Utilization of non-US educated nurses in US hospitals: implications for hospital mortality

A systematic review of typologies on aged care system components to facilitate complex comparisons

Objectives: Typologies are frequently utilised in analyses of the quality, funding, and efficiency of aged care systems. This review aims to provide a comprehensive resource identifying and critiquing existing aged care typologies. Methods: Systematic search of MEDLINE, Econlit, Google Scholar, greylit.org and Open Grey databases from inception to July 2020, including typologies of national, regional or provider aged care systems. Article screening, data extraction, and quality appraisal were conducted in duplicate. Results: 14 aged care typologies were identified; five applied to residential care, two to home care and seven to mixed settings; eight examined national systems and seven regional or provider systems. Five typologies classifying national financing or home care services, provider financing of staff and services and quality of residential care were considered high quality. The schematic provided summarises the focus area and aids in typology selection. Discussion: The aged care typologies identified cover a wide range of areas and contexts of aged care provision. This schematic, summary and critique will aid researchers, providers, and aged care policy makers to examine their own setting, compare it to other approaches to aged care provision and assist in identifying alternatives and important considerations, when undertaking aged care reform.

The Association between Nursing Skill Mix and Mortality for Adult Medical and Surgical Patients: Protocol for a Systematic Review

Skill mix refers to the number and educational experience of nurses working in clinical settings. Authors have used several measures to determine the skill mix, which includes nurse-to-patient ratio and the proportion of baccalaureate-prepared nurses. Observational studies have tested the association between nursing skill mix and patient outcomes (mortality). To date, this body of research has not been subject to systematic review or meta-analysis. The aim of this study is to systematically review and meta-analyse observational and experimental research that tests the association between nursing skill mix and patient mortality in medical and surgical settings. We will search four key electronic databases—MEDLINE [OVID], EMBASE [OVID], CINAHL [EBSCOhost], and ProQuest Central (five databases)—from inception. Title, abstract, and full-text screening will be undertaken independently by at least two researchers using COVIDENCE review management software. We will include studies where the authors report an association between nursing skill mix and outcomes in adult medical and surgical inpatients. Extracted data from included studies will consist measures of nursing skill mix and inpatient mortality outcomes. A meta-analysis will be undertaken if there are at least two studies with similar designs, exposures, and outcomes. The findings will inform future research and workforce planning in health systems internationally.

Are hospital nurse staffing practices associated with postoperative cardiac events and death? A systematic review

INTRODUCTION

Postoperative cardiac events are frequent complications of surgery, and their occurrence could be associated with suboptimal nurse staffing practices, but the existing evidence remains scattered. We systematically reviewed studies linking nurse staffing practices to postoperative cardiac events and two related outcomes, all-cause mortality and failure-to-rescue.

METHODS

A systematic search of the English/French literature was undertaken in the CINAHL, PsychInfo, and Medline databases. Studies were included if they: a) were published between 1996 and 2018; b) used a quantitative design; c) examined the association between at least one of seven staffing practices of interest (i.e., staffing levels, skill mix, work environment characteristics, levels of education and experience of the registered nurses, and overtime or temporary staff use) and postoperative cardiac events, mortality or failure-to-rescue; and d) were conducted among surgical patients. Data extraction, analysis, and synthesis, along with study methodological quality appraisal, were performed by two authors. High methodological heterogeneity precluded a formal meta-analysis.

RESULTS

Among 3,375 retrieved articles, 44 studies were included (39 cross-sectional, 3 longitudinal, 1 case-control, 1 interrupted time series). Existing evidence shows that higher nurse staffing levels, a higher proportion of registered nurses with an education at the baccalaureate degree level, and more supportive work environments are related to lower rates of both 30-day mortality and failure-to-rescue. Other staffing practices were less often studied and showed inconsistent associations with mortality or failure-to-rescue. Similarly, few studies (n = 10) examined the associations between nurse staffing practices and postoperative cardiac events and showed inconsistent results.

CONCLUSION

Higher nurse staffing levels, higher registered nurse education (baccalaureate degree level) and more supportive work environments were cross-sectionally associated with lower 30-day mortality and failure-to-rescue rates among surgical patients, but longitudinal studies are required to corroborate these associations. The existing evidence regarding postoperative cardiac events is limited, which warrants further investigation.

U.S. Hospital Employment of Foreign-Educated Nurses and Patient Experience: A Cross-Sectional Study

INTRODUCTION

For over half a century, hospitals in the United States have actively recruited foreign-educated nurses (FENs) in response to nurse shortages in hospitals and nursing homes. Little attention has been paid to the quality of care in the United States related to employment of FENs.

AIMS

The purpose of this retrospective study was to determine whether employment of FENs in U.S. hospitals is associated with patient care experience.

METHOD

This study used cross-sectional data from three sources in 425 hospitals in four large states to evaluate the relationship between patient perceptions of care and hospital employment of FENs. The study linked data from publicly reported patient experience of care surveys, nurse surveys, and administrative data using unique hospital identifiers common across the data sets.

RESULTS

Patient-reported care experience was found to be more negative in hospitals employing more FENs, after controls for other possible explanations. Each 10% increase in FENs was associated with a decrease in the percentage of patients who would recommend their hospital and a decrease in the percentage of patients giving favorable reports on five nursing-specific aspects of patient experience.

CONCLUSIONS

The results of this study suggest that employment of substantial numbers of nurses educated outside the United States may have implications for quality of care. The findings suggest that research on the outcomes of transition programs for FENs would be useful to inform regulatory policies.

Patient satisfaction and non-UK educated nurses: a cross-sectional observational study of English National Health Service Hospitals

OBJECTIVES

To examine whether patient satisfaction with nursing care in National Health Service (NHS) hospitals in England is associated with the proportion of non-UK educated nurses providing care.

DESIGN

Cross-sectional analysis using data from the 2010 NHS Adult Inpatient Survey merged with data from nurse and hospital administrator surveys. Logistic regression models with corrections for clustering were used to determine whether the proportions of non-UK educated nurses were significantly related to patient satisfaction before and after taking account of other hospital, nursing and patient characteristics.

SETTING

31 English NHS trusts.

PARTICIPANTS

12,506 patients 16 years of age and older with at least one overnight stay that completed a satisfaction survey; 2962 bedside care nurses who completed a nurse survey; and 31 NHS trusts.

MAIN OUTCOME MEASURE

Patient satisfaction.

RESULTS

The percentage of non-UK educated nurses providing bedside hospital care, which ranged from 1% to 52% of nurses, was significantly associated with patient satisfaction. After controlling for potential confounding factors, each 10-point increase in the percentage of non-UK educated nurses diminished the odds of patients reporting good or excellent care by 12% (OR=0.88), and decreased the odds of patients agreeing that they always had confidence and trust in nurses by 13% (OR=0.87). Other indicators of patient satisfaction also revealed lower satisfaction in hospitals with higher percentages of non-UK educated nurses.

CONCLUSIONS

Use of non-UK educated nurses in English NHS hospitals is associated with lower patient satisfaction. Importing nurses from abroad to substitute for domestically educated nurses may negatively impact quality of care.

Use of foreign-educated nurses and patient satisfaction in U.S. hospitals

PURPOSE

In the context of value-based purchasing, this study examines the association between the utilization of foreign-educated registered nurses (RNs) and patient satisfaction among U.S. acute care hospitals.

DATA SOURCES/STUDY SETTING

We utilized data from the Hospital Consumer Assessment of Healthcare Providers and Systems to measure patient satisfaction and data from the American Hospital Association regarding the utilization of foreign-educated RNs in 2012.

METHODOLOGY/APPROACH

In this study, a cross-sectional design with propensity score adjustment to examine the relationship between use of foreign-educated nurses and 10 patient satisfaction outcome measures. Control variables include hospital size, ownership, geographic location, teaching status, system membership, a high-technology index, and U.S. region based on census categories.

FINDINGS

The utilization of foreign-educated RNs was negatively and significantly related to six patient satisfaction measures. Specifically, hospitals with foreign-educated RNs scored, on average, lower on measures related to nurse communication (β = -0.649, p = .01), doctor's communication (β = -0.837, p ≤ .001), communication about administered drugs (β = -0.539, p = .81), and communication about what to do during their recovery at home (β = -0.571, p = .01). Moreover, hospitals utilizing foreign-educated RNs scored, on average, lower on overall satisfaction measures including rating the hospital as 9 or 10 overall (β = -1.20, p = .005), and patients would definitely recommend the hospital (β = -1.32, p = .006).

PRACTICE IMPLICATIONS

Utilization of foreign-educated RNs is negatively associated with measures of patient satisfaction pertaining to communication and overall perceptions of care. Hospitals that utilize foreign-educated RNs should consider strategies that enhance communication competency and aid improving perception of care among patients.

Foreign nurse importation and the supply of native nurses

The importation of foreign registered nurses has been used as a strategy to ease nursing shortages in the United States. The effectiveness of this policy depends critically on the long-run response of native nurses. We examine the effects of immigration of foreign-born registered nurses on the long-run employment and occupational choice of native nurses. Using a variety of empirical strategies that exploit the geographical distribution of immigrant nurses across US cities, we find evidence of large displacement effects - over a ten-year period, for every foreign nurse that migrates to a city, between 1 and 2 fewer native nurses are employed in the city. We find similar results using data on nursing board exam-takers at the state level - an increase in the flow of foreign nurses significantly reduces the number of natives sitting for licensure exams in more dependent states relative to less dependent states. Using data on self-reported workplace satisfaction among a sample of California nurses, we find suggestive evidence that part of the displacement effects could be driven by a decline in the perceived quality of the workplace environment.

The globalization of the nursing workforce: Pulling the pieces together

The "globalization" of health care creates an increasingly interconnected workforce spanning international boundaries, systems, structures, and processes to provide care to and improve the health of peoples around the world. Because nurses comprise a large sector of the global health workforce, they are called upon to provide a significant portion of nursing and health care and thus play an integral role in the global health care economy. To meet global health care needs, nurses often move within and among countries, creating challenges and opportunities for the profession, health care organizations, communities, and nations. Researchers, policy makers, and industry and academic leaders must, in turn, grapple with the impacts of globalization on the nursing and health care workforce. Through this special issue, several key areas for discussion are raised. Although far from exhaustive, our intent is to expand and stimulate intra- and interprofessional conversations raising awareness of the issues, uncover unanticipated consequences, and offer solutions for shaping the nursing and health care workforce of the future.

Immigration policy and internationally educated nurses in the United States: A brief history

Since the 1980s, U.S. policy makers have used immigration policy to influence the supply of nurses by allowing or restricting the entry of internationally educated nurses (IENs) into the U.S. workforce. The methods pursued have shifted over time from temporary visa categories in the 1980s and 1990s to permanent immigrant visas in the 2000s. The impact of policy measures adopted during nursing shortages has often been blunted by political and economic events, but the number and representation of IENs in the U.S. nursing workforce has increased substantially since the 1980s. Even as the United States seeks to increase domestic production of nurses, it remains a desirable destination for IENs and a target market for nurse-producing source countries. Hiring organizations and nurse leaders play a critical role in ensuring that the hiring and integration of IENs into U.S. health care organizations is constructive for nurses, source countries, and the U.S. health care system.