Are foreign nurses culturally prepared to work in the U.S.?

Why do we need cultural training for foreign nurses, or for that matter, for other health care professionals coming to the United States?

As an immigrant to the U.S. and as a nurse of over twenty years, I know from experience that culture is a resource but it is also a barrier, not only in our personal, and social, but also in our professional lives.

Much research on cross-cultural training and acculturation come from multinational corporations who understand the business impact of poor cultural preparation and acculturation of expatriates and inpatriates. Research shows that failure to adjust in international settings is costly not only because of the relocation expenses of expatriates and their families, but also in terms of lower productivity, poorer relationship with the host country, mistakes in negotiation practices, and poor business outcomes.

Unfortunately, there is not much information on the acculturation issues of foreign nurses in the U.S. Nurses are the frontline workers in health care. They have the most impact on the care of their clients. With the current shortage of nurses in the U.S., health care facilities continue to recruit nurses from overseas, particularly from the Philippines, China, Canada, and increasingly from India and Africa. There is general agreement that with the rapidly changing demographics in the U.S, our current health care workforce is not culturally competent to care for these diverse clients in a way that respects and considers their cultural backgrounds. It is not fair for the clients and for the incoming nurses, to expect them to practice culturally competent care in their new environment without preparation and training.

National indicators for the need for cultural training:

National Institute of Health has published standards for Culturally and Linguistically Appropriate Services.
The Joint Commission for Accreditation of Healthcare Organizations requires documentation that linguistic and cultural issues are addressed.
The American Nurses Association has maintained that cultural competency requires more than cultural sensitivity and cultural awareness to specific knowledge and skills to care for a culturally diverse clientele.
Incorporation of cultural competency in medical schools is an accreditation requirement.
Providers and stakeholders are increasingly interested in the delivery of culturally responsive services.
Legal implications of inability to provide culturally competent care.

Professional indicators for the need for cultural training:

Moving to a new culture is a time of intense learning and adjustment. Culture shock has been used to describe the stress that accompanies the acculturation process. Culture shock is the affective, cognitive and behavioral human response to a foreign environment. Research has shown that the additive stress that accompanies cultural shock affects personal, social and job performance. Ultimately, it affects patient care in the work setting.

A multicultural work team requires knowledge and skills in cross-cultural management. Are the managers equipped to provide the motivation, support and leadership to manage multicultural workers? Are the employees aware of the dynamics that affect cultural differences? It is a myth that only the foreign nurses need cultural training. Teamwork requires cross-cultural communication skills of all workers in the organization.

The professional imperative. Madeleine Leininger, the nurse theorist, said that it is every patient's right to have his or her rights to culturally appropriate care respected and upheld.

All RNs who practice in the U.S. have to pass the minimum requirements for practice, the NCLEX exam. Foreign nurses, in addition, have to pass screening exams such as the CGFNS and TOEFL. Most of the foreign nurses have educational nursing curriculum that is based on the U.S. model. However, foreign nurses who are not familiar with the cultural diversity of this country are not prepared to provide culturally congruent care. Cultural knowledge is integral to prudent professional practice.

The ethical imperative. Without cultural awareness, without cultural knowledge and without cross-cultural skills, a healthcare professional is not able to properly provide for the dignity of the person that is consistent with the essence of professional nursing.

Health care organizations that employ foreign health care professionals need to ensure that they provide their new employees with cultural knowledge and preparation. U.S. companies that offshore business processing operations to other countries provide cultural training to call-center employees and even to tax preparers so they can relate better to their American customers. How much cultural training do foreign health care workers receive? In addition, acculturation of foreign employees has to be addressed as a stress factor that impacts productivity and performance. Employers need to provide acculturation support as part of the employee benefits system.

Clients, patients, and the community need to question and demand that health care practitioners have to be culturally knowledgeable, not just technically competent. Research has shown that cultural ignorance contributes to increased health care cost and potentially harmful mistakes.

Foreign health care workers need to be accountable for their own training and education in culturally competent professional nursing. Although caring is a universal value in nursing, the practice of nursing is culture-bound. There are differences in the caring beliefs, values, and practices between clients and care-givers that are accentuated when the practitioners come from different cultures. In order to properly respect the dignity of the person, it is imperative that nurses practice culturally congruent care. Do your part in order to survive, thrive, and excel in this new environment.

"Globalization has changed us into a company that searches the world, not just to sell or to source, but to find intellectual capital - the world's best talents and greatest ideas."
--Jack Welch

Foreign educated nurse survey
Survey for foreign nurses working in the U.S.