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International Journal of Nursing Studies Advances logoLink to International Journal of Nursing Studies Advances
. 2024 Mar 27;6:100195. doi: 10.1016/j.ijnsa.2024.100195

Transitioning experiences of internationally educated nurses in host countries: A narrative systematic review

Aasia Rajpoot a,⁎, Clair Merriman b, Anne-Marie Rafferty b,c, Catherine Henshall d
PMCID: PMC11145537  PMID: 38832236

Abstract

Background

The shortage of nurses worldwide is a well-known issue that has changed the health and social workforce picture. Increased recruitment and migration of internationally educated nurses in the health and social care workforce pose many risks to successful integration into the healthcare system. Understanding the barriers and enablers affecting their integration in their host countries is imperative.

Objective

To critically and systematically review the current literature to explore the transitioning experiences of internationally educated nurses to understand the enabling influences affecting their workforce integration into their host countries.

Design

A narrative systematic literature review was conducted. This study was registered in the International Prospective Register of Systematic Reviews (Registered Number: CRD42023401090). The study results were reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Methods

A comprehensive literature search using the search engines CINAHL, MEDLINE, PsycINFO, Academic Search, and PubMed was conducted. Only peer-reviewed papers written in the English language were included. Primary research studies published between 2019 and 2023, which explored the lived experiences of internationally educated nurses, were considered for review.

Results

Seventeen studies (16 qualitative and one quantitative) were included in the review. Three main themes were developed: (1) push and pull factors that mediated internationally educated nurses' migration experiences, (2) one-way integration logic, and (3) expectations versus reality.

Conclusions

There is a need for a comprehensive and collaborative organisational approach to enhance the integration experiences of internationally educated nurses into their host countries. This can also ensure their contribution is recognised and will help them fulfil the responsibilities of their role and become influential team members within their organisations. This comprehensive and collaborative approach is also required to tackle discrimination, racism, communication and language barriers. Addressing these challenges can improve internationally educated nurses' job satisfaction and, thereby, improve retention.

Tweetable abstract

A new systematic review study explores barriers and enablers for optimising internationally educated nurses' experiences of working in their host country @cathy_Henshall @clairmerriman9 @annemarieraffer

Keywords: Foreign nurse, International nurse, Overseas nurse, Literature review, Attitude, Experiences, Feelings, Perception

What is already known about the topic.

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    Internationally educated nurses face many challenges, including cultural, communication, and practice differences, which affect their experiences of the integration process.

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    The successful integration of internationally educated nurses is vital for long-term job satisfaction and workforce retention.

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What this paper adds.

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    Integrating internationally educated nurses into their host countries' healthcare systems is complex.

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    Long-term integration planning and continuous support from individual organisations and policymakers are required to successfully integrate internationally educated nurses into their host countries' healthcare systems.

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1. Background

The WHO, 2020 reported that there was an estimated shortage of 6.6 million nurses in 2016, slightly reduced to 5.9 million in 2018. Nearly 90 % of these shortages were in low - and lower-middle income countries (WHO, 2020). The recruitment and retention of nurses is affected by various factors, including a reduction in nursing students, an ageing nursing workforce, high turnover, and increasing demand for nurses (WHO, 2020; RCN, 2022; NSI, 2023). This demand continues to rise, leading to an increasing reliance on the recruitment of nurses from other countries (OECD, 2022; NSI, 2023). Internationally educated nurses are nurses who initially completed their professional training and registration in their home countries before moving to another country to work as nurses. Internationally educated nurses comprise a substantial proportion of the health and social care workforce (OECD, 2022). For example, in the United Kingdom (UK), there were approximately 1954 (135% increase) new internationally educated nurses registering each month between April 2021 and March 2022 (Sutcliffe, 2022). In Canada, the proportion of internationally educated nurses has increased from 7 % to 9 %, and in New Zealand, this proportion has risen from 23 % to 31 % since 2010 (OECD, 2021, 2022; Byrne, 2023; OECD 2023).

The significant rise in the recruitment and migration of nurses from one country to another may help address the shortage of nurses (Philip et al., 2019; Roth et al., 2021), but it also poses several risks because of cultural differences, language barriers, and practices (Covell et al., 2018; Vafeas and Hendricks, 2018). A study conducted in Canada (Nourpanah, 2019) reported that internationally educated nurses faced significant barriers to employment due to discrimination and a lack of recognition of their qualifications. Similarly, a study conducted in the United States of America (USA) found that internationally educated nurses experienced difficulties obtaining a professional licence and faced discrimination due to their accents and cultural differences (Rosenkoetter et al., 2017). The 'Ambitious for Change' report published in 2020 by the UK Nursing and Midwifery Council reported that Black, Asian, and disabled health and social care workers experienced lower progression and pay, higher discrimination, and more mental health issues than their White counterparts (Sutcliffe, 2020). This report also highlighted many issues related to different educational experiences, lower licensure rates, and higher referrals to fitness-to-practice processes across health and social care professions, including doctors, dentists, nurses, and social workers (Sutcliffe, 2020). Low job satisfaction, burnout, and high staff turnover were associated with these risks and have costly implications for healthcare organisations. For example, between 2022 - 2023, 26,755 nurses left the UK Nursing and Midwifery Council register (Sutcliffe, 2020), contributing to concerns about retention. Therefore, the Nursing and Midwifery Council recommended that healthcare organisations help and support internationally educated nurses to integrate better by making their working environment as inclusive as possible. This aligns with literature about global nurse shortages, which suggests that treating all employees appropriately results in better patient outcomes, increased job satisfaction for nurses, and a better work environment for everyone (Drennan and Ross, 2019; Labrague et al., 2021).

Although evidence exists exploring the integration challenges internationally educated nurses face (Davda et al., 2018; Bond et al., 2020; Abuliezi et al., 2021), most studies focused on either internationally educated nurses from a specific healthcare setting (Almansour et al., 2022), ethnicity (Al‐Hamdan et al., 2015; Stubbs, 2017; Gillin and Smith, 2021; Almansour et al., 2022) country (Al‐Hamdan et al., 2015; Zhong et al., 2017) or on their registration processes; e.g., passing exams such as the Overseas Nursing (Stubbs, 2017) or Bridging Programmes (Högstedt et al., 2021). To our knowledge, no systematic reviews have explored barriers and enablers to optimising internationally educated nurses' experiences of working in their host countries. Such understanding is imperative and can provide valuable insights into these challenges. Moreover, identifying strategies and informing policies and practices to overcome these challenges can help improve the integration of internationally educated nurses and their job satisfaction and retention within the healthcare system, hence the need for this review.

2. Aim of the review

We aimed to synthesise literature exploring the transitioning experiences of internationally educated nurses to understand the enabling influences affecting their workforce integration into their host countries. Transition experiences of nurses refer to the experiences associated with professional, cultural, and social adjustment when internationally educated nurses move to their host country.

3. Methods

A narrative systematic literature review was conducted. The population, exposure, and outcome framework was used as a tool to develop a review question (Heaslip and Lindsay, 2019). Primary studies published between 20192023 and that explored the lived experiences of internationally educated nurses were considered for inclusion in the review. The time frame was chosen because there was an increase in the UK's recruitment drive for internationally educated nurses after 2019 due to the UK government's pledge to attract 50,000 extra nurses by 2025. This study was registered in the International Prospective Register of Systematic Reviews (Registered Number: CRD42023401090). The results of the study were reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021) (Fig. 1).

Fig. 1.

Fig 1

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PRISMA 2020 flow diagram (Page et al., 2021).

*International educated Nurses.

3.1. Search process

A search was conducted through the EBSCO host, and the following databases were selected: Academic Search Complete, Medline, CINAHL, and PsycINFO. A separate search was conducted through PubMed. A search for grey literature was also performed through Google Scholar to identify any studies not published in indexed journals. The reference list of each article was reviewed to identify any studies not listed in the searched databases. Key search terms (international nurse, overseas nurse, foreign nurse, migrant nurse) AND (experience, perception, attitude, feel, view), including Boolean operators (OR, AND) and wildcards and truncation symbols (*), were used. The filters, 'English language' time frame and 'peer-reviewed', were applied.

The eligibility criteria used when screening papers for inclusion in the review are outlined in Table 1. The initial database search retrieved (N = 636) studies; 312 duplicates were removed. The remaining 324 studies were screened against the eligibility criteria, and all papers were screened by at least two members of the review team (AR, CH, CM). During the first phase, a careful screening of the (n = 324) studies' titles and abstracts was conducted, which resulted in 290 papers being excluded. This left 34 articles; the full texts of the remaining papers were then screened against the eligibility criteria, and 17 papers were excluded (Fig. 1), leaving 17 (16 qualitative and one quantitative) for inclusion in the review.

Table 1.

Inclusion and exclusion criteria.

Inclusion criteria Exclusion criteria
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    Primary research studies.

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    Peer-reviewed studies.

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    Studies published in English between 20192023.

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    Studies that explored internationally educated nurses' experiences of working in host countries.

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    Studies that explored the lived experiences of internationally educated nurses.

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    Quantitative, qualitative, randomised controlled trials, ethnographic, cohort or mixed methods studies.

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    Studies included 50 % or more internationally educated nurses within the study population.
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    Studies published before 2019.

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    Studies focussing not on internationally educated nurses' experiences and perceptions but on processes such as their registration processes.

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    Theoretical papers, case studies, case reports, opinion pieces, commentaries, and editorials.

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    Studies where the population was made up of less than 50% of internationally educated nurses.

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    Studies focussing on nursing students or nurse educators.
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3.2. Quality appraisal

A robust quality appraisal of the 17 selected studies was conducted using the Critical Appraisal Skills Programme (2018) checklists to enhance the review's overall rigour and reliability. Quality appraisal was carried out by the AR, CM, and CH. AR appraised all papers, and CM and CH reviewed 17 papers each. No quality concerns were reported. The Critical Appraisal Skills Programme qualitative checklist (2018) was used for qualitative studies, and the Critical Appraisal Skills Programme checklist for cohort studies (2018) was used for quantitative study. The Critical Appraisal Skills Programme allows holistic study assessment considering the overall methodological rigour, transparency, and adherence to best practices. All 16 qualitative studies were of good quality, meeting all ten quality indicators on the Critical Appraisal Skills Programme tool (Table 2). One quantitative study (Zanjani et al., 2021) was also of good quality as it met all 12 quality indicators of the Critical Appraisal Skills Programme (2018) for cohort studies.

Table 2.

Quality appraisal of the qualitative studies.

No Author and year of publication 1- Was there a clear statement of the aims of the research? 2- Is a qualitative methodology appropriate? 3- Was the research design appropriate to address the aims of the research? 4. Was the recruitment strategy appropriate to the aims of the research? 5. Was the data collected in a way that addressed the research issue? 6. Has the relationship between researcher and participants been adequately considered? 7. Have ethical issues been taken into consideration? 8. Was the data analysis sufficiently rigorous? 9. Is there a clear statement of findings? 10. How valuable is the research? Overall risk of bias
1 Brunton et al., 2019 √ √ √ √ √ √ √ √ √ √ Low
2 Calenda et al., 2019 √ √ √ √ √ √ √ √ √ √ Low
3 Nourpanah, 2019 √ √ √ √ √ √ √ √ √ √ Low
4 Philip, et al., 2019a √ √ √ √ √ √ √ √ √ √ Low
5 Philip et al., 2019b √ √ √ √ √ √ √ √ √ √ Low
6 Leone et al., 2020 √ √ √ √ √ √ √ √ √ √ Low
7 Angus et al., 2021 √ √ √ √ √ √ √ √ √ √ Low
8 Dywili et al., 2021 √ √ √ √ √ √ √ √ √ √ Low
9 Ham, Anita, 2021 √ √ √ √ √ √ √ √ √ √ Low
10 Korzeniewska, et al., 2021 √ √ √ √ √ √ √ √ √ √ Low
11 Pawlak, 2021 √ √ √ √ √ √ √ √ √ √ Low
12 Rodriguez-Arrastia et al., 2021 √ √ √ √ √ √ √ √ √ √ Low
13 Almansour et al., 2022 √ √ √ √ √ √ √ √ √ √ Low
14 Antón-Solanas et al., 2022 √ √ √ √ √ √ √ √ √ √ Low
15 Joseph et al., 2022 √ √ √ √ √ √ √ √ √ √ Low
16 Kamau et al., 2022 √ √ √ √ √ √ √ √ √ √ Low
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3.3. Data extraction and synthesis

In alignment with the study aim, a data extraction template was developed for extracting relevant information, informed by the JBI Data Extraction form for literature reviews and research synthesis (Aromataris and Munn, 2017). Data were extracted under the following headings: author details, year of publication, aim and purpose of the study, geographical location of the study, study design, study setting, sampling approach, sample characteristics (age, sex, and year of work experience), participants country of origin, data collection and data analysis, study findings, conclusion, and recommendations. This helped to systematically identify and extract the main study characteristics and results, ensuring consistency and accuracy and minimising the chances of overlooking and misinterpreting valuable information. The data extraction and synthesis process were carried out initially by the AR. CM, AMR, and CH undertook the confirmation process.

The data extraction template assisted with the synthesis and analysis of data and in developing structured and coherent themes. This was achieved by repeated reading, familiarising with data, and developing codes and categories. After that, codes were grouped based on similarities and relationships into potential themes. The themes were constantly compared and revised to capture the real essence of the data. Sub-themes were also developed based on similarities and connections within the main themes.

4. Results

4.1. Focus of the studies and participants' characteristics

Seventeen studies were included in the review. Table 3 presents a summary of each study's key characteristics. The selected studies were published between 2019 and 2023. Thirteen studies focused on exploring internationally educated nurses' experiences, which included transition (Pawlak, 2021; Joseph et al., 2022), integration (Calenda et al., 2019; Kamau et al., 2022), temporary work permits (Nourpanah, 2019), mobile nursing, (Leone et al., 2020), early experiences, (Dywili et al., 2021), experiences and perceptions of being migrants (Rodriguez‐Arrastia et al., 2021), and sociocultural adaptation (Zanjani et al., 2021). Three studies (Brunton et al., 2019; Philip et al., 2019; Philip, Woodward‐Kron and Manias, 2019) focused on the communication of internationally educated nurses, and one study focused on perceptions of internationally educated nurses' job satisfaction (Almansour et al., 2022).

Table 3.

Characteristics of included studies.

No Author and year of publication Country Study setting Study design or methods Study focus Sampling type
1 Brunton et al., 2019 New Zealand and the United Arab Emirates Hospitals and Residential Care Facilities Exploratory qualitative Communication Convenient
2 Calenda et al., 2019 Finland Social and Health CareOrganisations, Hospitals and Private Elderly Care Home Qualitative: Content analysis Integration experience of internationally educated nurses Purposive
3 Nourpanah, 2019. Canada Caring for an Ageing Population Qualitative: Ethnographic Experienced by Foreign Nurses on Temporary Work Permits Purposive
4 Philip, et al., 2019a Australia Hospital, Aged Care, and Rehabilitation Exploratory qualitative Communication Purposive
5 Philip, et al., 2019b Australia Hospital Qualitative: Observations and Discourse Communication Purposive
6 Leone et al., 2020 UK Organisational and Policy Levels and NHS Exploratory qualitative Experience of Mobile Nursing Workforce Snowball
7 Angus et al., 2021 New Zealand Aged Residential Care (ARC) Qualitative descriptive Experience of internationally qualified nurses Self-selected, Convenient
8 Dywili et al., 2021 Australia Rural New South Wales (NSW) Qualitative hermeneutical phenomenological Early experiences of internationally educated nurses Snowballing, Purposive
9 Ham, 2021 Netherlands Dutch Health Care Institution (located in a rural village) Qualitative: Ethnographic Experience of internationally qualified nurses Purposive
10 Korzeniewska, et al., 2021 Oslo, Norway Nursing Home, Hospital, Rehabilitation Centre, Short-Term Care Centre Qualitative: Comparative Professional experience Purposive
11 Pawlak, 2021 Norway Hospital and Nursing Home Qualitative: Ethnographic Transitioning Snowball
12 Rodriguez-Arrastia et al., 2021 UK UK Healthcare Setting Qualitative survey Experiences and perceptions of migrant Purposive
13 Zanjani et al., 2021 Australia Australian Health Care Setting Quantitative cross-sectional Sociocultural adaptation Random
14 Almansour et al., 2022 Saudi Arabia Hospital Qualitative descriptive Perceptions of job satisfaction Purposive
15 Antón-Solanas et al., 2022 Belgium, Portugal, Spain, Turkey Health Services (both public and private) Qualitative phenomenological Experience working in European health services Convenience
16 Joseph et al., 2022 Australia Mental Health Qualitative hermeneutical Transition Experiences Purposive
17 Kamau et al., 2022 Finland Finnish Primary or Tertiary Health Care System Qualitative descriptive Experiences of integration Snowball
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*UK: United Kingdom.

* Internationally Educated Nurses.

* NHS: British National Health Services.

The total number of participants from all studies was 939. This included 492 females and 117 males; the sex of the remaining 330 participants was not reported. The participants' ages ranged from 20 to 62 years. The length of time spent working in their host countries ranged from 1 to 32 years within various roles, such as staff nurses, clinical practice facilitators, practice nurses, nursing directors, associate directors of human resources, nurse unit managers, associate nurse unit managers, and clinical nurse specialists. Participants were from a wide range of countries (Table 3).

4.2. Study settings and geographical location

Apart from one study conducted in a mental healthcare setting (Joseph et al., 2022), all other studies (n = 16) were conducted in acute and primary care settings, including hospitals, rehabilitation services, tertiary healthcare systems, and nursing homes. (Table 3).

4.3. Study designs

Studies included in the review employed various sampling approaches. Of 17 studies, 16 adopted a range of qualitative methodologies (Table 3). Methods selected included interviews, focus groups, observations, and surveys. In the remaining study, Zanjani et al. (2021) used a quantitative methodology with a cross-sectional approach.

Three studies collected data through the combination of two methods. Ham (2021) used a shadowing and a semi-structured interview approach. Pawlak (2021) used observation and semi-structured interviews, whereas Angus et al. (2021) collected data through focus groups and semi-structured interviews.

4.4. Key themes

Data analysis of the included studies resulted in three themes that explored the enabling influences affecting internationally educated nurses' workforce integration into their host countries. These three themes were Push and pull factors, One-way integration logic, and Expectations versus reality.

The first two themes had two sub-themes, and the third had four. The process of developing the themes and sub-themes is outlined in Table 4. The following section presents each theme in detail.

Table 4.

Process of developing the theme and sub-theme.

Themes Sub-themes Concepts from studies Contributing studies
Push and pull factors that mediate the experiences of migration of internationally educated nurses Personal & Professional push & pull factors Unemployment, pay rates, better jobs, better careers, upskilling processes, better standards of living, better family life, political factors, and job security Calenda et al., 2019; Leone et al., 2020; Dywili et al., 2021; Korzeniewska, et al., 2021; Pawlak, 2021; Rodriguez-Arrastia et al., 2021; Zanjani et al., 2021; Almansour et al., 2022
Socio-Economical Push & pull factors Unemployment, better pay rates, lack of career progression opportunities, the countries' socio-economic decline, established contacts, and support. Calenda et al., 2019; Leone et al., 2020; Dywili et al., 2021; Korzeniewska, et al., 2021; Pawlak, 2021; Rodriguez-Arrastia et al., 2021; Zanjani et al., 2021; Almansour et al., 2022
One-way integration logic Pre-departure support Inflexible regarding registration, requirements, pre-departure training, lack of information to help make informed decisions, and lack of Intra-organisational communication Calenda et al., 2019; Nourpanah, 2019; Leone et al., 2020; Joseph et al., 2022
Organisational support Induction programme, training, education, professional development, promotion/grades
lack of Intra-organisational support, professional relationships, deskilling		 Brunton et al., 2019; Calenda et al., 2019; Nourpanah, 2019.; Philip, et al., 2019a; Angus et al., 2021; Joseph et al., 2022; Korzeniewska, et al., 2021; Rodriguez-Arrastia et al., 2021; Kamau et al., 2022
The expectation versus reality Communication and Language problems Native language is isolating, feelings of exclusion, limited opportunities for professional recognition, deskilling, job satisfaction, language proficiencies requirement, language context created self-doubt, difficulty to understand the accent, especially on the phone, unfamiliar language patterns and articulation, the way of communication, not medical knowledge, language barriers were fundamental factors influencing job satisfaction, less proficient were not treated well, language skills challenges Brunton et al., 2019; Calenda et al., 2019; Nourpanah, 2019; Philip, et al., 2019a; Angus et al., 2021; Ham, 2021; Pawlak, 2021; Rodriguez-Arrastia et al., 2021; Almansour et al., 2022; Antón-Solanas et al., 2022; Kamau et al., 2022
Cultural Competence and Sensitivity Cultural shock, values and beliefs, ways of working Brunton et al., 2019a; Philip et al., 2019; Angus et al., 2021; Joseph et al., 2022; Kamau et al., 2022
Differences in Clinical Practices and Professional Development Advocating for patients, providing personal care, resilience, empowerment Brunton et al., 2019; Calenda et al., 2019; Philip, et al., 2019a; Philip, et al., 2019b; Angus et al., 2021; Korzeniewska, et al., 2021; Pawlak, 2021
Discrimination and Racism Seen as strangers and threats, bullying, safety at work or job security, social Isolation, refused care, and not facilitated equally based on ethnicity and nationality Calenda et al., 2019; Nourpanah, 2019; Philip, et al., 2019a; Angus et al., 2021; Dywili et al., 2021; Ham, 2021; Zanjani et al., 2021; Almansour et al., 2022; Antón-Solanas et al., 2022; Joseph et al., 2022; Kamau et al., 2022
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4.4.1. Push and pull factors that mediate the migration experiences of internationally educated nurses

This theme details circumstances that compelled internationally educated nurses to migrate. Out of 17 studies, eight (Calenda et al., 2019; Leone et al., 2020; Dywili et al., 2021; Korzeniewska and Erdal, 2021; Pawlak, 2021; Rodriguez‐Arrastia et al., 2021; Zanjani et al., 2021; Almansour et al., 2022) identified push factors that motivated nurses to look for opportunities overseas and pull factors that helped nurses overcome challenges and settle into the new country. Push factors may have initially motivated the internationally educated nurses to seek opportunities; for example, better pay. After they arrived in the host country and experienced high salaries compared to their home country, this acted as an enabling influence reinforcing their decisions to stay in their host countries. This theme is divided into two subthemes: personal and professional factors and socio-economic factors, explored below. Push and pull factors mediated internationally educated nurses' migration experiences, driven by personal, professional, and socio-economic considerations.

4.4.1.1. Personal and professional factors

This sub-theme explores personal and professional factors that affected internationally educated nurses' motivations to migrate and adjust to the host countries.

Several studies identified personal push factors like limited career opportunities (Leone et al., 2020; Dywili et al., 2021; Korzeniewska and Erdal, 2021; Rodriguez‐Arrastia et al., 2021; Zanjani et al., 2021), low wages, complex and unsafe working conditions (Brunton et al., 2019; Angus et al., 2021; Pawlak, 2021; Almansour et al., 2022), and political instability and socio-economic insecurity (Leone et al., 2020; Dywili et al., 2021; Korzeniewska and Erdal, 2021; Pawlak, 2021; Rodriguez‐Arrastia et al., 2021; Zanjani et al., 2021; Almansour et al., 2022) that compelled internationally educated nurses to migrate to host countries for their personal development as well as to ensure their own and their families safety and wellbeing

Studies also identified professional push factors, including a lack of professional recognition, lack of specialised and advanced role opportunities, lack of job satisfaction, and lack of autonomy that hindered their professional development and career progression, so seeking 'greener pastures' motivated internationally educated nurses to migrate (Calenda et al., 2019; Leone et al., 2020; Dywili et al., 2021; Korzeniewska and Erdal, 2021; Rodriguez‐Arrastia et al., 2021; Zanjani et al., 2021). Positive accounts shared on social media and the recruitment agencies promoting the benefits of working in the UK were also seen as pull factors (Leone et al., 2020; Rodriguez‐Arrastia et al., 2021).

Factors that helped internationally educated nurses adjust in the host countries were pull factors that included professional recognition (Philip et al., 2019; Korzeniewska and Erdal, 2021; Rodriguez‐Arrastia et al., 2021), opportunities to utilise their skills and knowledge to their fullest potential (Philip et al., 2019; Korzeniewska and Erdal, 2021; Rodriguez‐Arrastia et al., 2021), and career advancement opportunities (Philip et al., 2019; Korzeniewska and Erdal, 2021; Pawlak, 2021; Rodriguez‐Arrastia et al., 2021). These were viewed as influences in migrating internationally educated nurses to well-established healthcare systems and improved work-life balance, including flexible working hours, shift patterns, and social support designs.

4.4.1.2. Socio-economical push and pull factors

Socio-economic factors, like economic instability, unemployment, inflation or economic crises, inadequate healthcare infrastructure, low grades, and low pay rates (Leone et al., 2020; Dywili et al., 2021; Korzeniewska and Erdal, 2021; Pawlak, 2021; Rodriguez‐Arrastia et al., 2021; Zanjani et al., 2021) substantially influenced the decisions of internationally educated nurses to migrate to regions where there was a better healthcare system and better remuneration (Leone et al., 2020; Zanjani et al., 2021). Other issues that impacted on internationally educated nurses' job satisfaction included racial differences and racism in the workplace (Calenda et al., 2019; Nourpanah, 2019; Philip et al., 2019; Angus et al., 2021; Dywili et al., 2021; Ham, 2021; Zanjani et al., 2021; Almansour et al., 2022; Antón-Solanas et al., 2022; Joseph et al., 2022; Kamau et al., 2022), as well as cultural and practice differences (Brunton et al., 2019; Philip et al., 2019; Angus et al., 2021; Korzeniewska and Erdal, 2021; Almansour et al., 2022; Joseph et al., 2022). A study by Ham (2021) highlighted challenges relating to power dynamics and organisational constraints. These challenges were also considered push factors influencing nurses' decisions to seek better integration opportunities elsewhere.

4.4.2. One-way integration logic

One-way integration logic describes a mindset approach of a host country's work colleagues who think that integration into the new healthcare system is the sole responsibility of incoming internationally educated nurses (Philip et al., 2019). Several studies (Calenda et al., 2019; Philip et al., 2019; Leone et al., 2020; Angus et al., 2021; Ham, 2021; Rodriguez‐Arrastia et al., 2021; Zanjani et al., 2021; Kamau et al., 2022) identified this approach. The theme is composed of two sub-themes: Pre-departure support and Organisational support.

4.4.2.1. Pre-departure support

The successful integration of internationally educated nurses into the healthcare system and their new roles was influenced by the level of pre-departure support from their host country's employing organisation. Seven studies (Calenda et al., 2019; Philip et al., 2019; Leone et al., 2020; Korzeniewska and Erdal, 2021; Zanjani et al., 2021; Almansour et al., 2022; Kamau et al., 2022) explored these factors and their effects on integration. The studies conducted by Brunton et al. (2019) Nourpanah (2019), Philip et al. (2019a), Angus et al. (2021), Joseph et al. (2022) and Kamau et al. (2022) reported that a lack of pre-departure information, such as limited information about the host country and its healthcare system, licensing requirements, and cultural norms, caused difficulties in navigating the new environment and meeting professional expectations; this could lead to frustration and confusion in many internationally educated nurses. It was also reported that many internationally educated nurses struggled to understand the legal and ethical frameworks, clinical policies and procedures, and required documentation for their settings (Angus et al., 2021; Ham, 2021; Kamau et al., 2022). A study by Nourpanah (2019) examined the experiences of internationally educated nurses in Canada, with challenges relating to a lack of support and guidance before they arrived in Canada. Participants felt unprepared for the cultural, social, and professional differences they encountered. The importance of pre-departure preparation programmes and support systems in facilitating a smoother transition and integration of internationally educated nurses into the Canadian healthcare system was highlighted. Similarly, Korzeniewska and Erdal (2021) examined the experiences of Filipino and Polish nurses in Norway. They highlighted the challenges immigrant nurses face, including the need to complete a nursing degree in Norway for Filipino nurses and the constant changes in authorisation regulations and language requirements after arrival in the host country.

An inadequate understanding of cultural and social dynamics and professional norms led internationally educated nurses to face challenges in building professional relationships with colleagues and patients, which could result in misunderstanding, mistrust, and cultural clashes as well as sub-optimal patient care (Brunton et al., 2019; Philip et al., 2019; Philip, Woodward‐Kron and Manias, 2019; Pawlak, 2021; Almansour et al., 2022; Kamau et al., 2022). Due to these factors, internationally educated nurses often found it challenging to meet the expectations of their new employers in their host countries (Philip et al., 2019; Angus et al., 2021; Kamau et al., 2022). A lack of information about local customs, language barriers, and different healthcare practices was reported in some studies to make internationally educated nurses feel isolated and disoriented (Brunton et al., 2019; Calenda et al., 2019).

Several researchers found that insufficient pre-departure support significantly mediated internationally educated nurses' experiences, affecting their cultural adjustment, professional readiness, psychological and emotional wellbeing, and overall successful integration into the new healthcare system (Calenda et al., 2019; Korzeniewska and Erdal, 2021; Rodriguez‐Arrastia et al., 2021; Kamau et al., 2022). It was recommended that host countries provide comprehensive pre-departure support to internationally educated nurses to enable their smooth transitioning and integration into the healthcare system, thus bringing benefits to both internationally educated nurses and the healthcare systems they worked within (Calenda et al., 2019).

4.4.2.2. Organisational support

Organisational support refers to policies, practices, and resources provided by healthcare organisations and employers to facilitate the successful integration of internationally educated nurses into the workplace (NHS, 2023). Data relating to this sub-theme was present in nine studies (Brunton et al., 2019; Philip, Woodward‐Kron and Manias, 2019; Angus et al., 2021; Dywili et al., 2021; Ham, 2021; Pawlak, 2021; Rodriguez‐Arrastia et al., 2021; Almansour et al., 2022; Kamau et al., 2022) and highlighted the importance of such support, which included orientation programs, mentorship, language and cultural training, equal opportunities, a safe work environment, and how this mediated the migration and integration experiences of internationally educated nurses. A study conducted in Canada by Nourpanah (2019) discussed the experiences of registered nurses who navigated foreign environments, including language issues, hierarchy, and cultural values clashes. Nourpanah (2019) also examined how positive support from organisations, especially colleagues and the human resources departments, helped them navigate these challenges.

4.4.3. Expectations versus reality

This theme referred to the high expectations and perceptions internationally educated nurses often had about the host countries and the healthcare system they had migrated to. They looked forward to better wages, improved working conditions, professional recognition, and career advancement. However, their reality was often more complex and beyond their expectations. This theme was widely discussed in 13 of the 17 included studies (Brunton et al., 2019; Calenda et al., 2019; Nourpanah, 2019; Philip et al., 2019; Angus et al., 2021; Dywili et al., 2021; Ham, 2021; Korzeniewska and Erdal, 2021; Pawlak, 2021; Zanjani et al., 2021; Almansour et al., 2022; Antón-Solanas et al., 2022; Joseph et al., 2022; Kamau et al., 2022). This theme was further divided into four sub-themes, which are detailed below.

4.4.3.1. Communication and language problems

Communication and language barriers were dominant concerns reported by many internationally educated nurses in their host countries. Eleven selected studies (Brunton et al., 2019; Calenda et al., 2019; Nourpanah, 2019; Philip et al., 2019; Angus et al., 2021; Ham, 2021; Pawlak, 2021; Rodriguez‐Arrastia et al., 2021; Almansour et al., 2022; Antón-Solanas et al., 2022; Kamau et al., 2022) highlighted that communication and language barriers affected not only internationally educated nurses' relationships with work colleagues (Brunton et al., 2019; Philip et al., 2019; Kamau et al., 2022) but also with patients (Brunton et al., 2019; Philip et al., 2019; Almansour et al., 2022). This also affected their personal and professional development.

Many studies (Brunton et al., 2019; Philip et al., 2019; Angus et al., 2021; Ham, 2021) reported that internationally educated nurses were expected to have no communication problems after passing the language proficiency exam, but the reality was different. Internationally educated nurses reported communication challenges because of cultural and language context, accent, tone, and fluency (Brunton et al., 2019; Philip et al., 2019; Angus et al., 2021; Ham, 2021). This not only created tension and barriers between speakers but also created self-doubt and impacted the confidence of internationally educated nurses (Calenda et al., 2019; Philip et al., 2019).

4.4.3.2. Cultural competence and sensitivity

Cultural competence refers to the ability of healthcare professionals to understand and effectively respond to the unique cultural and linguistic needs of individuals and communities (Jeffreys, 2010). It involves acquiring knowledge, attitudes, and skills that enable healthcare providers to work effectively with people from different cultural backgrounds (Boehm-Davis et al., 2015). Cultural competence and sensitivity were reported by some papers as essential aspects in the context of internationally educated nurses (Brunton et al., 2019; Philip et al., 2019; Joseph et al., 2022).

Various studies suggested that meeting the needs of patients from diverse cultural backgrounds was reported as a challenge by internationally educated nurses (Brunton et al., 2019; Philip et al., 2019; Angus et al., 2021; Almansour et al., 2022). These researchers revealed that despite expecting a cultural difference, internationally educated nurses felt shocked and unprepared for the new culture (Brunton et al., 2019; Philip et al., 2019; Angus et al., 2021; Joseph et al., 2022; Kamau et al., 2022). Their cultural values and beliefs added a layer of difficulty in adapting the cultural beliefs, values, and practices of the communities they served in the host country (Joseph et al., 2022). In addition to individual cultural competence (Philip et al., 2019), some studies reported that healthcare organisations played a crucial role in fostering a culturally sensitive work environment (Philip et al., 2019; Leone et al., 2020; Kamau et al., 2022).

4.4.3.3. Differences in clinical practices and professional development

Some researchers (Brunton et al., 2019; Calenda et al., 2019; Philip et al., 2019; Philip, Woodward‐Kron and Manias, 2019; Angus et al., 2021; Korzeniewska and Erdal, 2021; Pawlak, 2021) reported that internationally educated nurses faced several challenges due to differences in their nursing practices; for example, advocating for their patients (Brunton et al., 2019; Pawlak, 2021), providing personal hygiene (Calenda et al., 2019), observing power differences among nurses and doctors (Philip et al., 2019; Pawlak, 2021), and being held accountable for their actions (Pawlak, 2021). Brunton et al. (2019) reported that internationally educated nurses often felt enslaved in their home country because of the power difference between nurses and doctors, whereas in the host country, nurses could talk to the doctor on behalf of their patients and advocate for their patients (Brunton et al., 2019; Philip et al., 2019). Because of these differences in practices, on occasion, when nurses failed to take the initiative (Calenda et al., 2019), they felt isolated, undervalued, and incompetent (Calenda et al., 2019; Philip et al., 2019; Angus et al., 2021). This also caused deskilling and lack of autonomy in some internationally educated nurses (Calenda et al., 2019; Dywili et al., 2021; Ham, 2021; Kamau et al., 2022). Differences in nursing practices not only affected internationally educated nurses' confidence (Philip et al., 2019; Angus et al., 2021) but also impacted their ability to provide effective and safe care (Calenda et al., 2019; Angus et al., 2021; Ham, 2021), as well as their overall integration into their host country (Philip et al., 2019; Rodriguez‐Arrastia et al., 2021; Zanjani et al., 2021).

4.4.3.4. Discrimination and racism

This sub-theme looked at the experiences of internationally educated nurses who faced discrimination and racism upon their arrival in their host country. Many researchers (Calenda et al., 2019; Nourpanah, 2019; Philip et al., 2019; Angus et al., 2021; Dywili et al., 2021; Ham, 2021; Zanjani et al., 2021; Almansour et al., 2022; Antón-Solanas et al., 2022; Joseph et al., 2022; Kamau et al., 2022) reported that internationally educated nurses experienced explicit racism in the workplaces of their host countries. This included negative attitudes from colleagues and patients (Calenda et al., 2019; Nourpanah, 2019; Philip et al., 2019; Angus et al., 2021; Dywili et al., 2021; Ham, 2021; Antón-Solanas et al., 2022; Joseph et al., 2022; Kamau et al., 2022), which led them to feel unwelcome and isolated (Philip et al., 2019; Dywili et al., 2021). Discrimination was evident in various forms, such as limited career advancement opportunities.(Kamau et al., 2022), unequal pay (Almansour et al., 2022), and different treatment based on nationality or ethnicity (Almansour et al., 2022). Power dynamics also contributed to racism and discrimination(Ham 2021).

5. Discussion

In this review, we highlighted factors affecting internationally educated nurses' integration into their host countries' healthcare systems. The insufficient information, lack of understanding about a host country's healthcare system, differences in clinical practices, and role expectations across different countries all influenced the integration experiences of internationally educated nurses. We suggest that improved pre-departure support, including information about the host country's healthcare systems, settings, and practices, may help internationally educated nurses make informed decisions about their migration to the host country (Newton et al., 2012; Balante et al., 2021). For internationally educated nurses to feel more prepared and ready to integrate into new healthcare systems, host country organisations should offer pre-departure programs that are tailored to address the unique needs of internationally educated nurses from different origins (Iheduru-Anderson and Wahi, 2018; Ghazal et al., 2020). Orientation programs, preceptorship or mentorship programs, language and cultural training (Moyce et al., 2016; Ghazal et al., 2020), and enhanced organisation support may help internationally educated nurses navigate new healthcare systems successfully, with resulting positive integration experiences (Ghazal et al., 2020).

Another reality identified from the selected studies was discrimination and racism directed towards internationally educated nurses. This discrimination was reported to be based on internationally educated nurses' cultural backgrounds, nationalities, and ethnicities (Calenda et al., 2019; Nourpanah, 2019; Philip et al., 2019; Angus et al., 2021; Dywili et al., 2021; Ham, 2021; Zanjani et al., 2021; Almansour et al., 2022; Antón-Solanas et al., 2022; Joseph et al., 2022; Kamau et al., 2022). Studies suggested that carefully tackling this issue is crucial to prompt wellbeing among staff (Zanjani et al., 2021). If this issue is not tackled, it can affect the motivation, productivity, and quality of care patients receive (Chin et al., 2019; Zanjani et al., 2021). To address this issue, healthcare organisations should promote inclusivity and diversity. Culturally-sensitive training and implementation of policies to promote equal opportunities can help create a welcoming and supportive environment. We also found (Moradi et al., 2017) that healthcare organisations play a crucial role in creating a culturally-sensitive work environment. This can be achieved by providing training and resources that promote cultural understanding and sensitivity and facilitating cross-cultural collaboration and communication opportunities, as nurses are expected to work collaboratively to provide safe, quality, culturally consistent care (Ong-Flaherty, 2015). Cultural competence and sensitivity are also particularly relevant regarding patient-centred care, informed consent, and end-of-life decision-making (Angus et al., 2021). Culturally-sensitive policies and practices of organisations can enable internationally educated nurses to navigate complex situations more effectively and minimise cultural misunderstandings (Ong-Flaherty, 2015). In addition, we found that the integration experiences of internationally educated nurses were influenced by their cultural norms, values, and beliefs. Evidence suggests that the culture of any organisation, department, or professional group, such as nurses, can also be influenced by the perceptions, attitudes, and beliefs of those already working there (Braithwaite et al., 2017). New staff, including internationally educated nurses, may face challenges adapting to organisational culture because of their cultural beliefs (Chun Tie, Birks and Francis, 2019; Pawlak, 2021). Therefore, there is a need for a culturally sensitive work environment to help internationally educated nurses learn the new norms of an organisation and department, as well as transfer their previous skills and knowledge to meet the expectations of their job roles.

Language and communication barriers, including differences in accents, tone, and use of language in its cultural context, were reported to cause conflicts, mistrust, and confusion between internationally educated nurses, colleagues, and patients in their new work environments. Intra- and inter-professional communication was poor between internationally educated nurses and colleagues from the host country (Philip, Woodward‐Kron and Manias, 2019). Other factors like hesitancy and not being assertive also affected this communication (Omura et al., 2018). To address the factors related to communication, specific programs on language training designed to address specific cultural contexts of the work environment and community might be helpful. Providing such training can help internationally educated nurses navigate the challenges connected to language and communication barriers effectively. This can also help to break down any communication barriers, boost internationally educated nurses' confidence, and promote team collaboration with an improved ability to provide quality care to patients. The guidance and support from experienced preceptors, mentors, and supervisors can also help overcome language and communication barriers and can provide internationally educated nurses with opportunities to clarify any language difficulties that may arise, fostering a sense of belonging and professional growth (Kamau et al., 2022). Moreover, to support internationally educated nurses' successful integration into new healthcare settings, there is also a need for training on the importance of intra and inter-professional communication for all staff (Neiterman and Bourgeault, 2015).

Push and pull factors heavily affected the decisions of internationally educated nurses to migrate to their host countries. However, differences between their initial expectations versus reality may lead to internationally educated nurses facing many challenges in their host countries. This is reinforced by a recent German study (Roth et al., 2022), which found that nurses leaving or joining organisations are influenced by a complex range of push and pull factors (Okafor and Chimereze, 2020; Roth et al., 2021). Therefore, successfully integrating internationally educated nurses requires a multi-faceted approach by organisations (Sasso et al., 2019; Leone et al., 2020). Sasso et al. (2019) reported that to create a safe and supportive work environment for nurses; healthcare organisations need to work on policies that promote safe staffing, fair salaries, and opportunities for professional development to help retain skilled nurses. By addressing the push and pull factors (Okafor and Chimereze, 2020) and creating better opportunities for nurses by offering comprehensive support to internationally educated nurses in their host countries, their integration experiences can be improved to ensure a more sustainable and efficient healthcare workforce (Roth et al., 2022).

5.1. Limitations

The review has several limitations. These include that some relevant studies may not have been identified during the review process due to the application of limiters like "studies published between 20192023″, "English Language", and "Peer Reviewed." In addition, studies were international in context, originating from Asia, Europe, North America, and Oceania. Whilst this ensured a comprehensive overview of the challenges and enablers facing internationally educated nurses, different continents have different healthcare systems and workforce structures, which may have limited the applicability of the findings to specific settings.

5.2. Conclusions

A comprehensive and collaborative organisational approach is required to successfully integrate internationally educated nurses into their host countries. By tackling discrimination and racism and proactively addressing communication and language barriers, healthcare organisations can create a more inclusive and supportive environment. This, in turn, can lead to better integration, improved patient care outcomes, and increased job satisfaction among internationally educated nurses, benefiting the entire healthcare system. Addressing push and pull factors, providing pre-departure support, and offering comprehensive organisational support can enhance the integration experiences of internationally educated nurses, ensuring they contribute and fulfil the responsibilities of their roles and become influential team members within their organisations. By addressing these challenges collectively, a more robust and diverse healthcare workforce can emerge to provide high-quality care to patients from diverse backgrounds and within different healthcare contexts.

5.3. Recommendations for policy and practice

There are several implications for healthcare organisations and policymakers based on the conclusions drawn from this review.

The researchers highlighted a need for a comprehensive support system that helps internationally educated nurses during their integration. Therefore, employers need to maximise this support by investing in and offering pre-departure and post-departure programmes and training (induction programs, preceptorships and mentorship packages, and language proficiency training). This will facilitate internationally educated nurses' integration and allow them to navigate the challenges they face during integration into their host countries' healthcare systems.

Organisations need to acknowledge the diversity that internationally educated nurses bring to the workforce. Hence, an inclusive, culturally sensitive, supportive work environment should be created. This will not only help to develop intra and inter-professional trustworthy relationships, which will promote patient-centred quality care, but also help to address the issues related to race and discrimination. Ultimately, this will increase job satisfaction and result in workforce retention.

Integrating internationally educated nurses into their host countries' healthcare systems is a complex and ongoing process requiring long-term integration planning and continuous support from individual organisations and policymakers. Future studies need to be conducted to see the impact of any supportive intervention.

To address some of the challenges internationally educated nurses face due to a lack of support from colleagues, there is a need to explore these colleagues' perspectives about their experiences of working with internationally educated nurses. This will aid in our understanding of the challenges of inter-professional colleagues. This can lead to the developing an evidence-based support program that can lead to more effective and targeted interventions to address these challenges and promote successful integration.

Additionally, through longitudinal studies and monitoring integration experiences of internationally educated nurses over time, policymakers and healthcare organisations can identify areas for improvement and tailor support programs to meet the changing needs of internationally educated nurses.

Overall, proactive, collaborative efforts from healthcare organisations, policymakers, and the nursing community to create a more supportive and inclusive environment for internationally educated nurses are vital in addressing some of the issues identified in this review. By addressing the challenges highlighted in the conclusions and implementing evidence-based interventions, healthcare systems can harness the potential of internationally educated nurses, improve job satisfaction and patient care, and create a more resilient and culturally competent nursing workforce.

Funding sources

This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Aasia Rajpoot: Conceptualization, Methodology, Formal analysis, Writing – original draft, Visualization. Clair Merriman: Conceptualization, Methodology, Formal analysis, Writing – review & editing, Supervision. Anne-Marie Rafferty: Writing – review & editing, Supervision. Catherine Henshall: Conceptualization, Methodology, Formal analysis, Writing – review & editing, Supervision.

Declaration of competing interest

All authors declare no conflicts of interest.

Acknowledgements

The authors acknowledge the support of the National Institute for Health and Care Research (NIHR) Oxford Health Clinical Research Facility. The views expressed are those of the authors and not necessarily those of the NIHR, UK National Health Service, or the UK Department of Health and Social Care.

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