that I will conduct face to face

interviews which will last at least one hour and it will take place in a mutually agreed upon

location. I will use guidelines in the form of an open-ended protocol for my questions so I can


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concentrate on listening to their answers and observe body movements. I will also ask

permission to use a tape-recorder or video camera during interview to facilitate the collection of

information. I will also ask permission if we can use Skype or video-conferencing if participants

move away during the course of the study. After the interview, I will transcribe data for analysis

to understand the participants’ meaning. I will ask each participant for permission to call on them

if a follow up interview is needed to clarify information obtained during the first interview and

possibly to obtain more information. I will share the data with each participant to obtain

feedback. I will ask participants to share with the researcher any written artifacts related to the

lived experience such as diaries or notes discussing their journey. Data will be securely stored in

an encrypted computer or jump drive and data can only be accessed by the researcher.

Data Analysis Procedure

The phenomenology research design is a highly integrated design in which data

collection and analysis are conducted simultaneously (Glazer & Strauss, 1967). The method of

analysis that will be employed in this study is the constant comparative method which is an

analytic procedure of constant comparison with an explicit coding system designed to develop

themes. Once certain techniques and strategies are introduce into the data analysis they will

continue to be performed throughout the process. As the analysis progresses there will be new

data continually being gathered by theoretical sampling and there will be new analytic tools and

strategies which will be introduced to analyze data. All the while this is going on there will be

previously introduced techniques and strategies that are continually working alongside. Finally,

the new strategies and tools will operate back and forth with recently acquired data as well as


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previously acquired data. By means of this method themes will emerged which will answer the

research questions.

The beginning stage of analysis is “open coding” which has the purpose of breaking data

into separate pieces. This will involve conceptualizing the data by labeling each segment with an

abstract title that will describe what the participants are communicating. These abstract labels are

called concepts. Once a significant number of concepts have been assembled the process of

“axial coding” will begin. Axial coding (Corbin & Strauss, 2008) involves sorting, synthesizing,

ordering, and relating the concepts to each other. The purpose of axial coding is to bring the

fractured data back together at the conceptual level and reassemble them into explanatory

segments which will develop themes that will answer the research questions.

The first step in axial coding will be to sort the concepts into higher level and lower level

concepts. Higher level concepts are designated as “categories” because they are prominent in the

data and have cohesive characteristics (Corbin & Strauss, 2008). Lower level concepts are

designated as “properties” because they combine to give explanation to the categories. The next

activity will be to dimensionalize the properties of each category which evaluate the properties

along a continuum of intensity and weakness (Goulding, 2002).

The second step in axial coding will be to relate categories with each other. This process

takes the data analysis to a higher level of abstraction and will be accomplished by a technique

designated as “relational mapping” (Clarke, 2005). Relational mapping graphically traces the

relationships which exist among the various categories that have emerged. This technique will

begin the process of identifying the nature of the relationships which exist among the categories.


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The third step of axial coding focuses upon contextual matters which influence the

participants’ marginalization. This part of the analysis situates the marginalization process within

its historical, social, and political environments. Two analytical tools will be use to satisfy this

objective. The first will be the “paradigm” which utilizes the questions “why,” “where.” “how,”

and “what happens” in order to determine the macro as well as the micro influences upon the

participants and their experience of marginalization. The second tool will be the “conditional

consequential matrix” (Corbin and Strauss, 2008). The matrix is a more rigorous tool than the

paradigm and relates micro conditions to the macro conditions in a way that reveals how the

situation shapes and influences the process of marginalization as it is experienced by the

participants (Goulding, 2002).

The fourth step in axial coding involves” process analysis” which defines the process of

marginalization and describes its nature as linear, non-linear, or chaotic (Corbin & Strauss,

2008). A further goal of this stage of axial coding will be to situate the process of

marginalization within its personal, historical, political, and social contexts which are established

and delineated in the previous step. Two analytical tools will be used to accomplish this goal. A

series of summary memos will be written with the purpose of identifying patterns within the data

further linking of categories. The product of this analytical procedure will be a conceptual

diagram which will describe the marginalization process, will situate it within its various

contexts, and will depict the patterns of categorical relationships.

The final step of axial coding will be the thematic integration which will unite all

categories into an organic whole and produce an analytical framework which will answer the

research questions. This step of data analysis will fulfill the goal of this phenomenology study


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which is to better understand the lived experiences of Internationally Educated Nurses and to

better understand their lived experiences related to socio-cultural differences, language barriers

and adaptation to their new working environment while transitioning to the U.S. nursing

workforce. (This section on data analysis has been adapted with permission from Webb, A. L.,

The factors which influence the transfer advising process of advisers in the Alabama transfer

advising corps: A grounded theory. Unpublished doctoral dissertation. The University of

Alabama (pp. 57-60).

Validity

One of the serious validity threats to my study is bias. I have experienced both

marginalization and difficulty adjusting to the socio-cultural differences and to the language

barriers where I worked as a newly hired IEN in 1973. I hope my experiences, values and

subjectivity will not interfere with the goals and validity of my study. I will make sure to be

cognizant of my behaviors, facial expressions, and body movements when I am asking questions

and especially when the participants are answering the questions. I will make sure not to interfere

or interject while the participant is answering questions. I should not give my opinion or argue

with a participant after providing answers. I will not challenge any of their answers. This is a

serious threat since the participant might start feeling intimidated and might start refusing to

answer questions or provide answers to please me. The worst scenario could be the participant

might withdraw from the study. Explaining my bias and how I will deal with these issues is an

important task to my research proposal. Fred Hess, a qualitative researcher stated that “validity in

qualitative research is not the result of indifference, but of integrity.” (Creswell, J.A. 2013).


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Another serious threat is confidentiality and participant fear that answers provided by the

participant will be shared with the hospital management team including the Nurse Residency

Program Coordinator. I will make sure to assure the participant that his/her name will not appear

in any reports or any data from the study and that all information given is confidential and will

be kept in a confidential location. I will tell each participant that only researchers that are

associated with the study will have access to the data.

Another serious threat will be the interview site. Most of the participants are from the

Philippines. Most IENs working in the community hospitals in the Southeastern part of the

United States are Filipino nurses. If the participant(s) choose to be interviewed at their own

home, the possibility of turning the interview session into social gathering will be greater. In the

Filipino culture, if you have visitor(s) coming to your house, the family members normally will

cook all kinds of food and desserts and likely, the whole family will entertain their visitor(s) to

show their hospitality and show that they welcome you to their house. The intended interview

might be interpreted by members of the family as part of the social gathering and this will surely

affect the validity of the data collected. Selecting a site for the interview in which the researcher

or the participant have an interest in the outcomes in not a good idea. It does not allow for

objectivity or full expression of multiple perspectives that is needed by qualitative research. This

requires that inquirers, especially in qualitative studies involving prolonged observation or

interviewing at a site be cognizant of their impact and minimize disruption of the physical setting

(Creswell, 2005, p. 96-97). Researcher and participant need to select a site where both are

comfortable and with few distractions.

Strategies that I will use to eliminate threats to validity are triangulation, member

checking and peer debriefing. I will triangulate different data sources of information by


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examining evidence from the sources and using it to build a coherent justification for the themes.

If themes are established based on converging several sources of data or perspective from

participants, then this process can be claimed as adding to the validity of the study (Creswell,

2014, p. 201). I will use member checking to determine the accuracy of the qualitative findings

through taking the final report or specific descriptions or themes back to participants and

determining whether these participants feel that they are accurate, the researcher takes back part

of the polished or semi-polished product, such as the major findings of the themes, the cultural

descriptions, and so forth. This procedure can involve conducting follow-up interviews with

participants in the study and providing an opportunity for them to comment on the findings

(Creswell, 2014 p. 202). I will consider using rich, thick description to convey the findings. This

description may transport readers to the setting and give the discussion an element of the shared

experiences. When qualitative researchers provide detailed descriptions of the setting and

individual participants without particular identifiers, for example, or offer many perspectives

about a theme, the results become more realistic and richer. Use of peer debriefing will enhance

the accuracy of the account. This process involves locating a person (a peer debriefer) who

reviews and ask questions about the qualitative study so that the account will resonate with

people other than the researcher. This strategy, involving an interpretation beyond the researcher

and invested in another person, adds validity to an account. I think using an external auditor to

review the entire project will provide an objective assessment of the project throughout the

process of research or at the conclusion of the study (Creswell, 2014 p. 202).

Conclusions


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Internationally Educated Nurses (IENs) are integral members of and

contributors to the U.S. healthcare systems. For IENs, the transition and

adaptation associated with integrating into the US nursing workforce is

difficult, and more so for those who experience themselves as recipients of

discriminatory and marginalized behaviors by their nursing colleagues,

physicians, and other countries that employs large numbers of IENs realize

the challenges associated with the transition and adaptation process. These

organizations have undertaken initiatives to ease the transition with the

hope of increasing IENs retention. Retention of IENs is paramount given the

organizational financial investment in each IEN (Osuji et al., 2014).

Some healthcare organizations are now developing programs to

support the transition of IENs to their new practice environments. Yet, these

transition programs differ across organization and there has been minimal

research to document that the desired outcomes of these programs are

being achieved. Initiating a national policy that would mandate healthcare

organizations to have transitional programs like the nurse residency program

requires an appreciation of the complexity of the problems and the answers

needed to support the creation of such programs. National, local

governmental agencies, professional groups, and organizational policy

makers, academia, and healthcare organizations need to sit at the table to

discuss how they can work together to create a positive environments for

IENs. If this is not done for any other reason, it should be done for ensuring


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the safety of those who receive nursing services from IENs. Specific groups

that need to sit at the table include: The American Nurses Association (ANA),

The International Center for Nurse Migration (ICNM), nurse researchers, and

academia, healthcare organizations, recruiting agencies, and internationally

educated nurses (Lin, 2014); Smith & Ho, 2014; Wolcott, Llamado & Mace,

2013; Xu & He, 2012).

The significance of the study is for healthcare organization to develop

an effective transition programs such as the Nurse Residency Program that

will support and facilitate IENs transition into the U.S. healthcare workforce

and to advocate for the development of a national policy to standardize

transition programs for IENs in the United States.

APPENDIX A

Interview Questions:


22

1. Tell me about the most significant experiences of your transition into the U.S. nursing

workforce?

2. Tell me if this is your first US employer? How long have you been at your present job?

3. The marginalization experiences you described, is it because you are from another

country or is it because of your gender, ethnicity, sexuality or disability?

4. Tell me how the marginalization experiences you described affected you in terms of your

self-esteem, self-perception, and job performance?

5. Tell me what support you received from your co-workers, managers or from hospital

administration?

6. Tell me about your initial nursing orientation program?

7. Tell me if a nurse residency programs could have helped you in your transition related to

socio-cultural differences?

8. Tell me if nurse residency programs could have helped you in your transition related to

language barriers?

9. Tell me if nurse residency programs could have helped you in your transition related to

adaptation to your new living and working environment?

APPENDIX B


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Ethical Considerations

In the August 1947 verdict, the judges included a section called Permissible Medical

Experiments. This section became known as the Nuremberg Code and was the first

international code of research ethics. This set of directives established the basic principles that

must be observed in order to satisfy moral, ethical, and legal concepts in the conduct of human

subject research. The Code has been the model for many professional and government codes

since the 1950s and has, in effect, served as the first international standard for the conduct of

research.

“To respect autonomy is to give weight to the autonomous person’s considered opinions and

choices while refraining from obstructing his or her actions.” (Belmont Report)

(http://phrp.nihtraining.com/history/04_history.php).

Given the importance of ethics for the conduct of research, it should come as no surprise

that many different professional associations, government agencies, and universities have

adopted specific codes, rules, and policies relating to research ethics (Resnik, 2015). Researchers

need to protect their research participants; develop a trust with them; promote the integrity of

research; guard against misconduct and impropriety that might reflect on their organizations or

institutions; and cope with new, challenging problems (Israel & Hay, 2006). Ethical issues in

research command increased attention today. The ethical considerations that need to be

anticipated are extensive and they are reflected through the research process (Creswell, 2014,

p.92).

Since I will be conducting a research study, one of my primary responsibilities is always

to act in an ethical manner, which includes having an independent review committee review my

research for its adherence to ethical standards (Sieber & Tolich, 2012). I need to adhere to the


24

code of ethics by using the ANA code of ethics and abiding by the rules and regulations of The

University of Alabama Institutional Review Board (IRB) and the community hospital IRB where

I will conduct most of my study. The population for my study will be the Internationally

Educated Nurses (IENs) working in a community hospitals. The IENs are not members of a

vulnerable population and there is minimal risk for them to participate in this study. It is my

responsibility to obtain necessary documentation before collecting data. I need to write my letter

of invitation and provide information about the study and why their involvement is very

important if they decide to take part in the study. After obtaining their consent, the participant

needs to know the purpose of the study, other participants who will be involve like the hospital

administrator, nurse managers and the Nurse Residency Program coordinator. I will explain to

the IENs why they are best suited to speak to the various issues such as perceived discrimination

and oppression in the workplace and how it affects their self-esteem, self-perception and work

performance and if they think Nurse Residency Program will be an effective facilitator in their

socio-cultural adaptation and transition to the US nursing workforce. The participant needs to

know that their participation is voluntary, that it will involve an interview which may last at least

one hour and it will take place in a mutually agreed upon location. They may decline to answer

any of the interview questions, they may decide to withdraw for the study at any time without

any negative consequences. I need to get the participant’s permission to use a tape-recorder

during interview sessions in order to collect information. After the interview I will transcribe

data for analysis. After the interview and after the data have been transcribed and analyzed, I will

send copies of the transcript to the participant to give her the opportunity to confirm the accuracy

of our conversation and to add or clarify any points which that participant wishes. I will tell the

participant that all information she provided is considered completely confidential and her/his


25

name will not appear in any report resulting from the study. Data collected from the study will be

retained for one year and will be saved in an encrypted computer laptop and jump drive for

privacy and security. The participant needs to know that only researchers associated with the

study will have access and that there is no known or anticipated risks to the participants in the

study. I need to share with participants that there is no payment or incentives for participation.

Some ethical issues which may come up could be related to participant sharing their

answers with other IENs participating in the study. Participants maybe hesitant to answer some

of the questions for fear that hospital administrators might find out that they are complaining or

reporting dissatisfaction with their job. Being an IEN myself, I might show bias or create bias

with participants and influence their answers. Making sure that participants are treated fairly. To

eliminate the participant’s fear, I will tell them repeatedly that all information that they share is

confidential, that their name will not appear on any results or on any data collected, that only

researchers have access to data and the data will be kept in locked cabinets, encrypted computers

and a jump drive. I will respect participants and attempt to build trust with them. To eliminate

bias, I need to be conscious and aware of my environment when I am asking questions and not

give my opinion about the questions being asked.

Other ethical issues that could possibly arise will be the selection of the interview site.

Some of the IENs might prefer to be interview outside the hospital and may feel comfortable at

their living space or a restaurant. The researcher might suggest a different location where she/he

is comfortable. Selecting a site to study in which the researcher has an interest in outcomes is not

a good idea. It does not allow for objectivity or for the full expression of multiple perspectives

which are needed by qualitative research. Researchers need to respect research sites so that they

are left undisturbed after a research study. This requires that inquirers, especially in qualitative


26

studies involving prolonged observation or interviewing at a site, be cognizant of their impact

and minimize disruption of the physical setting (Creswell, 2005, p. 96-97).

To summarize, it is very important for researchers to follow ethical codes in conducting a

study. Respect for human subjects is on top of the list, accuracy of data and reporting of data

honestly is important, and keeping everything secure and private to prevent someone from

accessing your data unnecessarily. The confidence of the participants and the public on the

researcher and in the results of the study needs to be protected.

APPENDIX C

Research Letter of Invitation

May 6, 2017

Dear Mrs. Minerva Samson:

This letter is an invitation to consider participating in a study that I am conducting as part

of my Doctoral degree in the College of Education at The University of Alabama under the

supervision of Dr. Nirmala Erevelles. I would like to provide you with more information about

this study and what your involvement would require if you decide to take part. Nursing shortages


27

impact every country around the world, including the United States (U.S.). As the nursing

shortage has become so severe, U.S. employers have been forced to look for new ways to

improve staffing, including recruiting and hiring of Internationally Educated Nurses (IENs) from

other countries. There is lack of understanding of how these nurses transition into the US nursing

workforce. The purpose of this study is to explore if Nurse Residency Programs will effectively

facilitate IENs socio-cultural adaptation and transition into U.S. nursing workforce.

This study will focus on the transition of IENs linked to socio-cultural differences,

including the structure of the health care systems; language barriers and unfamiliarity with their

new surroundings. Marginalization in the workplace remains an issue of concern for IENs and

healthcare organizations. You are one of many IENs who are presently working in the

community hospital You are best suited to the various issues, such as perceived discrimination of

IENs and how it affects your self-esteem, self-perception and work performance.

Participation in the study is voluntary. It will involve an interview of approximately one

hour in length which will take place in a mutually agreed upon location. You may decline to

answer any of the interview questions. You may decide to withdraw from this study at any time

without any negative consequences by telling the researcher. With your permission, the interview

will be tape-recorded or video-taped to facilitate collection of information, and later transcribed

for analysis. After the interview, I will send you a copy of the transcript to give you an

opportunity to confirm the accuracy of our conversation and to add or clarify any points that you

wish. All information you provide is considered completely confidential. There are no known or

anticipated risks to you as a participant in this study.

I am looking forward to speaking with you and thank you in advance for your assistance in the

study.


28

Sincerely.

Amelia E. Delos Reyes, RN, MSN Dr. Nirmala Erevelles

Student Researcher Research Chairman

College of Education College of Education

The University of Alabama The University of Alabama

APPENDIX D

Participants Profiles

Participants Textual DescriptionMina Mina is a 65 year old Filipino woman with

three sons. She is married. She holds a bachelor degr970s and she has worked in seven community hospitals. She started in the operating room, and then moved to medical-surgical units, critical care. She found her niche in psychiatry nursing.

Susan Susan is a 60 year old Filipino woman with one son and two daughters. She is married. She holds an associate degree in nursing. She came to the U.S. in 1973 and has worked in the same community hospital for 30 years. She works 3-11 in the surgical unit.

Leila Leila is a 62 year old Filipino woman with two daughters and two sons. She is married. She holds a bachelor degree in nursing. She


29

came to the U.S. in 1974 and has worked in several community hospitals. She sued one of the community hospitals for deleting her management position and a month later hiring someone to her position. She went back to school and obtained a Master’s Degree in nursing administration. She is now director of a long term facility.

Adel Adel is a 55 year old Filipino woman with one son. She is married. She came to the U.S. in 1975. She holds a Bachelor’s Degree in nursing. She has worked in a medical/surgical unit since she joined the community hospital. She was promoted to the 3-11 shift charge nurse. After three years in that position, she gave up her management position and went back as staff nurse is the same nursing unit.

Bella Bella is a 50 year old Filipino woman with two daughters and one son. She is married. She came to the U.S. in 1980. She holds a Bachelor’s Degree in nursing. She works in medical/surgical nursing as a staff nurse. She was posted in the pulmonary unit. After five years, she moved to the Resource Department where she works on nursing units that are short staffed.

Doris Doris is a 45 year old Filipino woman with two sons. She is married and she is related to Bella. She holds a Bachelor’s Degree in nursing. She came to the U.S. in 1982. She left her original employer located in North Carolina. She joined the community hospital and has been working in the 11-7 shift in the pulmonary unit since 1985.

Flo Flor is a40 year old Filipino woman with one daughter. She is married and she holds a Bachelor’s Degree in nursing. She came to the U.S. in 1995 and works in the community hospital. She started on the 3-11 shift, then was moved to the 7-3 shift. She worked initially in the critical care unit, then went to the float pool and she is now working in the in-patient dialysis unit.

Cleo Cleo is a 42 year old Filipino woman with two sons. She is divorced and she holds an


30

Associate’s Degree in nursing. She came to the U.S.in 2005. She joined the community hospital and is working the 3-11 or 11-7 shift in the labor and delivery room.

Note: These names are pseudonyms. All names are randomly assigned to protect the identity and confidentiality of the actual participants in the study.

References

Adeniran, R., Rich, V., Gonzalez, E., Peterson, C., Josh, S., Gabriel, M. (May 31, 2008)

Transitioning internationally educated nurses for success: A model program. OJIN:

The Online Journal of Issues in Nursing; Vol. 13 No.2 Manuscript 3

http://dx.doi.org/10.3912/OJIN.Vol13No02Man03

Aiken, L.H., Buchan, J., Sochalski, J., Nichols, B., & Powell, M. (2004). Trends in international

nurse migration. Health Affairs, 23(3), 69-77.

Alliance for Ethical International Recruitment Practices (2006). Retrieved on May 16, 2017

From http://www.fairinternationalrecruitment.org/index.php/the_code.

American Organization of Nurse Executives. (2005). Healthy work environments: Foreign nurse

recruitment best practices (Vol No.3). Philadelphia, PA: Author

Baptiste, M. (2015). Workplace discrimination: An additional stressor for internationally


31

educated nurses. The Online Journal of Issues in Nursing, 20(3), 1-15

Berry, C.M., Lelchook, A.M., & Clark, M.A. (2012). A meta-analysis of the interrelationships

Between employee lateness, absenteeism, and turnover: Implications for model of

withdrawal behavior. Journal of Organizational Behavior, 33(5), 678-699.

doi: 10.1002/job.778

Bieski, T. (2007). Foreign-educated nurses: An overview of migration and credentialing issues.

Nursing Economics$, 25(1), 20-23, 24.

Blakeney, B. (2006). International Nurses Migration Crisis or Opportunity Paper presented

at the NNA Meeting. Retrieved May 15, 2017 from

www.icn/triad/nna2006/Barbara_Blakeney.pdf

Clarke, A.E. (2005). Situational analysis: Grounded theory after the postmodern turn.

Thousand Oaks, CA: Sage Publications

Commission on Graduates of Foreign Nursing Schools. (2002). Characteristics of foreign nurse

graduates in the United States workforce, 2000-2001. Philadelphia, PA: Commission on

Graduates of Foreign Nursing Schools.

Cooper, R.A., & Aiken, L.H. (2006). Health Services Delivery: Reframing Policies for

Global Migration of Nurses and Physicians—a U.S. Perspective. Policy Politics Nursing

Practice, 7(3_suppl), 66S-70.

Corbin, J., & Strauss, A. (2008). Basics of qualitative research: Techniques and procedures

for developing grounded theory. (3rd Ed.). Los Angeles, CA: Sage Publications.

Creswell, J. W. (2009). Research design qualitative, quantitative, and mixed methods

approaches (3rd ed.) Thousand Oaks, CA: Sage Publications, Inc.

Davis, C. R. (2003). How to help international educated nurses adjust. Nursing 2003.


32

Retrieved February 1, 2017 from http://www.nursingcenter.com

Davis, C.R., & Nichols, B.L. (2003). How to help international nurses adjust. Nursing 2003.

Retrieved November 30, 2016 from http://www.nursingcenter.com

DiCicco-Bloom, B. (2004). The racial and gendered experiences of immigrant nurses from

Kerala, India. Journal of Transcultural Nursing. 15 (1), 26-33

Edwards, P.A., & Davis, C.R. (2006). Internationally educated nurses’ perceptions of their

clinical competence. The Journal of Continuing Education in Nursing, 37(6), 265-269.

Emanuel, E., Abdoler, E., & Stunkel, L. (n.d.). Research ethics: How to treat people who

participate in research. Retrieved from www.bioethics.nih.gov

Giegerich, M. (2006). A Survey of Foreign-Educated Nurses: Workplace Experience.

Honors Project. Paper 10. http://digitalcommons.iwu.edu/nursing_honpro/10

Gilligan, C. (1982/1993). In a different voice: Psychological theory and women’s

development. Cambridge, MA: Harvard University.

Glaser, B.G., & Strauss, A.L. (1967). The discovery of grounded theory: Strategies for

qualitative research. London: Aldine Transaction

Glesne, C. (2011). Becoming qualitative researchers an introduction (4th ed.). Boston, MA:

Pearson Education Inc.

Goulding, C. (2002). Grounded theory: A practical guide for management, business,

and market researchers. London: Sage Publications

International Council of Nurses. (2005). The migration of Nurses: Trends and Policies;

Geneva, Switzerland.

International Organization for Migration (2005). World migration: Costs and benefits of

international migration. Retrieved May 15, 2017 from


33

http://publications.iom.int/bookstore/free/wmr_2005.pdf

Jackson, A.Y., & Mazzei, L.A. (2012). Thinking with theory in qualitative research; viewing

data across multiple perspective. Routledge, New York, New York.

Johnstone, M. J., & Kanitsaki, O. (2009). The spectrum of ‘new racism’ and discrimination

in hospital contexts: A reappraisal. Collegian, 16(2), 63-69.

Kingma, M. (2006). Nurses on the move: Migration and the global health care economy.

New York: Cornell University Press.

Kvale, S., & Brinkmann, S. (2009). Interviews learning the craft of qualitative research

Interviewing (2nd ed.). Thousand Oaks, CA: Sage Publications.

Lin, L.C. (2014). Filipino nurses’ transition into the US hospital system. Journal of

Immigrant and Minority Health, 16(4), 682-688.

http://dx.doi.org/10.1007/s10903-013-9793-9

Matiti, M.R., & Taylor, D. (2005). The cultural lived experience of internationally recruited

nurse: A phenomenology study. Diversity in Health and Social Care, 2, 7-15.

Maxwell, J.A. (2013). Qualitative research design: An interactive approach (3rd ed.).

Thousand Oaks, CA: Sage Publication, Inc.

Minority Nurse Staff, (2013) Discrimination in Nursing. Retrieved May 15, 2017 from

www.minoritynurse.com

Moreci, J. T. (2012). Bias in the nursing workplace: Implications for Latino (a) nurses.

Journal of Cultural Diversity, 19(3), 94-101

National Council of State Boards of Nursing. (2012). Number of candidates taking NCLEX

Examination. National Council of State Boards of Nursing: Chicago, IL.

Retrieved on May 15, 2017 from https://www.ncsbn.org/1237.htm.


34

Osuji, J., Uzoka, F.M., Aladi, F., & El-Hussein, M. (2014). Understanding the factors that

determine registered nurses’ turnover intentions. Research and Theory in Nursing

Practice, 28(2), 140-161

Polit, D. F., & Beck, C. T. (2008). Nursing research generating and assessing evidence for

nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Protecting Human Research Participants

Retrieved from: http://phrp.nihtraining.com/quiz_review.php?id=4

Randles, C. (2012). Phenomenology: A review of literature. National Association for Music,

30(2), 11-12

Resnik, D. B. (2015). What is ethics in research & why is it important?

Http://www.niehs.nih.gov/research/resources/bioethics/whatis

Roberts, S. J. (1983). Oppressed group behavior: Implications for nursing. Advances in Nursing

Science, 5(4), 21-30.

Roberts, S.J., DeMarco, R., & Griffin, M. (2009). The effect of oppressed group behaviours on

the culture of the nursing workplace: a review of the evidence and interventions for

change. Journal of Nursing Management, Vol 17 (3), 288-293

Rossman, G.B., & Rallis, S.F. (2012). Learning in the field an introduction to qualitative

research (3rd ed.). Thousand Oaks, CA: Sage Publications, Inc.

Roy, C. (2009). The Roy adaptation model (3rd ed.). Upper Saddle River, NJ: Pearson.

Ryan, M. (2003). A buddy program for international nurses: Journal of Nursing

Administration, 33(6), 350-352.

Saldana, J. (2016). The coding manual for qualitative researchers. Thousand Oaks, CA:

Sage Publications, Inc.


35

Smith, C. D., & Ho, J. O. (2014). How to positively integrate internationally educated nurses.

Nurs Manage, 45(6), 30-36. http://dx.doi.org/10.1097/01.NUMA.0000449761.61253.a7

Sokolowski, R. (2000). Introduction to phenomenology. New York, NY: Cambridge University

Press.

Taylor, B. (2005). The experience of overseas nurses in the NHS. Results of a qualitative

Study. Diversity in Health and Social Care. 2, 17-27.

Tregunno, D. (2009). International nurse migration: U-turn for safe transition. Nursing Inquiry.

Vol. 16 (3), 182-190

Van Manen, M. (1990). Researching lived experience: Human science for an action sensitive

pedagogy. Albany, NT: State University of New York Press.

U.S. Department of Health and Human Services (2005). March 2004 preliminary findings: 2004

national sample survey of registered nurses No. 8) Washington, DC: US Department

of Health and Human Services Health Resource and Services Administration.

U.S. Department of Labor Bureau of Labor and Statistics (2013). Occupations with the largest

Predicted number of job openings due to growth and replacement needs, 2012 and

Projected 2022. Economic News Release. Retrieved May 16, 2017 from

http://bls.gov/news.release/ecopro.t08.htm

Volpone, S.D., & Avery, D.R. (2013). It’s self-defense: How perceived discrimination promotes

Employee withdrawal. Journal of Occupational Health Psychology, 18(4), 430-448.

doi: 10.1037/a0034016

Webb, A. L. (2016). So do you want to do a qualitative dissertation? Copyright Alan L. Webb

2016

Wheeler, R.M., Foster, J.W., & Hepburn, K.W. (2014). The experience of discrimination by US


36

and internationally educated nurses in hospital practice in the USA: a qualitative

study. Journal of Advanced Nursing, 70(2), 350-359. doi: 10.1111/jan.12197

Withers, J., & Snowball, J. (2003). Adaptation to a new culture: A study of the expectations

And experiences of Filipino nurses in Oxford Radcliffe Hospitals NHS Trust.

NT Research, 8, 278-290.

Xu, Y., & Kwak, C. (2005). Characteristics of internationally educated nurses in the United

States, Nursing Economics. 23 (5), 233-238

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

Economics, 30(4), 215-223, 239.


37

Documents

tomlinson.ua.edu 8/Responses/AmeliaDelosRey… · Web viewThis study addresses the issue of the lack of transition programs for internationally educated nurses (IENs) migrating to