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  1. Edward, Joyce MSN, MPH, RN


To assist foreign-trained nurses to improve their nursing care and enhance outcomes in nursing practice, educators must have specific teaching strategies to build the nurses' self esteem, improve their openness to explore new ideas, and help them obtain new knowledge. The author discusses specific efforts and teaching strategies to facilitate this process.


Nurses who emigrate to the United States are faced with new ways of life, education difficulties, and various challenges in their every day activities within their first year of arrival. One of the greatest challenges for foreign nurses is their return to the classroom for inservice classes or continuing education programs. These nurses come from a different education system and often have a fear of not being understood by the educator or vice versa. Educators have the unique opportunity to impart ideas, knowledge, and specific strategies to facilitate learning. This article presents some useful hints to help the nurses adjust to their new environment.


As of December 1993, there were 64,844 graduates of foreign nursing programs currently practicing as registered nurses in the United States. The majority of these nurses were educated in the Philippines, the British Commonwealth countries, the United Kingdom, Ireland, Australia, Canada, and New Zealand (Andrews & Boyle, 1999). Any combination of these foreign-trained nurses may be in the classroom at any given time. These nurses may be accustomed to a broader scope of practice in their country and will need specific strategies to aid the acquisition of new skills and learning.


Most foreign-trained nurses were allowed to perform highly technical skills-such as passing nasogastric tubes and removal of sutures-that, in the United States, can only be done by physicians. Nurses took orders from physicians only, whereas now they have to listen to nurse practitioners (NPs) and physician assistants (PAs). These nurses feel at a disadvantage trying to fit with current nursing practice. Educators should be flexible with the curriculum and address these issues in the cultural diversity class during centralized orientation or with the unit-based educator during the clinical orientation. Programs should be adapted to meet the needs of the participants. NPs and PAs should be included as part of the introductory program to clarify their roles to new orientees.


Nurses in the United Kingdom and Ireland have greater freedom in ordering nursing modalities based on their assessments. These nurses face new challenges related to healthcare delivery. Explain the nursing role to all foreign-trained nurses and the care that the patients expect to help the nurses function safely with unfamiliar medications, equipment, and supplies.


During the lecture, use story-telling and give several examples to illustrate the point. Use a multilevel approach to correlate didactic and clinical practice simultaneously. Teach the nurses to articulate and understand the healthcare needs and the cultural diversity of the U.S. population. Although nurses are familiar with different customs, applying the knowledge to nursing care in Western society is new to them.


Many nurses from different cultures will sometimes talk during lectures. This is not always a sign of disrespect. Often they are trying to explain to their colleagues the meaning of a word, phrase, or statement. Some nurses find it easier to interpret in their native language. Ask these nurses if there is a need for further clarification. Acknowledge individual differences and use small groups to problem solve.


Another strategy is to inject humor in interactions with these nurses. Humor can be used at the beginning of the lecture as an ice breaker. Know your audience before using humor because not every culture appreciates it. I found that Russian, Caribbean, and Hispanic nurses liked humor; however, some Asian cultures may not welcome humor as a strategy. According to White and Lewis (1990), humor has the potential to stimulate the thought process, thereby acting as motivation for learners to explore new ideas and evaluate the relationship among concepts.


As adult learners, these nurses have different levels of knowledge. Introduce collaborative learning by allowing them to work together and help each other. Divide the nurses into cultural groups to work on a given topic to share their views with each other. After each group completes the assignment, offer new ways of assessing nursing situations in the United States. This will help the nurses gain insight into new knowledge. This educational process will influence their practice and prepare them to assess and manage patients effectively.


When demonstrating procedures in the lab or clinical setting, the educator should inquire about customs and ask the nurses how skills differ and what can be done to help the nurses improve or change their practice. Be open to suggestions, but explain the rationale for current practice. The nurses should become familiar with the new equipment in order to practice safe nursing care. Some nurses who are presently familiar with a technique might ask to be excused from performing a skill. Do not allow nurses to be exempted from performing a demonstration based on their prior experience. Explain that they need to meet expectations for their current practice by demonstrating safe operation of unfamiliar equipment. Compliment the nurses with different styles for their previous knowledge and techniques and show them ways to improve their nursing practice.


Except for nurses who have been trained in the Philippines, most foreign nurses' test-taking skills differ from those of nurses trained in the American system. They are used to essay-type questions instead of multiple choice questions. Nurses from the Caribbean learn more from memory as opposed to creative learning-they are expected to read a paragraph and repeat it word for word. Having been exposed to two different cultures-England and the Caribbean-with the same essay questions, I had difficulty answering multiple choice questions. Many words and medications are spelled and pronounced differently. A discussion of the rationale proved helpful. Provide nurses with information on review courses and books to help them improve their test-taking skills. Give mock tests and identify the person's learning style to be of more help to him or her.


In conclusion, occupational prestige for nurses is extremely important. It may result in improved job satisfaction, enhanced abilities in health promotion activities, and autonomy in decision making related to patient care (Johnson & Bowman, 1997). Providing positive self-image to these nurses throughout the educational process will help build their confidence and increase awareness of their new roles and responsibilities.