Impact of Transitional Experiences on the Preparedness of Internationally Educated Nurses to Provide Care for Older Adults in U.S. Long-Term Care Settings: A Qualitative Study

Abstract

PURPOSE:

To explore the transitional experiences of internationally educated nurses (IENs) in U.S. long-term care (LTC) settings, focusing on their preparedness to provide care for older adults and the perceived quality of professional development opportunities.

METHOD:

A qualitative descriptive methodology was used with 22 IENs from eight countries participating in semi-structured interviews. Braun and Clarke’s thematic analysis framework integrated inductive and deductive approaches.

RESULTS:

Two key themes emerged from the analysis—Preparation for Care of Older Adults and Navigating Professional Growth. IENs with prior gerontological care experience felt more prepared for LTC roles. Professional development opportunities varied significantly, with many participants citing inadequate ongoing training. Findings suggest that a comprehensive clinical orientation program and ongoing professional development opportunities are essential for IENs to succeed in LTC facilities.

CONCLUSION:

Findings underscore the importance of comprehensive orientation and structured, continuous professional development tailored to IENs’ needs. Enhanced support systems could improve IEN integration, care quality, and workforce retention in U.S. LTC settings.

The aging population in the United States has led to increased demands for health care professionals, particularly in long-term care (LTC) settings. The number of older adults in the United States is projected to grow significantly in the future (Haddad et al., 2022). Approximately 55.8 million U.S. adults are aged ≥65 years, comprising 16.9% of the total population (U.S. Census Bureau, 2020). The demand for gerontological care will increase, including care for those with chronic diseases and comorbidities as the older adult population grows. The health care system should ensure that there is adequate availability of nurses prepared to care for the growing population of older adults, as researchers have predicted that by 2030, 70% of nurses in all health care settings will be largely caring for older adults (Roberts et al., 2018).

The distribution of nurses among various settings will change in the near future as the composition of the U.S. population includes more older adults who may live in LTC settings (U.S. Census Bureau, 2020). A recent survey conducted by the American Health Care Association (2024) involving 441 nursing home providers revealed that 94% of facilities faced challenges in recruiting new staff, with 67% attributing these difficulties to a shortage of interested or qualified candidates. Numerous studies have found a positive correlation between increased RN staffing levels and improved quality of care for residents in nursing homes (Dellefield et al., 2015). Gerontological nurse leaders highlight the critical issue of insufficient RN staffing in U.S. nursing homes and propose solutions for improving care quality and RN recruitment/retention (Kolanowski et al., 2024). To address the growing RN shortage, most developed countries, including the United States, have turned to internationally educated nurses (IENs) who obtained their initial nursing education outside the United States, as a valuable resource (World Health Organization, 2016). However, the transition of IENs into the U.S. health care system, especially in gerontological care, presents unique challenges that may impact their preparedness and the quality of care they provide (Adeniran et al., 2008; Kokorelias et al., 2024). Although IENs bring diverse knowledge and skills to their new practice areas, they often face sociocultural differences, language barriers, and unfamiliarity with the U.S. health care system that can affect their ability to deliver high-quality care to older adults (Adeniran et al., 2008; Olanrewaju & Loeb, 2024).

IENs are essential in LTC as they provide individualized care to residents (Jenkins & Huntington, 2016) and have a fundamental role in transforming health care by providing a value-driven and high-quality environment for LTC residents (Tomlinson et al., 2020). IENs have become crucial contributors to the U.S. nursing workforce, fostering a more diverse pool of nursing staff that aligns with the increasing diversity of the U.S. patient population (Olanrewaju & Loeb, 2024). Hiring IENs can enrich the U.S. nursing workforce as these individuals bring diverse knowledge and skills acquired in their home countries.

Despite the potential role of IENs in addressing the shortage of gerontological care providers, there is limited research on their experiences and support needs within the context of caring for older adults in the United States. Cultural, economic, and social factors influence the variations in educational preparation for the care of older adults across countries (Jenkins & Huntington, 2016). These differences can impact the way IENs approach gerontological care when they transition to working in the U.S. health care system. Without additional support, the mismatch between IENs’ skills and the responsibilities of positions they fill challenges their successful adaptation (Xiao et al., 2014). IENs’ gap in knowledge is particularly concerning given the complex nature of gerontological care, which requires specialized skills and knowledge. Furthermore, the impact of IENs’ transitional experiences on their preparedness to provide care for older adults in LTC settings remains largely unexplored. Thus, the current study aimed to address this gap by examining how IENs perceive the impact of their transitional experiences on their preparedness to provide care for older adults and the quality of care delivered in LTC settings in the United States. In addition, the study sought to explore IENs’ perspectives on the quality of opportunities for ongoing professional development in these settings, recognizing the importance of continuous learning and skill enhancement in gerontological care. There is a need for further research using personal narratives to explore the real-life experiences of IENs caring for older adults in LTC settings. To achieve this objective, the following research questions were developed:

Research Question (RQ) 1: How do IENs perceive the impact of their transitional experiences on their preparation to care for older adults and the quality of care delivered in U.S. LTC settings?

RQ2: How do IENs view the quality of opportunities for ongoing professional development in U.S. LTC settings?

METHOD

Study Design

The Consolidated Criteria for Reporting Qualitative Research guidelines (Tong et al., 2007) were followed for the current study. The study adopted a qualitative descriptive methodology to understand how various transitional experiences affect IENs’ readiness and capacity to work with older adults in U.S. LTC settings (Bradshaw et al., 2017; Sandelowski, 2000; Willis et al., 2016). This methodology fosters profound exploration of IENs’ narratives and perceptions, providing rich insights into their unique experiences caring for older adults (Bradshaw et al., 2017; Magilvy & Thomas, 2009; Sandelowski, 2010).

Participants, Recruitment, and Ethical Consideration

Participants were IENs who completed their initial nursing education outside the United States and were currently practicing in the United States. IENs included those who had migrated to the United States, were currently employed as RNs in a LTC setting, and provided care to older adults (aged ≥65 years). Individuals who were interested in the study were asked to complete the eligibility questions (based on inclusion criteria) using the information on the recruitment flyer. Participants were recruited via the Long-Term Care Nurses Association and various IEN professional associations (e.g., Society of Internationally Educated Nurses in North America). In addition to direct recruitment from professional associations, social media advertising was engaged via professional and organizational social media platforms, including Twitter, Facebook, LinkedIn, and Instagram. Purposive sampling was used to recruit IENs working in LTC settings, ensuring a diverse group of participants with varying backgrounds and experiences. Additional participants were recruited through snowball sampling (Polit & Beck, 2014), where existing participants referred other eligible IENs to the study. A total of 22 participants enrolled to achieve data saturation. Figure 1 depicts the recruitment process. IENs who participated and completed individual interviews were compensated with a $50 gift card. Pennsylvania State University Institutional Review Board approved this research.

Figure 1.

Flow chart of participant selection.

Data Collection

Individual interviews were conducted via Zoom with 22 IENs across the United States. A semi-structured interview guide (Table A, available in the online version of this article), specifically designed for the study, was developed and underwent pretesting to identify unclear questions, estimate interview duration, and evaluate the reliability and validity of the instrument (Waltz et al., 2016). A pretest was conducted with four RNs working in nursing homes who did not participate in the research but possessed relevant experience, including an international nursing background. Zoom video conferencing was selected because of its ability to facilitate virtual meetings and its increasing popularity (Lobe et al., 2022). Interviews were conducted by the lead author (S.O.), who possessed formal training in the theoretical foundations and practical application of descriptive qualitative data collection and analysis.

Each interview lasted 45 to 90 minutes. Verbal consent was obtained diligently from all participants prior to data collection. Demographic information on gender, age, race, educational level, marital status, country of origin, country of initial nursing education (if different from the country of origin), number of years in their first nursing position in the United States, years of experience working with U.S. older adults, workplace environment, and state of residence were collected. Audio recordings and transcripts were securely stored in a password-protected folder on the university’s Microsoft Teams. Data collection continued until no new themes or insights emerged, indicating data saturation (Creswell & Poth, 2017). Following each interview, a skilled transcriptionist transcribed the content verbatim, which was verified by the lead author.

Data Analysis

Demographic data were analyzed using descriptive statistics, whereas thematic analysis was used to examine the qualitative interviews. Verbatim transcripts of the interviews were imported into NVivo 14 software to organize the data. Data analysis followed Braun and Clarke’s (2019) six-phase thematic procedure: familiarization, coding, theme generation, theme review, theme naming, and theme writing. The familiarization phase involved engaging with the transcripts through multiple readings. The second step involved reorganizing the data to generate the preliminary codes. The third stage entailed coding data clustering, ultimately yielding defined themes. The lead author conducted the initial three stages of the analysis and compiled a summary document containing themes, subthemes, and participants’ quotes. This summary was then shared with all coauthors (S.L., M.B., Y.-L.J.), and any discrepancies were resolved to arrive at the study’s final thematic framework. Deductive and inductive approaches were used. Deductive analysis provided a structured framework for initial coding, whereas inductive analysis allowed for an organic exploration of the data, ensuring that themes emerged directly from participants’ experiences without preconceived biases.

The study used multiple strategies to ensure trustworthiness. Credibility was achieved through persistent observation, member checking, and sustained participant engagement. Transferability was enhanced by providing detailed information about the research setting, participant demographics, and methodological procedures. Dependability was maintained through critical review by coauthors, ensuring findings reflected participants’ perspectives and minimizing researcher bias. Confirmability was reinforced by cross-referencing written notes with audio transcripts. Lastly, authenticity was upheld by fully informing participants, addressing their questions, and safeguarding their confidentiality and privacy.

FINDINGS

Demographic Characteristics

Twenty-two participants originated from eight different countries: Nigeria (n = 9), the Philippines (n = 5), Kenya (n = 3), and one participant each from India, Jamaica, Ghana, South Korea, and Zimbabwe. Participants were employed in seven states: Maine, Missouri, Maryland, New York, Illinois, Texas, and Pennsylvania. Mean age of participants was 40.45 years (SD = 7.67 years, range = 30 to 57 years). The majority of participants were female (82%, n = 18). Most participants were married (68%, n = 15), whereas the remaining were single; none were divorced or separated. Except for one participant from Kenya, who completed their nursing education in the United Kingdom, all participants received their initial nursing education in their home countries. The highest educational attainment reported was a Master of Science in Nursing, whereas the majority held a Bachelor of Science in Nursing degree (73%, n = 16). Table 1 provides the demographic characteristics of individual participants. Table 2 presents the final names of the themes. Findings are organized and presented according to the RQs addressed by each theme.

TABLE 1.

Participant Demographics (N = 22)

Participant	Gender	Ethnicity	Country of Origin	Educational Level	Years Working in U.S. LTC	Facility Type
P1	Female	Black	Nigeria	BSN	3	Assisted living
P2	Male	Asian	Philippines	MSN	2	Nursing home
P3	Female	Black	Nigeria	ADN	1	Nursing home
P4	Male	Asian	India	BSN	1.5	Nursing home
P5	Female	Black	Nigeria	ADN	1.5	Nursing home
P6	Female	Black	Nigeria	BSN	2	Nursing home
P7	Male	Black	Nigeria	BSN	2	Assisted living
P8	Female	Black	Nigeria	ADN	2	Nursing home
P9	Female	Black	Kenya	BSN	4	Nursing home
P10	Female	Asian	Philippines	BSN	26	Nursing home
P11	Female	Black	Nigeria	BSN	1	Home care
P12	Female	Black	Nigeria	BSN	1	Nursing home
P13	Female	Asian	Philippines	BSN	4	Nursing home
P14	Female	Black	Nigeria	BSN	3	Nursing home
P15	Female	Black	Kenya	ADN	4	Nursing home
P16	Female	Asian	Philippines	BSN	1	Nursing home
P17	Female	Black	Jamaica	BSN	2	Hospice
P18	Female	Asian	Philippines	BSN	26	Nursing home
P19	Female	Black	Kenya	ADN	1	Nursing home
P20	Male	Black	Ghana	BSN	2	Hospice
P21	Female	Asian	South Korea	BSN	3	Nursing home
P22	Female	Black	Zimbabwe	BSN	1	Nursing home

Note. BSN = Bachelor of Science in Nursing; MSN = Master of Science in Nursing; ADN = Associate Degree in Nursing.

TABLE 2.

Themes

Label	Definitions
Transition impacts on preparation and quality of care	Explores how pre-migration training, initial orientation, workplace adaptation, and ongoing support affect their ability to meet the demands of geriatric care
	Theme 1: Preparation for Care of Older Adults
Transition impacts on professional development (PD)	Highlights the dual impact of barriers (e.g., limited or inconsistent PD, competing PD) and positive experiences (e.g., mandatory continuing education) in PD on internationally educated nurses’ skill enhancement, integration, and ability to deliver quality geriatric care in U.S. long-term care settings
	Theme 2: Navigating Professional Growth

RQ1 Theme 1: Preparation for Care of Older Adults

This theme encapsulates the ways in which the transitional experiences of IENs influence their readiness to provide care and the quality of care delivered to older adults in LTC settings. Twenty of 22 participants contributed data to this theme. This theme’s findings reveal participants’ preparation at the time of their transition to provide high-quality care to older adult LTC residents. Participants without pre-migration knowledge and experience in caring for older adults (n = 11), initially felt unprepared to provide high-quality care.

I wasn’t really prepared, as such. I applied in the hospital, and I applied in the nursing home, and the nursing home took me first, so I wasn’t prepared at the time … When I started working, I was a little overwhelmed. I remember sometimes I would go home crying and like, “What am I really doing? Will I really make it?”

(P15, Kenya, female)

P15, therefore, reported experiencing emotional distress due to unpreparedness to care for older adults. Another participant requested orientation from her hiring agency because she felt unprepared:

I was never fully prepared. I was really nervous. I told my agency; I was very upfront with them. That’s why they were offering me 2 weeks of orientation. I said, “No, I can never be prepared in 2 weeks.” I asked for at least a month.

(P16, Philippine, female)

P16’s agency finally gave her 1 month of orientation, but she still did not feel prepared. Another participant similarly expressed feeling underprepared because of limited pre-migration experience in caring for older adults:

I catered to mostly children and adolescents. I have a limited background in taking care of geriatrics, but mostly, I have a background in dealing with mental health issues. I was not fully equipped, at first, to care for older adults in a U.S. LTC setting.

(P2, Philippine, male)

Nine participants reported that caring for older adults in their countries of origin helped prepare them to provide high-quality care when they transitioned to U.S. LTC settings.

With the experiences I had in Nigeria with older adults, coming back here to work with older adults wasn’t really a tough experience. I know their needs. I know what they want, and I know when they want it. I know how they want it.

(P1, Nigeria, female)

P1, therefore, indicated that caring for older adults in her country of origin and caring for older adults in the United States were similar jobs and that her pre-migration experiences prepared her to provide high-quality care in the United States. Although many participants did not specialize in caring for older adults in their countries of origin, many had substantial experience in working with older adults that prepared them to work in U.S. LTC settings:

I was at 75% or so prepared. Because back home, we have a lot of older population in the hospital, because I was in a surgical unit. So, most of our surgical patients were middle-aged or older adults.

(P17, Jamaica, female)

P17 also indicated that because of childhood experiences of caring for an older adult, she enjoyed caring for older adults and that her preference for working with that population contributed to easing her transition. Another participant provided a similar response, reporting that caring for adults in his country of origin helped him feel partially prepared to provide high-quality care in a U.S. LTC setting:

I would say that I was 70% prepared. Because when I was in my home country, we took care of older adults, so I know what was going on.

(P20, Ghana, male)

Although most participants with prior experience working with older adults gained that experience in their countries of origin, one gained experience in working with older adults in the United States while she was waiting to be credentialed as a nurse:

Prior to working in a nursing home, when I was preparing for my board exams, I worked in an assisted home facility with the aged, [with] people with Alzheimer’s…. After I got licensed, when I wanted to work as a RN, it was just easy for me to transition into working with the elderly because I was already used to that from the assisted living homes.

(P8, Nigeria, female)

Thus, participants who felt prepared to provide high-quality care when they transitioned into U.S. LTC settings had prior experience working with older adults, whereas participants who lacked prior experience reported feeling unprepared.

RQ2 Theme 2: Navigating Professional Growth

This theme examines how IENs’ transitional experiences influence their access to and engagement with professional development (PD) opportunities in LTC settings. All 22 participants contributed data to this theme. This theme reflects potential findings related to how IENs might perceive the quality of PD opportunities in LTC settings, capturing positive and negative experiences. This theme also encompasses aspects such as barriers to accessing PD, level of support provided by employers, and overall structure of ongoing PD.

Fifteen participants reported having no PD experience beyond the initial orientation and onboarding processes provided by their employers. This finding suggests that PD opportunities were limited or not prioritized for a majority of participants. However, seven participants shared differing experiences, indicating that they received some form of PD support through their employers.

There have been seminars. I think there’s one we did on practical experience. This is being done quarterly to assess and reassess your knowledge, and this has been of help.

(P12, Nigeria, female).

P12’s statement reflects the availability of PD opportunities at least on a quarterly basis, which she found beneficial in maintaining and enhancing her clinical skills.

They have a pre-recorded monthly continuing education. Nobody has time to do continuing education, [but] it’s recorded in the system, so you must do it.

(P17, Nigeria, male)

This participant indicated that PD was offered monthly, although it was challenging to find time to engage with these opportunities due to other professional demands. Despite this, the mandatory nature of the recorded sessions ensured that some level of ongoing learning was incorporated into their professional routine. Other participants reported less frequent PD engagement.

The health stream, or iCare, we do once every year. That’s it. Because we’re given some specific topics to read, and we have to answer questions. And this can take 3 hours.

(P1, Nigeria, female)

This finding suggests that although annual PD was available, it was limited in scope and duration, potentially leaving nurses feeling under-supported in their PD needs throughout the rest of the year. Overall, findings indicate a considerable variation in how IENs perceive and experience PD opportunities in LTC settings, ranging from consistent engagement to minimal or no ongoing development.

DISCUSSION

The current study examined how IENs perceive the influence of their transitional experiences on their readiness to provide care for older adults and the quality of care delivered in U.S. LTC settings. Current study findings demonstrated that IENs felt unprepared to provide high-quality care if they did not have prior clinical knowledge and experience in caring for older adults. Although some participants highlighted feeling unprepared due to lack of experience working with older adults, other participants acknowledged that although they did not specialize in caring for older adults in their countries of origin, they had substantial experience working with older patients that prepared them to work in U.S. LTC settings.

Comprehensive clinical orientation is essential for preparing IENs to succeed in LTC facilities. Effective orientation programs should address the specific demands of gerontological care, such as managing chronic illnesses and providing emotional support, to enhance IENs’ preparedness for working with older adults. In addition, incorporating cultural sensitivity training into these programs can equip IENs to better understand and meet the diverse needs of the geriatric population in the United States. This finding aligns with existing research, which emphasizes the importance of tailored orientation programs, as standardized approaches often overlook the unique needs of culturally diverse nursing groups (Brunton et al., 2019; Brunton et al., 2020; Calenda et al., 2019). IENs who feel well-prepared and supported are more likely to provide patient-centered care, effectively manage complex health conditions, and contribute positively to the overall care environment. Participants’ views contributed to the ever-growing body of evidence by establishing that IENs feel unprepared to provide high-quality care if they do not have prior experience in caring for older adult residents.

Although some participants indicated limited experiences with PD, other participants’ responses indicated they had no experience with PD. The discrepancies highlight the need for a more standardized and supportive approach to PD for IENs in LTC environments. PD plays a crucial role in enhancing IENs’ readiness to care for older adults effectively in LTC settings. Providing continuous learning opportunities and targeted training programs enables IENs to enhance their cultural competence, refine communication skills, and deepen their understanding of gerontological care principles. These initiatives not only increase IENs’ confidence but also improve patient outcomes. Findings align with prior research and emphasize the importance of fostering inclusive workplace cultures that support open dialogue, peer collaboration, and ongoing PD (Jenkins & Huntington, 2016; Stokes & Iskander, 2021). Structured PD pathways tailored to the unique needs of IENs can help build confidence, reduce internal challenges, and promote successful integration into the health care system (Angus et al., 2021; Korzeniewska & Erdal, 2021; Philip et al., 2019). Several studies have identified modifiable organizational factors associated with nurses’ participation in professional development, such as insufficient staff coverage while attending training, unforeseen workload, difficulties accessing PD due to shorter workdays or working exclusively on nights and weekends, and limited hospital financial resources (Pressley et al., 2022; Vázquez-Calatayud et al., 2021). These factors may significantly impede nurses’ engagement in ongoing PD.

As the global population continues to age, providing enhanced care services and improved outcomes for older adults has become increasingly important. Gerontological and geriatrics education plays a pivotal role in this effort by fostering an understanding of international aging and health, developing teamwork attitudes and skills, and promoting the application of knowledge in clinical practice (Clark et al., 2017). However, efforts to establish a unified international framework for geriatrics education are hindered by variations in accreditation standards and cultural differences (Brunner & Kada, 2010). Meanwhile, professional development programs informed by the Gerontological Nursing Competency model have strengthened gerontological nursing as a specialty and hold promise for improving nurse recruitment, retention, and overall care quality (Traynor et al., 2025). Deeper understanding of nurses’ experiences and participation in PD and examining factors associated with their PD engagement is warranted. Furthermore, it may also be worth exploring how nurses’ length of time in the United States influences their PD participation and readiness.

STRENGTHS AND LIMITATIONS

A major strength of the current study was the rich data on IENs’ experiences in transitioning to work with older adults in U.S. LTC settings. The participant pool was notably varied, encompassing individuals from eight different countries, which added to the study’s breadth. Interviews ranged from 45 to 90 minutes, ensuring ample opportunity for participants to offer detailed accounts of the phenomenon investigated. In addition, the study specifically focused on IENs caring for older adults in LTC settings to understand their unique experiences. The study used member checking, providing participants with the opportunity to validate findings, thereby ensuring the themes accurately reflected their experiences. However, the study was constrained by its focus on a relatively small group of nurses. Interviewing a broader and more representative sample of IENs in U.S. LTC settings, representing diversity in country of origin and LTC setting, could enhance generalizability of findings. This study was limited by selection bias (oversampling IENs from Nigeria and the Philippines). In addition, the study only included participants who had lived in the United States for at least 1 year, which could potentially exclude individuals who faced the most challenges and did not stay for a year. More than one half of participants (n = 13) reported having previous experience in various health care settings, which may have influenced their transition experience into LTC. Despite these limitations, the study’s findings provide research evidence on the IEN experience in transitioning to clinical care for older adults in LTC in the United States.

CONCLUSION

The current study highlights the critical role of transitional experiences and professional development in shaping the preparedness and effectiveness of IENs in providing gerontological care in LTC settings. Addressing gaps in orientation and ongoing PD is crucial to support IENs, improve care quality, and mitigate workforce shortages in the U.S. health care system. Institutional leaders and policymakers are urged to establish robust frameworks that support IENs at institutional and national levels. This support includes implementing standardized orientation protocols and developing ongoing mentorship initiatives to facilitate seamless integration. Furthermore, future intervention research should examine the effectiveness of structured orientation or mentoring models specifically tailored to meet the needs of IENs.

Table A

Interview Question Guide

Welcome and thank you for taking the time to participate in this study. The overall purpose of this study is to understand how IENs describe their experiences transitioning to work with older adults in long-term care settings in the U.S. and what are the policies and practices that lead to successful integration of IENs. Your insights will help us improve the working conditions for IENs and enhance the quality of care for older adults. This interview should take approximately 60-90 minutes. Your identity will be kept confidential. Study findings that are shared via papers, presentations, and/or reports will include only de-identified data. As a reminder, this interview will be recorded. If there are no further questions [Pause], do I have your permission to begin the recording and proceed with this interview? Please do not include identifying information about others as part of your responses.

Section I: Preamble

1. Think back to when you transitioned to working in a long-term care setting following your move to the United States:

   1. How challenging would you rate your transition experience was on a scale of 1 to 5, with 1 being very challenging and 5 being very smooth?
   2. Why did you pick that number?

Section II: Transitioning Experience

1. Please describe for me in your own words, your experience transitioning from working in your home country to working in a U.S. long-term care setting?

   1. What were the significant moments or events during your transition?
   2. How did your previous educational/clinical experiences influence your adaptation to the U.S. long-term care setting?
2. How, if at all, were recruitment agencies involved in your transition?

   1. If you engaged with a recruitment agency, please describe your experience with them.
3. Do you or have or you ever belonged to a labor union also called (an organization of labor)? If so, which one and when?

   1. Please share your experiences on how the labor union influenced your adaptation to the U.S. long-term care setting?
4. Do you or have you ever belonged to a professional organization? If so, which one and when?

   1. Please share your experiences on how the professional organization(s) influenced your adaptation to the U.S. long-term care setting?
5. What challenges did you face as you transitioned to your Registered Nurse position in long-term care in the United States?

   1. Tell me about any challenges you experience in regard to:

      1. Cultural differences and attitudes or language/accent
      2. Socioeconomic status
      3. Personal or family (e.g., Weather, child rearing)
      4. Stigma, prejudice, & discrimination,
      5. Education & training
      6. Policies and practices (e.g., credentialing & accreditation bodies, National Council of States Board of Nursing, Mentoring & Peer Support)
   2. How did you overcome the challenges that you experienced?
6. What resources (facilitators) did you find helpful during your transition?

   1. Which of the following aided your transition? (only address prompt if participants did not early address it)

      1. Preparation
      2. Supportive other(s)
      3. Resources
      4. Programs/Training
   2. Which of the following policies and practices do you believe promote successful transitions for IENs like yourself? Please explain how they were helpful

      1. Orientation and Onboarding Programs
      2. Support and Mentorship in the Workplace
      3. Continuing Education Opportunities (seminar, workshop, conference)
      4. Nurse Licensure Compacts (NLC).
      5. Immigration Policy
      6. Others (specific)
   3. What were the three most important sources of support in navigating your transition to working in long-term care in the U.S.? Please provide details.

      1. Credentialing & Accreditation Bodies.
      2. National Council of States Board of Nursing (NCSBN).
      3. Mentoring & Peer Support.
      4. Professional Nursing Associations
      5. Language & Cultural Training Programs.
      6. Employers.
      7. Educational institutions.
      8. Others (specific).

Section III: Preparedness for Working with Older Adults

1. How prepared did you feel for working with older adults in the U.S.?

2. What led to your decision to work in a long-term care setting?

3. What were your views (perspectives) about working with older adults in long-term care when you decided to accept this position?

Section IV: Workplace Experiences

1. What are your current beliefs about working with older adults in long-term care?

2. How does working in the long-term care setting in the U.S. compare to your previous work experiences? (U.S. or your home countries)

3. Please describe your experiences with those you work with and care for in long-term care settings?

   1. How about your experience with the following. (only ask them if they have not addressed the group earlier)

      1. Residents (patients)
      2. Residents’ family members
      3. Co-workers
      4. Nursing home administrator/Nurse supervisor/ Manager
   2. Tell me about any relationships that have been pivotal in shaping your current professional role.

4. In your opinion, how has your transition influenced the quality of care you deliver in the U.S. long-term care settings?

Section V: Reflection and Recommendations

1. Describe how your work transition aligned with your expectations.

2. Describe how your transition experiences conflicted with your expectations.

3. What are some practices and policies that you wish existed when you were transitioning to working in a long-term care setting in the United States? (U.S. or your home country)

   1. How do you think the practices and policies that you just suggested would have made a difference?

4. Reflecting on your overall experience, what advice would you give to other IENs transitioning to registered nursing jobs in long-term care in the U.S.?

5. What recommendations would you make to employers or policymakers to help facilitate the successful integration of IENs?

Conclusion

Is there anything else you would like to share about your experiences as an IEN working in long-term care settings in the United States?

Thank you for sharing your experiences and insights. Your input is invaluable in deepening our understanding of IENs’ transitions in the U.S. long-term care settings.