Thursday, September 26, 2013

Employing Substantial Numbers of Foreign Educated Nurses in U.S. Hospitals Raises Risks of Poor Patient Outcomes

New Study Shows More Deaths in U.S. Hospitals That Have Higher Percentages of Nurses Educated Abroad

For over 60 years, U.S. hospitals have employed non-US-educated nurses during nurse shortages to supplement their workforce.  Although recruitment of nurses from abroad is cyclical, many foreign-educated nurses that come to the U.S. in times of shortages end up staying.  Thus their presence in the U.S. nurse workforce is long-lasting.

Little is known about the impact of foreign educated nurses on quality of hospital care in the U.S.  The majority of foreign-educated nurses in the U.S. are from countries with transitional economies, such as the Philippines, where the health care system is substantially different from that of the U.S. Unlike requirements for foreign trained physicians who practice in the U.S., nurses are not required to complete any educational program in the U.S. if they pass the licensure exam, English speaking and comprehension exams, and provide evidence that their education is “equivalent” to that required of U.S. nurses.  However, nurses from countries with transitional economies have RN licensure exam pass rates significantly lower than that of US nursing school graduates and often take the exam multiple times.

While the demand for foreign educated nurses is low at this time, improvements in the national economy and increased demand for nurses resulting from expanded health insurance coverage from the Affordable Care Act may trigger a new cycle of hospital nurse recruitment from abroad.  Thus knowing more about the potential implications of importing foreign educated nurses now is important in nursing workforce planning for the future.

Researchers from the University of Pennsylvania’s (Penn’s) Center for Health Outcomes and Policy Research in the School of Nursing in collaboration with the University of Florida’s College of Nursing in Gainesville undertook a study to determine whether U.S. hospital employment of non-US-educated nurses is associated with higher mortality after common surgical procedures, and if so, under what circumstances. They found that in hospitals in which patient-to-nurse ratios were average (five patients per nurse) or worse, mortality and failure to rescue patients with complications is significantly higher when 25 percent or more nurses were educated outside the U.S.

The study, “Utilization of non-US educated nurses in US hospitals: implications for hospital mortality,” was published in June 2013 in the International Journal for Quality in Health Care. The study was funded by the National Institute of Nursing and RWJF.

This study of 665 hospitals directed by Penn’s Center for Health Outcomes and Policy Research is one of the largest ever undertaken of the potential quality of care impact of utilization of non-US educated nurses in US hospitals.  The senior author of the paper is University of Pennsylvania professor and director of the School of Nursing’s Center for Health Outcomes and Policy Research and Leonard Davis Institute of Health Economics senior fellow, Linda H Aiken, RN, PhD, FAAN.  Co-authors include Donna Neff, RN, PhD, Associate Professor, University of Florida College of Nursing, Jeannie Cimiotti, RN, PhD, FAAN, formerly from Penn and now Associate Professor at Rutgers University College of Nursing and Director of the New Jersey Collaborating Center for Nursing, and Douglas M. Sloane, PhD, Adjunct Professor of Nursing at Penn.

The study concludes that employing substantial numbers of non-US-educated nurses in U.S. hospitals is associated with significantly higher risk-adjusted 30 day from admission mortality and failure to rescue patients who experience complications after common general, orthopedic, and vascular surgery. Only when nurse staffing in hospitals is better than average, as when nurses care for four or fewer patients each, do we find no effect of foreign educated nurses on mortality. Only 37 percent of hospitals in the study had staffing ratios of four patients per nurse or less.  The effect of having more than 25 percent non-US-educated nurses becomes increasingly deleterious as patient-to-nurse ratios increased beyond 5:1. Thus, in practical terms, high proportions of non-US-educated nurses are a potential risk factor for excess mortality.

Recruiting nurses from countries with greater burdens of illness and fewer nurses than the U.S. has been criticized in terms of its potential adverse effect on global health.  This study suggests that it is not in the public’s interest in the U.S. to rely extensively on foreign educated nurses.

The findings suggest that the US should be largely reliant on its own domestic supply of nurses to prevent future nursing shortages which would require better national nurse workforce planning and policy intervention to balance domestic nurse supply and likely future demands for nurses.         

1 comment:

  1. Dr. Aiken and colleagues:
    Thank you for stepping/standing on one of the "third rails" in the delivery of nursing care in the U.S. As a now-retired nurse living in California, I am amazed that you have performed and published this politically incorrect, but very important, study. I look forward to being able to read this entire study. I have often reflected on both the risks and benefits of our importation of foreign-nurse graduates as I have worked with many over the years. However, I remember that a Filipina nurse once told me that she came to the U.S. for her nursing education because she recognized the differences in education and wanted to be able to provide nursing care with the same knowledge, skill, and socialization to the role that U.S. educated RNs did. It is different and the patients know it--they have told me many times!