A Teaching Intervention to Improve the Self-Efficacy of Internationally Educated Nurses

Rhigel Alforque Tan, DNP , APRN, ANP , PMHNP , GNP , and Patricia T. Alpert, DrPH, MSN, FNP-BC, PNP-BC, CNE, FAANP

abstract
Increasingly, the U.S. health care system relies on internationally educated nurses to meet the staffing shortage. Many of these nurses come to the United States from Asian countries, especially the Philippines, India, Korea, and increasingly China. Because of conflicting professional and socioeconomic expectations, a growing body of literature has documented a range of challenges experienced by internationally educated nurses during their transition to the U.S. health care environment and American society. This article describes an increase in perceived self-efficacy for a group of internationally educated nurses (N = 18) who participated in an adverse cardiac event with the use of computerassisted simulation training. The findings indicate that internationally educated nurses may increase their selfefficacy in caring for patients in U.S. health care facilities if they receive some pre-employment simulation training to help them transition to the U.S. health care work force. J Contin Educ Nurs 2013;44(2):76-80.

and Davis (2006) found that internationally educated nurses perceive themselves as less proficient than nurses educated in the United States in certain nursing content, particularly cardiac assessment and intervention and the use of technology. Computer-assisted patient simulation offers an alternative to help internationally educated nurses to transition to the clinical setting and care for real patients. Clinical simulation is a low-risk method for teaching high-risk concepts safely (Radhakrishnan, Roche, & Cunnningham, 2007). Engaging in patient simulation with the use of clinical scenarios, such as cardiac assessment and intervention, can increase the confidence of internationally educated nurses (Smith & Roehrs, 2009). This study assessed the perceived self-efficacy of internationally educated nurses who care for cardiac patients through the use of high-fidelity computer-assisted simulation. BACKGROUND In many countries, nurses are not trained to practice autonomously, and in many foreign clinical settings, physicians are present to supervise nurses on care units. Moving from a more secure nursing role in a foreign
Dr. Tan is Assistant Professor and Dr. Alpert is Associate Professor & Chair, Physiologic Department, School of Nursing, University of Nevada, Las Vegas. The authors have disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Patricia T. Alpert, DrPH, MSN, FNPBC, PNP-BC, CNE, FAANP, Associate Professor & Chair, Physiologic Department, School of Nursing, University of Nevada, Las Vegas, 4505 Maryland Parkway, Box 453018, Las Vegas, NV 89154-3018. E-mail: Patricia.Alpert@unlv.edu. Received: August 16, 2012; Accepted: November 1, 2012; Posted: December 10, 2012. doi:10.3928/00220124-20121203-17

nternationally educated nurses are an essential part of the U.S. health care work force (Edwards & Davis, 2006) and are recruited to meet staffing needs during nursing shortages. Internationally educated nurses make up 5% to 10% of the nursing work force in industrialized countries, including the United States. However, the transition to professional nursing practice for these internationally educated nurses can be overwhelming because of unfamiliar technology, cultural differences, language difficulty, and lack of familiarity with the U.S. health care system (McGuire & Murphy, 2005). Edwards

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country to one where autonomy is valued can create perceived low self-confidence in nurses. Sherman and Eggenberger (2008) recommended immersion training for internationally educated nurses, in addition to ongoing education, which includes communication and clinical skill building, sharing of cultural norms, and the creation of an organizational culture that encourages questions. Acquisition of these skills is imperative to help internationally educated nurses to transition to the U.S. health care system. Adeniran et al. (2008) contended that U.S. hospitals have not adequately prepared internationally educated nurses for successful transition after recruitment. The research literature supports the development of a transition program that facilitates safe practice. Ryan (2003) asserted that there is a practice gap between internationally educated nurses and those educated in the United States. To adjust to the U.S. nursing work force, internationally trained nurses must be socialized to the professional role, acquire effective communication skills, and develop clinical and organizational workplace competencies. Use of Simulation in Training and Education Originally introduced in the field of aviation in the early 1930s, high-fidelity simulation has been used in health care training during the past 15 years, especially in the field of anesthesia (Monti, Wren, Haas, & Lupien, 1998). Recent technological advances have enhanced the capability of high-fidelity human simulation to duplicate clinical situations so that nurses can practice decision-making skills in a controlled, lower-stress environment (Howard, Englert, Kameg, & Perozzi, 2011). Computer-assisted patient simulation clinical scenarios provide a low-risk method for teaching high-risk concepts (Radhakrishnan et al., 2007). Teaching nursing skills using simulation builds confidence and is the teaching method frequently used in the United States (Smith & Roehrs, 2009). Students are exposed to the same case scenario to learn the what and how simultaneously, and they receive immediate faculty feedback, all in a controlled environment (Scherer, Bruce, & Runkawatt, 2007). According to Banduras (1997) Social Learning Theory, individuals self-efficacy or confidence in their capability strongly influences how they behave and how they perceive themselves. When nurses believe that they are competent, their contributions more often lead to successful outcomes. Nurse-regulated learning allows for more autonomous control, leading to better learning outcomes (Zimmerman & Schunk, 2001). Bolstering self-efficacy reinforces nurses engagement in modeling newly found behaviors learned through simulation, and
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internationally educated nurses may ultimately transfer these skills to real clinical situations. Project Design and Methods This descriptive study was conducted with internationally educated nurses who were employed at a long-term care facility. This project was conceived in part because of the administrators awareness that internationally educated nurses lacked the self-confidence to assert themselves as they performed their nursing duties. The prescribed training program used in this study was developed in accordance with the facilitys strategic plan to enhance patient safety. This project assessed the effect of participating in computer-assisted patient simulation on internationally educated nurses self-efficacy to manage cardiac events. The authors hypothesized that internationally educated nurses who received this simulation training would show improved perceived self-efficacy on completion of the training. Additionally, the authors anticipate transference of improved clinical competency from simulation to real patients in the long-term care facility. Sample Size This pilot project included a convenience sample of internationally educated nurses who were employed at a long-term care facility in a Southwestern U.S. state. A total of 35 internationally educated nurses were eligible to participate in the project, and 18 underwent training and completed both surveys (pre- and posttraining tools). Demographic data showed that 16 of the nurses were educated in the Philippines, 1 in India, and 1 in Korea. The average age of the internationally educated nurses was 27.5 years; 15 were female, and the average length of time working as a nurse in the United States was 1.5 years. Participants all held bachelor of science degrees in nursing, 16 held staff nurse positions, and 2 were charge nurses. The protection of human subjects information was reviewed and clearance was granted by a university in Utah and a letter of support was issued by the institutional review board at a university in Nevada before initiation of the project. Inclusion and Exclusion Criteria Registered nurses who met the following criteria were invited to participate: (1) internationally educated; (2) licensed as a registered nurse to practice in the state of Nevada; (3) employed at a long-term care facility in southern Nevada; and (4) willing to participate. Those who met the following criteria were excluded from participating: (1) born outside the United States but educated in the United States; (2) born in the United States
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and educated as a registered nurse in the United States; and (3) do not speak English. Instruments The Simulation Confidence Scale was used as the pre- and posttraining assessment tool to measure the self-efficacy of internationally educated nurses. This 10-item questionnaire measures the confidence level of individuals. Participants responded to each item using a Likert-type scale ranging from 1 to 5, with 1 indicating very confident and 5 indicating not confident at all (Scherer et al., 2007). Examples of the questions on the instrument include the following: How confident are you that you could initiate the appropriate nursing interventions based on interpretation of the patients laboratory and other diagnostic tests? How confident are you in formulating a nursing diagnosis for your scenario patient? To establish validity for this tool, Scherer et al. (2007) had the instrument reviewed by an acute care nurse practitioner with expertise in cardiology and piloted this tool with five nursing student volunteers. Based on student feedback, changes where made to improve the clarity of items. Case Scenarios Two cardiac case scenarios were used as part of the simulation training. Standardized scenarios were used with all participants to ensure consistency in training. The first scenario involved a 56-year-old Hispanic woman with type 2 diabetes, heart failure, and osteomyelitis who was hospitalized for management of acute heart failure. The second scenario involved a 51-yearold White woman with unstable myocardial infarction who was admitted to the hospital with a chief complaint of chest pain. METHODS The potential participants were informed about the project at a staff meeting. To reach all internationally educated nurses who worked at the long-term care facility, the project manager attended several staff meetings held during various shifts. The project was described to all potential participants, and they were told that participation meant that they would have to meet at the simulation center on three separate occasions. They were informed that someone would schedule their meetings at the simulation center. The time commitment would be a total of 5 hours for the three sessions (1 hour for the first session and 2 hours per session for the second and third sessions). The internationally educated nurses who were interested in participating were given a packet containing
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a letter of invitation and two copies of the Simulation Confidence Scale (a pretraining copy and a posttraining copy). Arrangements were made with participants to meet for the first session. First Session During the first session, participants (N = 18) were given a brief description of the project and the project manager answered questions. The nurses were told that participation was completely voluntary and that they could drop out at any point during the project without jeopardizing their job at the long-term care facility. Once the informed consent was completed, an orientation session was provided and participants completed the pretraining Simulation Confidence Scale. Each participant was assigned a participant number that was entered in the designated area on the pretraining and posttraining surveys. Code numbers were used in place of participants names to ensure confidentiality. Once the participants completed the surveys, the forms were placed in a manila envelope and deposited in the designated drop box. Second and Third Sessions On the day of the first simulation scenario, participants, in turn, assumed the role of the primary nurse providing care for the cardiac patient. During the actual simulation experience, the internationally educated nurses received report, performed assessments, gave medications, called the physician for appropriateness of orders, performed nursing procedures, and participated in cardiopulmonary resuscitation. Each participant fulfilled the role of primary nurse for a total of 15 to 20 minutes while others observed. After all participants completed a turn caring for the scenario patient, a debriefing session lasting approximately 10 to 15 minutes was held. Participants were asked to describe their thoughts and feelings about the simulation experience. They were also asked whether they felt that they were now more prepared to care for patients with cardiac conditions. The third session was conducted in the same manner using the second cardiac scenario. At the end of the debriefing session, participants were asked to complete the posttraining Simulation Confidence Scale and place the completed survey in the designated collection box. To comply with the best practices requirement for small group simulation sessions, nine total simulation sessions were conducted to accommodate the 18 internationally educated nurses. RESULTS Data were analyzed with the Statistical Package for the Social Sciences (SPSS, Inc., Chicago, IL), version
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14.0. To compare the results of the pre- and posttraining responses on the Simulation Confidence Scale, analysis of variance with repeated measures was used. The results showed a very strong association between the pretraining and posttraining survey responses, indicating the effectiveness of the intervention training (F(1,17) = 131.27, p < .0005, h2 = .89). The analysis indicated that 89% of the variance between the pretraining and posttraining results can be attributed to the simulation activity. In essence, the internationally educated nurses who participated in this training project showed higher confidence according to the posttraining analysis (M = 1.49, SD = 0.52) compared with the pretraining results (M = 2.76, SD = 0.56). As a measure of the consistency of responses, reliability is a metric of measurement error. Because the reliability of the Simulation Confidence Scale for both the pretraining and the posttraining scores exceeded an alpha of 0.90, it can be reasonably concluded that the participants responded consistently across items and across time. This finding is supported by the fact that the pretraining and posttraining scores correlated strongly and significantly (r = 0.63). Although the study was conducted with a small sample (N = 18), the Simulation Confidence Scale showed sound psychometric properties in assessing the self-efficacy (i.e., confidence) of internationally educated nurses in a variety of key nursing skills practiced via the simulation intervention. With high reliability (i.e., consistency of responses) comes low measurement error. The results showed that simulation training was successful in increasing the self-efficacy of internationally educated nurses in key nursing skills when pretraining responses were compared with posttraining responses. DISCUSSION Results of this study showed that the use of the cardiac simulation scenario enhanced the self-efficacy of internationally educated nurses. The participants expressed their satisfaction with this training and noted that they were willing to participate in future simulation activities. For example, one internationally educated nurse stated, I wish I had this experience when I was newly hired 2 years ago. Another participant stated, I was scared to participate in this simulation training, but now I realize how this experience helped me to feel more confident. I hope to have more opportunities to participate in the future. The research literature includes limited studies that show the effect of computer-assisted teaching on the selfefficacy of internationally educated nurses who come to the United States to work. Additional studies are needed to investigate the need to promote the self-efficacy of
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these nurses. Confidence and competence in the clinical setting have been linked to psychological empowerment of nurses, which can lead to better nursing performance and improved patient outcomes (Manojlovich, 2007). Addressing the assimilation needs of internationally educated nurses through evidence-based teaching methods can facilitate a more successful transition into the U.S. nursing work force. Additionally, this type of training is a safe way to enhance self-efficacy that may lead to increased job satisfaction, greater autonomy, and the opportunity for career advancement and greater retention in nursing. To ensure ongoing confidence building, a consistent simulation schedule is recommended to address complex, high-stakes patient situations. This continuous training can help internationally educated nurses to bridge the potential gap between their nursing education and the U.S. health care system. Limitations This study had several limitations, including the small number of participants who completed all training sessions. Some participants were not able to attend all sessions because of work and personal schedules. Another limitation was the number of participants who were from the Philippines (n = 16) versus one from India and another from Korea. The total number of participants was small, and this was also a fairly homogeneous group. The small sample size, and the smaller numbers of nurses from India and Korea compared with the number of participants from the Philippines (n = 16), may be the reason why there was no difference in self-confidence among the nurses when compared by country of origin. Future projects should include internationally educated nurses from other countries to help to identify differences between groups. Additionally, the one-group design prohibits the generalizability of the project findings. Despite these shortcomings, the fact that such a small measurement error and a large effect size were detected indicates that simulation is effective in increasing the self-confidence of internationally educated nurses. Future research can extend these findings with a longitudinal study that uses a larger sample size and an experimental design that includes a control group. CONCLUSION According to Adeniran et al. (2008), Society is only able to benefit fully from migration when it is accompanied by successful integration (p. 3). The nursing shortage in the United States will not be resolved in the near future. Health care facilities will continue to hire nursing professionals from other countries as a result of the nurs79

key points
Internationally Educated Nurses
Tan, R. A., Alpert, P. T. (2013). A Teaching Intervention to Improve the Self-Efficacy of Internationally Educated Nurses. The Journal of Continuing Education in Nursing, 44(2), 76-80.

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The use of simulation training to prepare nurses for high-risk situations is safe and effective. Simulation training to enhance skill acquisition increases nurses self-efficacy. Internationally educated nurses benefited from simulation training.

the self-confidence of these nurses and also may lead to greater job satisfaction, which can translate into work force stability and increased quality of care, making this a win-win situation for both employers and nurses. This study showed how teaching interventions involving computer-assisted human patient simulation helped internationally educated nurses to build self-efficacy by caring for complex patients in a safe environment. This approach can enhance job satisfaction, and the increase in self-efficacy enables these internationally educated nurses to adapt to their new professional environment. REFERENCES
Adeniran, R., Rich, V., Gonzalez, E., Peterson, C., Jost, S., & Gabriel, M. (2008). Transitioning internationally educated nurses for success: A model program. Online Journal of Issues in Nursing, 13(2). doi:10.3912/OJIN.Vol13No02Man03 Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: W. H. Freeman. Edwards, A. P., & Davis, C. R. (2006). Internationally educated nurses perceptions of their clinical competence. The Journal of Continuing Education in Nursing, 37(6), 265-269. Howard, V. M., Englert, N., Kameg, K., & Perozzi, K. (2011). Integration of simulation across the undergraduate curriculum: Student and faculty perspectives. Clinical Simulation in Nursing, 7, e1-e10. Manojlovich, M. (2007). Power and empowerment in nursing: Looking backward to inform the future. Online Journal of Issues in Nursing, 12(1), 1-15. McGrath, D. L. (2007). Implementing a holistic approach in vocational education and training. Australian Journal of Adult Learning, 47(2), 228-244. McGuire, M., & Murphy, S. (2005). The internationally educated nurse. Canadian Nurse, 101(1), 25-57. Monti, E. J., Wren, K., Haas, R., & Lupien, A. E. (1998). The use of an anesthesia simulator in graduate and undergraduate education. CRNA: The Clinical Forum for Nurse Anesthetists, 9(2), 59-66. Radhakrishnan, K., Roche, J. P., & Cunningham, H. (2007). Measuring clinical practice parameters with human patient simulation: A pilot study. International Journal of Nursing Education Scholarship, 4(1), 1-11. Ryan, M. (2003). A buddy program for international nurses. Journal of Nursing Administration, 33(6), 350-352. Scherer, Y. K., Bruce, S. A., & Runkawatt, V. (2007). A comparison of clinical simulation and case study presentation on nurse practitioner students knowledge and confidence in managing a cardiac event. International Journal of Nursing Education Scholarship, 4(1), 1-14. Sherman, R. O., & Eggenberger, T. (2008). Transitioning internationally educated nurses into clinical settings. The Journal of Continuing Education in Nursing, 39(12), 535-544. Smith, S., & Roehrs, C. J. (2009). High-fidelity simulation: Factors correlated with nursing student satisfaction and self-confidence. Nursing Education Perspectives, 30(2), 74-78. Zimmerman, B. J., & Schunk, D. H. (2001). Self-regulated learning and academic achievement: Theoretical perspectives (2nd ed.). Mahwah, NJ: Erlbaum.

ing shortage. These internationally educated nurses will continue to bring diversity to the nursing work force in various health care settings. Clinical needs vary and are dependent on the health care system in which the nurse was educated before coming to the United States. Designing continuing education and staff development programs that consider the needs of internationally educated nurses entering U.S. practice is essential. For many internationally educated nurses, clinical experiences in their homeland do not prepare them for working in the United States, primarily because of the increasing focus on health care technology in this country (Edwards & Davis, 2006). Adeniran et al. (2008) supported the idea that hospitals in the United States have not adequately prepared for the successful transition of internationally educated nurses after their recruitment. The literature supports the development of transition programs that facilitate clinically and culturally safe practice. The need to acculturate internationally educated nurses is a responsibility of both the nurses and their employers. Technology, such as human patient simulation, is a proven modality as a teaching tool that can potentially enhance individual nurses skills by building self-confidence in their ability to provide safe, cost-effective nursing care at the bedside. Simulation holds great potential for training internationally educated nurses in many other health care situations, other than high-stakes/high-impact areas of nursing care. Dollars invested in providing continuing education to help internationally educated nurses to acculturate into their newly found health care jobs can potentially increase

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