JOURNAL FOR NURSES IN STAFF DEVELOPMENT  Volume 25, Number 5, 222–226  Copyright A 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

. A diverse workforce enables an . organization to reflect and respond to . Creating a Successful community diversity. With an increase in . the number of nurses educated outside of . the United States seeking licensure and . Transcultural employment within U.S. hospitals, the . . development of an approach to assimilate . On-Boarding Program these international nurses is essential. A . thorough and holistic approach will ensure . . Beth Nease, MSN, RN, BC an ethical and safe introduction into the U.S. . nursing workforce. This article describes a . . program based on the hospital’s nursing . professional practice model that was . developed to address the challenges of skill . . transfer, role definition, and communication......

atient safety requires a qualified and committed care. Working to mirror the population served by Pnursing staff competent in skill and effective in providing a healthcare team reflective of the commu- communication. A transcultural on-boarding program nity can be an effective strategy for meeting the needs based on the hospital’s nursing professional practice of the increasing diversity seen in U.S. hospitals. Mutha model was developed to address the challenges of skill and Karliner (2006) defined culturally competent care transfer, role definition, and communication. On- as ‘‘the ability to deliver effective medical care to pa- boarding provides a focus on complete integration tients regardless of culture or language differences and assimilation of newly hired employees. On- between them and their provider’’ (p. 47). Further- boarding includes all processes and activities related more, Mutha and Karliner defined culture as the lens to new staff, including the recruitment and selection through which we view and organize an understand- process. On-boarding allows for necessary training and ing of the world. Culture goes beyond race and eth- education, provides for needed performance feedback, nicity and encompasses issues such as social class and and places an emphasis on assimilation and integration sexual orientation. Culture influences how we make of the new employee into the workplace culture decisions about medial care, because culture can in- (Humbard, 2005). The purpose of this article is to fluence health beliefs and decision making (p. 47). share the program developed. The International Council of Nurses (ICN), a fed- eration of more than 124 national nurses’ associations, BACKGROUND acknowledges the beneficial outcomes of a multicul- tural nursing practice. The ICN (2001) believes that Recruiting and retaining a diverse workforce can be a establishing a multicultural provider workforce sup- successful strategy for providing culturally competent ports culture-sensitive health care. The evolution of both a global economy and a global nursing shortage ...... has resulted in an increasingly mobile nursing work- Beth Nease, MSN, RN, BC, is Administrative Director of Education, Magnet Coordinator, Bon Secours Memorial Regional Medical force. Immigration and the foreign recruitment of Center, and Richmond Community Hospital, Richmond, Virginia. nurses have drastically increased the numbers of The author has disclosed that she has no significant relationships nurses educated outside the United States who are with, or financial interest in, any commercial companies pertaining to seeking work visas and licensure to practice in the this educational activity. United States. ‘‘In 2002 there were 12,762 first time

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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. NCLEX-RN examination candidates listing educational on-boarding program for international nurses, caring codes from other countries. That number represents was viewed as essential to support each nurse through an almost 50% increase over the 8,612 first-time can- the transition experienced in moving from his or her didates from other countries in 2001’’ (Crawford, 2004, country and culture of origin to America. The profes- p. 66). Nursing education departments can anticipate a sional practice model demonstrates a commitment to more diverse orientation group including nurses edu- providing safety and comfort to patients and families cated outside the United States. as well as to each other. An adequate supply of qual- The ethical issues of foreign recruiting are well ified competent and committed staff is necessary for debated in the literature. Although these issues will not the provision of safe patient care. The transcultural be the focus of this article, there are ethical respon- on-boarding program plays an important role in meet- sibilities of nursing education departments and hiring ing this standard. institutions identified in the ICN Position Statement on Global partnerships are a key element in the pro- Ethical Nurse Recruitment. The ICN denounces the fessional practice model. Global partnerships demon- unethical recruitment practices that exploit or mislead strate the value placed on the multicultural team and the nurses in regard to job responsibilities, working con- importance of the variety of gifts and talents brought to ditions, or both. The ICN (2001) supported quality patients through expression of the staff’s collective orientation programs that include proper supervision, diversity. Knowledge and evidence-based practice are mentoring, and continuing education. viewed as essential in providing quality care. An evidence- based transcultural on-boarding process was developed TRANSCULTURAL ON-BOARDING to ensure quality of orientation for international nurses. Transcultural on-boarding involves creating a process that addresses the learning and assimilation needs of COMPONENTS OF THE PROGRAM employees from different countries and cultures while On-boarding begins with the selection process, which supporting the existing staff in adapting to greater includes peer interviewing. Peer interviewing allows diversity in the workforce (Humbard, 2005). for staff feedback regarding unit fit and appropriate- The literature identifies a number of issues that need ness of the candidate’s skill set for the unit. Peer to be addressed when developing a transcultural on- interviewing also helps establish a staff commitment boarding program. There are many examples of the for on-boarding the new staff member. When offers are cultural differences seen in clinical nursing practice. made to international nurses, the nurse recruiter Some of the differences identified relate to role varia- works closely with the nurse educator. The nurse tions, including responsibility for physical assessment educator determines the appropriate usage of the and medication administration. In some countries, transcultural on-boarding program based on the in- nurses are not taught to assess heart and lung sounds, dividual situation. and some do not administer medication intravenously. Cultural awareness training for the accepting unit Units of measure used in assessing blood sugar levels staff is the second step of the program. The training can differ among regions. Issues like these are impor- uses teaching templates and handouts from the trans- tant to recognize. Identifying what practice differences cultural on-boarding notebook kept in the education exist and addressing them are critical to ensuring appro- department. Educational materials in the notebook in- priate qualifications and development of competency clude resources on the value of a diverse workforce and when hiring and orienting international nurses. the validation process of the international nurse, in- cluding educational background, English proficiency GUIDANCE FROM THE PROFESSIONAL testing, National Council Licensure Exam for Registered Nurses testing, and immigration procedures. The infor- PRACTICE MODEL mation provided to staff helps them gain confidence In an effort to provide a holistic, caring approach to that the international nurse will be able to function as transcultural on-boarding, the nursing professional a contributing team member once off orientation. The practice model of the organization was used as the nurse educator investigates and disseminates infor- framework for program development. The organiza- mation about the international nurse’s country of ori- tion’s nursing professional practice model was devel- gin, common cultural custom, food, dress, typical family oped based on Watson’s (2005) Theory of Human roles, language, and communication style with the staff Caring and the mission and values of the organization. prior to the international nurse’s arrival. The model demonstrates caring as its core, validat- A cultural coach is chosen for each international ing human caring as the interconnectiveness with nurse. The cultural coach role was established to help customers and each other. In the provision of an the international nurse adjust to the culture of the

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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. TABLE 1 Transcultural On-Boarding Needs Assessment ...... Discussion/Recommendations

Topic Role Definition and Skills Transfer Action Plan/Follow-up

Nursing process, daily Review knowledge of nursing process. routine, professional Provide a daily routine worksheet for the specific unit. practice model Review the purpose of the professional practice model. Assessment and Discuss previous experience with physical assessment of the patient and documentation expectations. Evaluate knowledge of assessment skills. Review and critique documentation of a nursing assessment. Review narrative documentation and charting by exception concepts. Infection control Review standard precautions. practices Review each specific isolation precaution category. Identify cultural practice differences. Medication Discuss previous role and experience in administration of medication. administration Review pharmacology test. Review the following: – Top 25 medications of specific unit – Insulin and heparin protocols as appropriate –Narcotic administration practices – PCA pump and safety precautions – IV push medication policy and procedure Provide practice exercises for computer pharmacology program. Pain management Discuss previous role in pain management. Discuss pain management expectations of the American culture. Review Joint Commission documentation requirements. Laboratory values Review CBC and Chem 18 units of measure, normal and reportable results. Review critical value reporting. Review Accucheck units of measure, reportable levels and expectations for treatment and follow-up. Assess knowledge of ABGs, discuss reporting, treatment, and follow-up expectations; do practice exercises. Discuss pan culture collection procedures. Identify cultural practice differences in regard to responsibilities for diagnostic tests and results. Chronic disease America’s primary healthcare challenge in adult and geriatric care is management chronic disease management; discuss major chronic disease states and their presentation as frequent combinations of comorbidities. Top DRGs Review top DRGs of unit. Surgery and Review consents and preoperative and postoperative procedures, procedures checklists. Review risk reduction strategies for DVT, infection, and pneumonia. Identify cultural practice differences in preoperative and postoperative care. Postmortem care Review postmortem care responsibilities and identify any cultural differences related to care of the dead or dying. Multidisciplinary Review RN, LPN, TA, AA, PCT, RT, MD roles, and others as appropriate. team roles Discuss relationships including delegation of tasks. Review the roles of the NP and PA as their roles in the hospital vary. Discuss receiving orders from intermediate care givers.

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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. TABLE 1 Continued ...... Discussion/Recommendations Topic Communication and Critical Thinking Action Plan/Follow-up

English as a Assess for accent vs. language difficulties in communication. second language Assess for understanding. Evaluate for a referral to ESL class or an accent reduction consultation. Communication style Assess for context of nonverbals: high context or low context. Are nonverbals congruent with American traditions? (Specifically yes and no) Assertive Evaluate assertive communication communication – Does new staff member speak loudly enough to be heard? – Do they look down or in the direction of the person to whom they are speaking? – Does new staff member make appropriate eye contact? – Does new staff member ask questions? – Does new staff member respond to open-ended questions appropriately? Role play telephone conversations with a physician, a dispute with a staff member, and a difficult situation with a family member. Role play a situation where therapeutic communication skills are required to calm the fears or tears of a patient. Discuss other communication style differences such as use of the left hand, etc. Critical thinking Use a unit-specific, case-based scenario to review situations which may occur in the work area and work through how each situation might be handled. This process should be both an assessment and a learning opportunity. Identify and discuss possible cultural nursing practice differences.

Note. JCAHO = Joint Commission on Accreditation of Healthcare Organizations; CBC = complete blood count; MD = doctor of medicine; NP = nurse-practitioner; ESL = English as a second language.

American hospital and community. The cultural coach assists the new international nurse to develop and docu- helps the international nurse identify community con- ment competency in the care of the patient population nections within his or her cultural context to maintain served. The goal for completion of orientation is 12–16 his or her cultural identity. The cultural coach is ideally weeks but may vary depending on individual needs. someone from the international nurse’s country of A transcultural needs assessment is performed by origin or a similar culture. The cultural coach, also a the nurse educator for the purpose of identifying prac- foreign trained healthcare professional, will be able to tice and communication gaps. Skills transfer, role defi- identify and empathize with the challenges that the nition, communication challenges, and critical thinking nurse will be facing in making the transition. The cul- were the four broad categories related to clinical nurs- tural coach makes frequent contact during the first few ing practice used to build the assessment tool. The months of employment, providing emotional support needs assessment objective was to identify areas of and friendship. The cultural coach might also assist the significant practice difference and provide education as new nurse in finding a church, grocery shopping for needed to ensure understanding and competency. The the first time, accessing health care, and getting chil- needs assessment was developed from practice issues dren registered for school. that were identified in the literature as challenges for The nurse educator and nurse manager work to- international nurses (see Table 1). The nurse educator gether to identify a culturally competent caring precep- meets individually with the international nurse a few tor who will work with the international nurse. The days a week over the first few weeks of orientation to educator meets with the preceptor to review the ex- complete the needs assessment. After each session, the pected challenge and additional information identified nurse educator provides feedback to the preceptor and through the assessment process. The educator and pre- nurse manager so all parties are informed of the educa- ceptor then set up weekly meetings. The preceptor tional plan and areas of focus. This focused assessment

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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. occurs in addition to the usual unit skills checklist used and promotes patient safety through the development to validate competency. of clinical competency.

CONCLUSIONS AND REFERENCES RECOMMENDATIONS Crawford, L. (2004). Nurses educated in other countries: Coming The transcultural on-boarding process is continuously to America. JONA’s Healthcare Law, Ethics, and Regulation, evolving. Preliminary evaluation results done by survey 6(3), 66–68. indicated that the international nurses have found the Humbard, D. (2005). Trans-cultural on-boarding. PowerPoint pre- program helpful. The nursing staff surveys show that sentation presented at Preceptor Workshop, Henrico Doctors Hospital, Richmond, VA. the staff believed that the program was more helpful International Council of Nurses. (2001). Position statement: than orientation alone. Recommendations included Ethical nurse recruitment. Retrieved April 15, 2007, from the provision of more in-depth information regarding http://www.inc.ch/psrecruit01.htm the nurse’s culture of origin. The international nurses Mutha, S., & Karliner, L. (2006). Improving cultural competence: believed that more emphasis could be placed on the Organizational strategies for clinical care. Journal of Clinical rationale of practice differences to help them better Outcomes Management, 13(1), 47–51. understand the underlying principles. Watson, J. (2005). Caring science as sacred science. Philadelphia: Nursing has become a global profession where global F.A. Davis Company. partnerships encourage a collaborative environment. ADDRESS FOR CORRESPONDENCE: Beth Nease, MSN, RN, Cultural competence allows for better service to diverse BC, Department of Education, Memorial Regional Medical customers. Respectful transcultural on-boarding of in- Center, 8260 Atlee Road, Mechanicsville, VA 23116 ternational nurses fosters healthy work relationships (e-mail: [email protected]).

For more than 9 additional continuing education articles related to cultural competence, go to NursingCenter.com\CE.

Errata

In the Staff Development Story, 10 Lessons in 10 Years, published in Volume 25, Number 3, pp 150–153, the author information for Susan L. Bindon was incorrect. The correct information is:

Susan L. Bindon, MS, RN-BC, is Senior Consultant, Education Development, Lifebridge Health, Baltimore, Maryland.

Address for Correspondence: Susan L. Bindon, Lifebridge Health, 2401 W. Belvedere Avenue, Baltimore, MD 21215 ([email protected]).

JNSD regrets the error!

This error has been noted in the online version of the article, which is available at www.jnsdonline.com.

REFERENCE Blindon, S.L. (2009). Staff development story. Journal for Nurses in Staff Development, 25(3), 150–153.

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