Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)

Graduate Group


First Advisor

Linda H. Aiken


Background & Significance: For decades, to counter nursing shortages, hospitals in developed countries have hired nurses from abroad. Although the certification and licensure process of foreign educated nurses aims to assure competency in educational training and language skills, systematic research evaluating the relationship between healthcare quality and hospital employment of foreign educated nurses has been lacking. Considering an increase in attention to the patient care experience and an increase in qualified applicants to nursing schools in England and the U.S., it is a prime time to examine the relationship between foreign educated nurses and patient experiences of care.

Methods: The approach used here is an independent replications analysis using similar cross-sectional secondary data in two countries. Data were gleaned from three 2009-2010 English sources and three 2006-2008 U.S. sources and included nurse survey data, hospital organizational data, and patient care experience data. The main outcomes of interest were measures of patient care experience from patient surveys. The analytic sample consisted of 31 hospitals in England and 407 hospitals in four states in the U.S. and nurses and patients at the participating hospitals. Nurses provided information about country of education and the organizational context that was aggregated to the hospital level. The sample was descriptively analyzed using chi-square tests and analysis of variance. Regression models estimated the effect of a higher proportion of foreign educated nurses on patient care experience in hospitals in England and the U.S., before and after taking hospital and modifiable organizational characteristics into account.

Results: Hospitals in England and the U.S. employing higher proportions of foreign educated nurses had lower global ratings of patient care experience and lower ratings of experience related to nursing care. Controlling for nurse and structural and organizational hospital characteristics slightly attenuated the strength and significance of the relationship between a higher proportion of foreign educated nurses and poorer patient experiences of care in England; it had no effect on this relationship in the U.S.

Conclusion: These findings reveal that in both England and the U.S., patients cared for in hospitals with a substantial proportion of nurses educated abroad rate the quality of their care lower than do patients in hospitals with fewer foreign educated nurses.

Implications: National and institutional Investment in a sufficient domestic workforce could contribute to better patient care experiences for patients.

Included in

Nursing Commons