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 222 September/October 2009 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 JOURNAL FOR NURSES IN STAFF DEVELOPMENT 223 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