Foreign Educated Nurses and Patient Care Experience in England and the United States

University of Pennsylvania ScholarlyCommons Publicly Accessible Penn Dissertations 2015 Foreign Educated Nurses and Patient Care Experience in England and the United States Hayley Drew Germack University of Pennsylvania, [email protected] Follow this and additional works at: https://repository.upenn.edu/edissertations Part of the Nursing Commons Recommended Citation Germack, Hayley Drew, "Foreign Educated Nurses and Patient Care Experience in England and the United States" (2015). Publicly Accessible Penn Dissertations. 1733. https://repository.upenn.edu/edissertations/1733 This paper is posted at ScholarlyCommons. https://repository.upenn.edu/edissertations/1733 For more information, please contact [email protected]. Foreign Educated Nurses and Patient Care Experience in England and the United States Abstract Background & Significance: orF decades, to counter nursing shortages, hospitals in developed countries have hired nurses from abroad. Although the certification and licensure process of foreign educated nurses aims to assure competency in educational training and language skills, systematic research evaluating the relationship between healthcare quality and hospital employment of foreign educated nurses has been lacking. Considering an increase in attention to the patient care experience and an increase in qualified applicants ot nursing schools in England and the U.S., it is a prime time to examine the relationship between foreign educated nurses and patient experiences of care. Methods: The approach used here is an independent replications analysis using similar cross-sectional secondary data in two countries. Data were gleaned from three 2009-2010 English sources and three 2006-2008 U.S. sources and included nurse survey data, hospital organizational data, and patient care experience data. The main outcomes of interest were measures of patient care experience from patient surveys. The analytic sample consisted of 31 hospitals in England and 407 hospitals in four states in the U.S. and nurses and patients at the participating hospitals. Nurses provided information about country of education and the organizational context that was aggregated to the hospital level. The sample was descriptively analyzed using chi-square tests and analysis of variance. Regression models estimated the effect of a higher proportion of foreign educated nurses on patient care experience in hospitals in England and the U.S., before and after taking hospital and modifiable organizational characteristics into account. Results: Hospitals in England and the U.S. employing higher proportions of foreign educated nurses had lower global ratings of patient care experience and lower ratings of experience related to nursing care. Controlling for nurse and structural and organizational hospital characteristics slightly attenuated the strength and significance of the elationshipr between a higher proportion of foreign educated nurses and poorer patient experiences of care in England; it had no effect on this relationship in the U.S. Conclusion: These findings er veal that in both England and the U.S., patients cared for in hospitals with a substantial proportion of nurses educated abroad rate the quality of their care lower than do patients in hospitals with fewer foreign educated nurses. Implications: National and institutional Investment in a sufficient domestic workforce could contribute to better patient care experiences for patients. Degree Type Dissertation Degree Name Doctor of Philosophy (PhD) Graduate Group Nursing First Advisor Linda H. Aiken Keywords foreign educated nurses, health services research, nurse staffing, patient care experience, patient outcomes, patient satisfaction Subject Categories Nursing This dissertation is available at ScholarlyCommons: https://repository.upenn.edu/edissertations/1733 FOREIGN EDUCATED NURSES AND PATIENT CARE EXPERIENCE IN ENGLAND AND THE UNITED STATES Hayley Drew Germack A DISSERTATION in Nursing Presented to the Faculties of the University of Pennsylvania in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy 2015 Supervisor of Dissertation ________________________ Linda H. Aiken, PhD, FAAN, FRCN, RN Claire M. Fagin Leadership Professor in Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research Graduate Group Chairperson ________________________ Connie M. Ulrich, PhD, RN, FAAN Associate Professor of Nursing and Bioethics, Department of Medical Ethics, School of Medicine Dissertation Committee Linda H. Aiken, PhD, FAAN, FRCN, RN, Professor of Nursing and Sociology Ann M. Kutney-Lee, PhD, RN, Assistant Professor of Nursing Matthew M. McHugh, PhD, JD, MPH, RN, CRNP, FAAN, Associate Professor of Nursing FOREIGN EDUCATED NURSES AND PATIENT CARE EXPERIENCE IN ENGLAND AND THE UNITED STATES COPYRIGHT 2015 Hayley Drew Germack This work is licensed under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 License To view a copy of this license, visit http://creativecommons.org/licenses/by-ny-sa/2.0/ iii Dedication To Mom and Dad, Who always taught me to work hard for what I believe in. To Dylan, My favorite nurse. To Pop pop, For making me want to change the system iv ACKNOWLEDGMENT A dissertation is like running a marathon. It makes you uncomfortable, it pushes you to your limits, and it asks you to constantly question yourself. But behind any dissertation is a team. I would like to acknowledge my team, those who have coached and supported me to the finish. First, I would like to acknowledge and thank my head coach, my dissertation chair, Dr. Linda Aiken. Her research accomplishments are inspirational and her support, guidance and feedback during the last seven years have challenged and encouraged me; all of which has been integral to my personal growth and intellectual development. Thank you and the Hillman Foundation for providing me with a fellowship and the opportunity to work under your tutelage to develop skills to become a successful researcher. I would also like to express my gratitude to Dr. Margo Brooks Carthon, Dr. Nancy Hanrahan, Dr. Sarah Kagan, Dr. Ann Kutney Lee, Dr. Eileen Lake, Dr. Matthew McHugh, Dr. Salimah Meghani, and Dr. Therese Richmond for their mentorship and support as well as their guidance in developing this body of work. I would also like to thank and acknowledge my teammates—the faculty and fellows at the Center for Health Outcomes and Policy Research who provided support, donated their time and willingly included me in projects that were fundamental to my scholarly development. Thank you to the Center staff as well, especially Amy Miller and Tim Cheney, who always happily answer my questions and helped make the Center a welcoming home for the last 3 years. I would be remiss if I didn’t acknowledge those who have nurtured and challenged me as a citizen of the world—thank you to Dr. Frances Barg and Dr. Kent Bream who offered me my v first opportunity to engage in international research. Thank you to the orthopedic nurses and patients at the JR. Thank you for supporting me in my time as a foreign educated nurse. And for those who have cheered me and laid a foundation for scholarship—I’d like to thank Mom and Dad for their love and support. Thank you for feeding my curiosity, letting me off my leash, challenging me. Thank you to my sister, Dylan, for making me a better person. Thank you to my best of friends, Adam and Jana, for taking care of me. Thank you to Coach Todd, my “real” coach, for harnessing my athletic prowess in the midst of academia. vi ABSTRACT FOREIGN EDUCATED NURSES AND PATIENT CARE EXPERIENCE IN ENGLAND AND THE UNITED STATES Hayley Drew Germack Linda H. Aiken Background & Significance: For decades, to counter nursing shortages, hospitals in developed countries have hired nurses from abroad. Although the certification and licensure process of foreign educated nurses aims to assure competency in educational training and language skills, systematic research evaluating the relationship between healthcare quality and hospital employment of foreign educated nurses has been lacking. Considering an increase in attention to the patient care experience and an increase in qualified applicants to nursing schools in England and the U.S., it is a prime time to examine the relationship between foreign educated nurses and patient experiences of care. Methods: The approach used here is an independent replications analysis using similar cross- sectional secondary data in two countries. Data were gleaned from three 2009-2010 English sources and three 2006-2008 U.S. sources and included nurse survey data, hospital organizational data, and patient care experience data. The main outcomes of interest were measures of patient care experience from patient surveys. The analytic sample consisted of 31 hospitals in England and 407 hospitals in four states in the U.S. and nurses and patients at the participating hospitals. Nurses provided information about country of education and the organizational context that was aggregated to the hospital level. The sample was descriptively vii analyzed using chi-square tests and analysis of variance. Regression models estimated the effect of a higher proportion of foreign educated nurses on patient care experience in hospitals in England and the U.S., before and after taking hospital and modifiable organizational characteristics into account. Results: Hospitals in England and the U.S. employing higher proportions of foreign educated nurses had lower global

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