Surviving the employment gap: a cross-sectional survey of internationally educated nurses.

AIM: To examine the extent to which the type of financial assistance (personal resources, social programmes and earnings) and source country influence the length of time for internationally educated nurses to secure employment as regulated nurses in Canada. BACKGROUND: Internationally educated nurses must professionally recertify in order to work as regulated nurses in Canada. For many, it can be a lengthy, cumbersome and costly process that delays employment, while others recertify and secure employment quickly. Financial assistance in the form of personal resources, or from social programmes or earnings from working could contribute to the length of time to recertify. When internationally educated nurses cannot readily recertify, they turn to survival jobs where they can remain and never practice their profession in Canada or leave the country to work in jurisdictions where it easier to obtain professional credentials. METHODS: Data were collected via cross-sectional survey of internationally educated nurses (n = 1186) who were immigrants, permanent residents and employed as regulated nurses. Multiple linear regression was employed to examine the influence of the type of financial assistance (personal resources, social programmes and earnings) and source country on time to regulated nurse employment. RESULTS: Regression model explained 9.3% of variance in time to regulated nurse employment. Three predictors were statistically significant: source country, social programmes and earnings. Personal resources was not a significant predictor. CONCLUSION: Financial assistance helps internationally educated nurses survive the regulated nurse employment gap. The type of financial assistance and source country influences the length of time to regulated nurse employment. IMPLICATION FOR NURSING AND SOCIAL POLICY: Provides initial evidence to support the development of policies, and educational and social programmes to assist internationally educated nurses with financially surviving the gap in regulated nurse employment.

Correlates of career satisfaction in internationally educated nurses: A cross-sectional survey-based study.

BACKGROUND: More and more high-income countries hire internationally educated nurses as part of their workforce. While the factors that push and pull internationally educated nurses to migrate and influence their workforce integration have been widely reported in the literature, little is known about internationally educated nurses' career development and whether they are satisfied with their nursing career in Canada. OBJECTIVE: This study aims to identify the main correlates of internationally educated nurses' career satisfaction. METHODS: A cross-sectional analysis of data from a pan-Canadian survey sample of 1,951 internationally educated nurses, including registered nurses, licensed practical nurses and registered psychiatric nurses, was conducted. Measures of career satisfaction included individual, job and career characteristics as well as organizational-related and integration process factors. Non-parametric Mann-Whitney U and Spearman rank correlation tests were used to examine the association of the various factors with career satisfaction. RESULTS: Overall, internationally educated nurses showed a high degree of career satisfaction. At the same time, career satisfaction varied greatly depending on sociodemographic characteristics, organizational setting, and geographic location. Older and more experienced internationally educated nurses tended to be more satisfied with their career than their younger or less experienced colleagues were. Furthermore, male were inclined to be less satisfied than their female counterparts, and having children tended to make all three groups (men, women and overall) more satisfied. The higher the level of education prior to immigrating the lower the career satisfaction. Internationally educated nurses who identified as White or Asian had the highest level of career satisfaction, whereas those who identified as Black tended to be the least satisfied. Career satisfaction was the highest among those who live in the Prairie Provinces (Alberta, Saskatchewan and Manitoba), and Ontario, the lowest in the Atlantic Provinces (New Brunswick, Nova Scotia, Prince Edward Island, Newfoundland and Labrador). As for organizational characteristics, full-time nurses were more satisfied than those working part-time or with occasional employment. Finally, internationally educated nurses who thought they had achieved their career goals were more satisfied, while those who experienced discrimination were less satisfied with their career. CONCLUSION: Our findings highlight the need for organizations to ensure a healthy work environment for internationally educated nurses, free of discrimination, where they can attain their career goals. Tweetable abstract: More and more countries rely on internationally educated nurses to ease their nursing shortages. This study aims to identify the main correlates of internationally educated nurses' career satisfaction, using non-parametric Mann-Whitney U and Spearman rank correlation tests on data from a pan-Canadian survey sample of 1,951 internationally educated nurses, including registered nurses, licensed practical nurses and registered psychiatric nurses. Overall, internationally educated nurses showed a high degree of career satisfaction. At the same time, career satisfaction varied greatly depending on the internationally educated nurses' sociodemographic characteristics, organizational settings and geographic location. Finally, internationally educated nurses who thought they had achieved their career goals were more satisfied, while those who experienced discrimination were less satisfied with their career. Our findings highlight the need for organizations to ensure environment free of discrimination, where internationally educated nurses can attain their career goals.

Does Being a Visible Minority Matter? Predictors of Internationally Educated Nurses' Workplace Integration.

STUDY BACKGROUND: Nurses continue to migrate to Canada. Majority are visible minorities. Once employed, internationally educated nurses can struggle to integrate into their workplaces. A comprehensive understanding of factors that support internationally educated nurses' workplace integration is lacking, limiting our ability to design appropriate policies and practices. PURPOSE: The aim is to (1) examine internationally educated nurses' perceptions of the extent to which they have integrated in their workplaces and the individual and contextual factors that supported their workplace integration, (2) explore whether internationally educated nurses' perceptions differed by visible minority status, and (3) identify the key factors that predict internationally educated nurses' workplace integration. METHODS: Cross-sectional survey of 1215 internationally educated nurses. All were immigrants, permanent residents, and employed as regulated nurses. Multiple linear regression was used to examine the influence of individual and contextual factors on perceived degree of workplace integration. RESULTS: Visible minority status had a large, statistically significant negative association with workplace integration (ß = -0.236, p < .001). Good relationships with coworkers (ß =0.043, p < .005), and continuing to develop nursing knowledge and skills (ß =0.178, p < .003), had statistically significant, positive associations with workplace integration. CONCLUSIONS: Internationally educated nurses' visible minority status can influence their workplaces. Providing education, managerial support, and mentorship fosters internationally educated nurses' workplace integration.

Mapping the peer-reviewed literature on accommodating nurses' return to work after leaves of absence for mental health issues: a scoping review.

BACKGROUND: The complexity of nursing practice increases the risk of nurses suffering from mental health issues, such as substance use disorders, anxiety, burnout, depression, and posttraumatic stress disorder (PTSD). These mental health issues can potentially lead to nurses taking leaves of absence and may require accommodations for their return to work. The purpose of this review was to map key themes in the peer-reviewed literature about accommodations for nurses' return to work following leaves of absence for mental health issues. METHODS: A six-step methodological framework for scoping reviews was used to summarize the amount, types, sources, and distribution of the literature. The academic literature was searched through nine electronic databases. Electronic charts were used to extract code and collate the data. Findings were derived inductively and summarized thematically and numerically. RESULTS: Academic literature is scarce regarding interventions for nurses' return to work following leaves of absence for mental health issues, and most focused on substance use concerns. Search of the peer-reviewed literature yielded only six records. The records were primarily quantitative studies (n = 4, 68%), published between 1997 and 2018, and originated in the United States (n = 6, 100%). The qualitative thematic findings addressed three major themes: alternative to discipline programs (ADPs), peer support, and return to work policies, procedures, and practices. CONCLUSIONS: While the literature supports alternative to discipline programs as a primary accommodation supporting return to work of nurses, more on the effectiveness of such programs is required. Empirical evidence is necessary to develop, maintain, and refine much needed return to work accommodations for nurses after leaves of absence for mental health issues.

What Do We Know and Not Know about the Professional Integration of International Medical Graduates (IMGs) in Canada?

BACKGROUND: The literature on international medical graduates (IMGs) in Canada is growing, but there is a lack of systematic analysis of the literature. OBJECTIVES: To examine (1) the major themes in academic and grey literature pertaining to professional integration of IMGs in Canada; and (2) the gaps in our knowledge on integration of IMGs. METHODS: This paper is based on the scoping review of academic and grey literature published during 2001-2013 about IMGs in Canada. RESULTS: The literature on IMGs focuses on (1) pre-immigration activities; (2) early-arrival activities; (3) credential recognition/professional recertification; (4) bridging and residency training; (5) workplace integration; and (6) alternative paths to integration. The gaps in the literature include pre-immigration and early-arrival activities, and alternative paths for integration for those IMGs who do not pursue medical license. CONCLUSION: Pre-immigration and early-arrival activities and alternative career paths for IMGs should be addressed in academic and policy research.

Internationally educated nurses in Canada: predictors of workforce integration.

BACKGROUND: Global trends in migration accompanied with recent changes to the immigrant selection process may have influenced the demographic and human capital characteristics of internationally educated nurses (IENs) in Canada and in turn the assistance required to facilitate their workforce integration. This study aimed to describe the demographic and human capital profile of IENs in Canada, to explore recent changes to the profile, and to identify predictors of IENs' workforce integration. METHODS: A cross-sectional, descriptive, correlational survey design was used. Eligible IENs were immigrants, registered and employed as regulated nurses in Canada. Data were collected in 2014 via online and paper questionnaires. Descriptive statistics were used to examine the data by year of immigration. Logistic regression modeling was employed to identify predictors of IENs' workforce integration measured as passing the licensure exam to acquire professional recertification and securing employment. RESULTS: The sample consisted of 2280 IENs, representative of all Canadian provincial jurisdictions. Since changes to the immigrant selection process in 2002, the IEN population in Canada has become more racially diverse with greater numbers emigrating from developing countries. Recent arrivals (after 2002) had high levels of human capital (knowledge, professional experience, language proficiency). Some, but not all, benefited from the formal and informal assistance available to facilitate their workforce integration. Professional experience and help studying significantly predicted if IENs passed the licensure exam on their first attempt. Bridging program participation and assistance from social networks in Canada were significant predictors if IENs had difficulty securing employment. CONCLUSIONS: Nurses will continue to migrate from a wide variety of countries throughout the world that have dissimilar nursing education and health systems. Thus, IENs are not a homogenous group, and a "one size fits all" model may not be effective for facilitating their professional recertification and employment in the destination country. Canada, as well as other countries, could consider using a case management approach to develop and tailor education and forms of assistance to meet the individual needs of IENs. Using technology to reach IENs who have not yet immigrated or have settled outside of urban centers are other potential strategies that may facilitate their timely entrance into the destination countries' nursing workforce.

Partners in research: building academic-practice partnerships to educate and mentor advanced practice nurses.

RATIONALE: Clinical practice is the primary focus of advanced practice nursing (APN) roles. However, with unprecedented needs for health care reform and quality improvement (QI), health care administrators are seeking new ways to utilize all dimensions of APN expertise, especially related to research and evidence-based practice. International studies reveal research as the most underdeveloped and underutilized aspect of these roles. AIMS: To improve patient care by strengthening the capacity of advanced practice nurses to integrate research and evidence-based practice activities into their day-to-day practice. METHODS: An academic-practice partnership was created among hospital-based advanced practice nurses, nurse administrators, and APN researchers to create an innovative approach to educate and mentor advanced practice nurses in conducting point-of-care research, QI, or evidence-based practice projects to improve patient, provider, and/or system outcomes. A practice-based research course was delivered to 2 cohorts of advanced practice nurses using a range of teaching strategies including 1-to-1 academic mentorship. All participants completed self-report surveys before and after course delivery. RESULTS: Through participation in this initiative, advanced practice nurses enhanced their knowledge, skills, and confidence in the design, implementation, and/or evaluation of research, QI, and evidence-based practice activities. CONCLUSION: Evaluation of this initiative provides evidence of the acceptability and feasibility of academic-practice partnerships to educate and mentor point-of-care providers on how to lead, implement, and integrate research, QI and evidence-based activities into their practices.

Scoping review about the professional integration of internationally educated health professionals.

BACKGROUND: Over the last decade, Canada has been one of the top destination countries for internationally educated health professionals (IEHPs). After arrival, many struggle to professionally recertify and secure employment in their field. Considerable funding has been allocated to the development of new policies and programs to facilitate IEHPs' professional integration. Literature about the professional integration process and the available policies and programs is abundant, not synthesized and dispersed among a wide range of health professions and the academic and grey literature. This, in combination with the sustained policy relevance, contributed to the timeliness and necessity for conducting this scoping review. METHODS: We used an updated version of Arskey and O'Malley's six-stage scoping review framework to summarize the amount, types, sources and distribution of the literature. Findings were summarized numerically and thematically. The themes included pre-immigration activities and programs, early arrival activities and programs, professional recertification and workplace integration. RESULTS: Four hundred and seven published sources from 2000-2012 were retained for data charting and extraction. Most focused on international medical graduates or internationally educated nurses. IEHPs from the allied health professions were underrepresented. Methodologically, about one quarter of the papers are empirical studies with the next largest category being reports from professional certification bodies and educational institutions. The overarching concern is with workplace integration, professional recognition and bridging programs. Nursing dominates the literature about pre-immigration activities and programs whereas the literature about early arrival activities and programs, professional recertification and workplace integration is dominated by medicine. Although the literature does contain some information for IEHPs in the allied health professions, the thematic analysis did not identify a clear trend. A notable increase in the number of publications was present. CONCLUSIONS: The literature about IEHPs' professional integration in Canada is abundant. This reflects the sustained policy relevance of the recruitment, recognition and professional integration for IEHPs in Canada. This demonstrates that Canada provides an excellent case for this review from which the findings may have international significance. Nevertheless, little information is available about the effectiveness of the policies and programs available to facilitate IEHP integration, an area that requires further consideration.

Nurses' Perceptions of Interventions for the Management of Patient-Oriented Outcomes: A Key Factor for Evidence-Based Practice.

BACKGROUND: Various barriers and facilitators to implementing evidence-based interventions in practice have been acknowledged. Nurses' perspectives on these interventions were overlooked as potential factors that influence their uptake in practice. The purpose of this study was to explore nurses' perception of evidence-based interventions targeting patient-oriented outcomes. METHODS: A mixed method design involving concurrent application of quantitative and qualitative approaches was used. Nurses (n = 56) working in acute and rehabilitation care settings completed the Intervention Acceptability scale and responded to open-ended questions. The scale presented information on the components, activities, dose, and mode of delivering evidence-based interventions targeting each patient-oriented outcome (fatigue, nausea and vomiting, dyspnea, pain, physical function, self-care) and items to rate the interventions on five attributes (relevance, applicability, frequency of use, likelihood, and comfort in implementation). The open-ended questions inquired about the appropriateness and resources needed to use the interventions in practice. RESULTS: The quantitative results indicated favorable perceptions of most interventions. Nurses rated acupressure, guided imagery, massage, and relaxation as having limited appropriateness and they reported low levels of comfort in applying them. The qualitative themes clarified the reasons underlying nurses' ratings. LINKING EVIDENCE TO ACTION: This study's findings highlight the importance of examining nurses' perceptions of evidence-based interventions as an initial step toward promoting the adoption of interventions in practice. Effective interventions that are considered of limited relevance are unlikely to be implemented in practice. Nurses' perceptions can guide the design or selection of dissemination strategies to clarify any misconception about the effectiveness and risk of evidence-based interventions.

A Scoping Review of the Literature on Internationally Educated Nurses in Canada: Mapping a Research Agenda.

The purpose of this scoping review was to map key themes in the Canadian literature on the professional integration of internationally educated nurses (IENs), identify the types and sources of and gaps in evidence, and offer recommendations for research. The work was guided by a 6-step methodological framework for scoping reviews. The search and selection of academic and grey literature for the period 2000-13 resulted in a sample of 157 papers for full-text screening. Themes derived from the literature reflect stages of IENs' professional integration: pre-immigration and early arrival, professional recertification, workforce integration, and workplace integration. Data were extracted, coded, and collated using electronic charts. Numerical and qualitative thematic summaries were used to analyze the data. Recommendations for research are as follows: create data systems to track IEN immigration and integration; determine the effectiveness of programs and policies for IENs; and examine the influence of language proficiency on professional recertification, workplace integration, and patient safety.

La présente analyse exhaustive a pour objectif de recenser les thèmes clés traités dans la documentation canadienne portant sur l'intégration professionnelle du personnel infirmier formé à l'étranger (PIFÉ), de déterminer les types et les sources des données probantes ainsi que les lacunes, et d'émettre des recommandations en matière de recherche. Dans le cadre de cette analyse, les auteures ont utilisé un cadre méthodologique comportant six étapes. Le recensement et la sélection d'une littérature didactique et d'une documentation parallèle couvrant la période de 2000 et 2013 a mené à un examen des textes intégraux de 157 documents de recherche. Les thèmes extraits de la littérature reflètent les étapes de l'intégration professionnelle des PIFÉ: la pré-immigration et l'arrivée au Canada; le recertification professionnelle; l'intégration au marché du travail; et l'intégration au travail. Des données ont été extraites, codées et rassemblées en utilisant des tableaux électroniques. Des résumés thématiques numériques et qualitatifs ont été utilisés pour analyser les données. Les recommandations en matière de recherche sont les suivantes: créer des systèmes de données pour suivre la démarche d'immigration et d'intégration du PIFÉ; déterminer l'efficacité des programmes et des politiques à l'intention des PIFÉ; et examiner l'influence de la maîtrise de la langue sur la recertification professionnelle, l'intégration au travail et la sécurité des patients.

Nursing intellectual capital theory: implications for research and practice.

Due to rising costs of healthcare, determining how registered nurses and knowledge resources influence the quality of patient care is critical. Studies that have investigated the relationship between nursing knowledge and outcomes have been plagued with conceptual and methodological issues. This has resulted in limited empirical evidence of the impact of nursing knowledge on patient or organizational outcomes. The nursing intellectual capital theory was developed to assist with this area of inquiry. Nursing intellectual capital theory conceptualizes the sources of nursing knowledge available within an organization and delineates its relationship to patient and organizational outcomes. In this article, we review the nursing intellectual capital theory and discuss its implications for research and practice. We explain why the theory shows promise for guiding research on quality work environments and how it may assist with administrative decision-making related to nursing human resource management and continuing professional development.

Nursing intellectual capital theory: testing selected propositions.

AIMS: To test the selected propositions of the middle-range theory of nursing intellectual capital. BACKGROUND: The nursing intellectual capital theory conceptualizes nursing knowledge's influence on patient and organizational outcomes. The theory proposes nursing human capital, nurses' knowledge, skills and experience, is related to the quality of patient care and nurse recruitment and retention of an inpatient care unit. Two factors in the work environment, nurse staffing and employer support for nurse continuing professional development, are proposed to influence nursing human capital's association with patient and organizational outcomes. DESIGN: A cross-sectional survey design. METHODS: The study took place in 2008 in six Canadian acute care hospitals. Financial, human resource and risk data were collected from hospital departments and unit managers. Clearly specified empirical indicators quantified the study variables. The propositions of the theory were tested with data from 91 inpatient care units using structural equation modelling. RESULTS: The propositions associated with the nursing human capital concept were supported. The propositions associated with the employer support for nurse continuing professional development concept were not. The proposition that nurse staffing's influences on patient outcomes was mediated by the nursing human capital of an inpatient unit, was partially supported. CONCLUSION: Some of the theory's propositions were empirically validated. Additional theoretical work is needed to refine the operationalization and measurement of some of the theory's concepts. Further research with larger samples of data from different geographical settings and types of hospitals is required to determine if the theory can withstand empirical scrutiny.

Nursing intellectual capital theory: operationalization and empirical validation of concepts.

AIMS: To present the operationalization of concepts in the nursing intellectual capital theory and the results of a methodological study aimed at empirically validating the concepts. BACKGROUND: The nursing intellectual capital theory proposes that the stocks of nursing knowledge in an organization are embedded in two concepts, nursing human capital and nursing structural capital. The theory also proposes that two concepts in the work environment, nurse staffing and employer support for nursing continuing professional development, influence nursing human capital. DESIGN: A cross-sectional design. METHODS: A systematic three-step process was used to operationalize the concepts of the theory. In 2008, data were collected for 147 inpatient units from administrative departments and unit managers in 6 Canadian hospitals. Exploratory factor analyses were conducted to determine if the indicator variables accurately reflect their respective concepts. RESULTS: The proposed indicator variables collectively measured the nurse staffing concept. Three indicators were retained to construct nursing human capital: clinical expertise and experience concept. The nursing structural capital and employer support for nursing continuing professional development concepts were not validated empirically. CONCLUSION: The nurse staffing and the nursing human capital: clinical expertise and experience concepts will be brought forward for further model testing. Refinement for some of the indicator variables of the concepts is indicated. Additional research is required with different sources of data to confirm the findings.

Does the sequence of data collection influence participants' responses to closed and open-ended questions? A methodological study.

BACKGROUND: The sequence used for collecting quantitative and qualitative data in concurrent mixed-methods research may influence participants' responses. Empirical evidence is needed to determine if the order of data collection in concurrent mixed methods research biases participants' responses to closed and open-ended questions. OBJECTIVES: To examine the influence of the quantitative-qualitative sequence on responses to closed and open-ended questions when assessing the same variables or aspects of a phenomenon simultaneously within the same study phase. DESIGN: A descriptive cross-sectional, concurrent mixed-methods design was used to collect quantitative (survey) and qualitative (interview) data. The setting was a large multi-site health care centre in Canada. METHODS: A convenience sample of 50 registered nurses was selected and participated in the study. Participants were randomly assigned to one of two sequences for data collection, quantitative-qualitative or qualitative-quantitative. ANALYSIS: Independent t-tests were performed to compare the two groups' responses to the survey items. Directed content analysis was used to compare the participants' responses to the interview questions. RESULTS: The sequence of data collection did not greatly affect the participants' responses to the closed-ended questions (survey items) or the open-ended questions (interview questions). CONCLUSIONS: The sequencing of data collection, when using both survey and semi-structured interviews, may not bias participants' responses to closed or open-ended questions. Additional research is required to confirm these findings.

Nurse dose: linking staffing variables to adverse patient outcomes.

BACKGROUND: Inconsistent findings in more than 100 studies have made it difficult to explain how variation in nurse staffing affects patient outcomes. Nurse dose, defined as the level of nurses required to provide patient care in hospital settings, draws on variables used in staffing studies to describe the influence of many staffing variables on outcomes. OBJECTIVES: The aim of this study was to examine the construct validity of nurse dose by determining its association with methicillin-resistant Staphylococcus aureus (MRSA) infections and reported patient falls on a sample of inpatient adult acute care units. METHODS: Staffing data came from 26 units in Ontario, Canada, and Michigan. Financial and human resource data were data sources for staffing variables. Sources of data for MRSA came from infection control departments. Incident reports were the data source for patient falls. Data analysis consisted of bivariate correlations and Poisson regression. RESULTS: Bivariate correlations revealed that nurse dose attributes (active ingredient and intensity) were associated significantly with both outcomes. Active ingredient (education, experience, skill mix) and intensity (full-time employees, registered nurse [RN]:patient ratio, RN hours per patient day) were significant predictors of MRSA. Coefficients for both attributes were negative and almost identical. Both attributes were significant predictors of reported patient falls, and coefficients were again negative, but coefficient sizes differed. DISCUSSION: By conceptualizing nurse and staffing variables (education, experience, skill mix, full-time employees, RN:patient ratio, RN hours per patient day) as attributes of nurse dose and by including these in the same analysis, it is possible to determine their relative influence on MRSA infections and reported patient falls.

Outcomes achieved from organizational investment in nursing continuing professional development.

Healthcare leaders invest in knowledge and skill development of nurses through continuing professional development activities with the objectives of retaining a competent workforce, ensuring the provision of quality patient care, and promoting the recruitment of nurses. However, it remains unclear if organizational investment in the knowledge and skill development of nurses actually benefits patients or organizations. The author discusses the evidence regarding the relationship between organizationally sponsored nursing continuing professional development and outcomes and the implications for organizations.

Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporting.

The purpose of this study was to obtain a comprehensive understanding of how nurses respond to medication errors and identify strategies that nurses believe may improve reporting of these errors within hospitals. The findings suggest that nurses use a decision-making process when reporting medication errors. Medication error reporting may be improved by instituting a problem-solving approach to respectfully manage the event and providing nurses with clear guidelines, remedial education, and timely feedback.

The middle-range theory of nursing intellectual capital.

AIM: This paper is a report of the development of the middle-range theory of nursing intellectual capital. BACKGROUND: Rising healthcare costs and advances in technology have contributed to the need for better understanding of the influence of nurses' knowledge, skills and experience on patient and organizational outcomes. METHOD: The middle-range nursing intellectual capital theory was developed using the strategies of concept and theory derivation. The principles of research synthesis were used to provide empirical support for the propositions of the theory. FINDINGS: The middle-range nursing intellectual capital theory was derived from intellectual capital theory to make it relevant and applicable to a specific aspect of nursing, continuing professional development. It proposes that the nursing knowledge available in healthcare organizations is influenced by variables within the work environment, and influences patient and organizational outcomes. CONCLUSION: The middle-range nursing intellectual capital theory should be tested in different healthcare systems and in different settings and countries to determine its effectiveness in guiding research.