Jay  Shen,  Ph.D.  Yu  Xu,  Ph.D.,  RN  (Posthumously)      Susan  VanBeuge,  DNP,  APRN    

Scott  Neishi    

Department  of  Health  Care  Administration  and  Policy  

School  of  Community  Health  Sciences  School  of  Nursing  

University  of  Nevada,  Las  Vegas    Jay.shen@unlv.edu    

Background  

�  Internationally  educated  nurses  (IENs)  joining  the  HC  workforce  has  gained  popularity  over  the  past  few  decades  (AcademyHealth,  2008;  Aiken  et  al.,  2004;  Buerhaus,  Auerback,  &  Staiger,  2009;  Davis  &  Nichols,  2002;  Polsky  et  al.,  2007)  

�  1970’s  -­‐  Estimated  50,000  (Masselink  &  Jones,  2014)  

�  2008  -­‐  Estimated  165,000  (Masselink  &  Jones,  2014)  

� Dependence  on  IENs  higher  in  certain  regions  of  the  United  States  has  increased:  � Nevada  -­‐  15.6%  with  estimated  10-­‐15%  under-­‐reporting  (Personal  communication  with  Criswold,  2007)  

Background  �  IENs  vs.  American  Educated  Nurses  (AENs):  

�  Linguistic  Skill:  IENs  need  improvements  as  evidenced  by  documented  phonological  errors  by  licensed  registered  nurses  (Xu,  Bolstad,  Shen,  et  al.,  2010*)  

�  Interpersonal  Communication:  The  interpersonal  skills  of  IEN  in  3  of  the  4  domains  (i.e.,  Domain  1:  Skills  in  Interviewing  and  Collecting  Information,  Domain  2:  Skills  in  Counseling  and  Delivering  Information,  Domain  3:  Rapport,  and  Domain  4:  Personal  Manner)  need  improvement  (Shen,  Xu,  Staples,  &  Bolstad,  2013*)  

� Non-­‐verbal  Communication:  IENs  below  average  in  5  of  12  categories  (hugging,  lowering  body  position  to  patient’s  level,  leaning  forward,  shaking  hands,  and  therapeutic  touch)  (Xu,  Staples,  &  Shen,  2012*)  

*Research  funded  by  NCSBN  

Significance  � Given  linguistic  and  communication  deficiencies  of  IENs,  anecdotal  cases  and  some  concerns  exist  about  quality  of  care  provided  by  IENs  

� However,  scientifically-­‐based  empirical  evidence  is  lacking  in  the  literature  comparing  IENs  to  AENs  on  patient  safety  and  quality  of  care,  specifically  medication  errors    

� Medication  errors  are  a  significant  patient  safety  and  quality  issues    �  It  is  estimated  up  to  1.5  million  medication  errors  occurring  annually  in  the  United  States  at  a  cost  of  $3.5  billion  (IOM,  2006)  

Research  Ques4ons  This  project  aimed  to  test  the  hypotheses  related  to  the  following  questions:  1.  Are  there  any  differences  in  frequencies  of  

medication  errors  between  IENs  and  AENs?    2.  Do  types  of  medication  errors  vary  between  

IENs  and  AENs?    3.  If  there  are  differences,  do  they  change  over  

time?    

Methods  –  Study  Design  &  Data  � A  quasi-­‐case-­‐control  study  

�  Case  group:  randomly  selected  from  the  2006  and  2010  medication  error  files    

�  Comparison  group:  randomly  selected  from  the  2006  and  2010  medication  files  from  pharmacy  dept.  

� Data  source:  4  hospitals  in  the  Southwestern  region    �  Sample  size:  1,716  RNs    

�  Case  group:  984;  comparison  group:  732  �  2006:  729;  2010:  987    

Methods  -­‐  Measures  � Dependent  variables  

� Medication  error  incident  � Multiple  errors  � Medication  error  consequence    

�  Error  not  reach  patient  �  Error  reached  patient  but  no  harm  �  Error  reached  patient  with  harm  

� Medication  type:  18  categories  �  Independent  variables  

�  IENs  vs.  AENs  �  Year:  2006  vs.  2010  (looking  for  trends)  

Results  Table  1.  RNs  Sociodemographics  and  Education  Status  

                         Case                Comparison

Variable IEN  

(n  =  315)   AEN  

(n  =  658)   IEN  

(n  =  246)   AEN  

(n  =  485)

Age  ,  year 43 41 43 41 Female 89% 89% 90% 86% Basic  nursing  education

       Associate  Degree 13% 46% 14% 48%        Licensed  Practiced  Nurse  (LPN) 4% 10% 5% 9%        BS  in  Nursing 78% 39% 76% 41%

       Diploma 5% 4% 5% 2% With  advanced  degree 4% 2% 7% 2%

Results  Table  2.  Nursing  Education  by  Country        

                               Case                                    

Comparison  

Nursing  Education 2006 2010   2006 2010

USA 65.9% 69.2% 65.4% 67.1%

Philippine 26.6% 22.3% 25.3% 25.2%

Other  countris 7.4% 8.5% 9.3% 7.6%

Total 100.0% 100.0%   100.0% 100.0%

Results  Table  3.  Medication  Error:  IENs  vs.  AENs  

2006  (n  =  729) Case Comparison p-­‐Value

IEN 34.1% 34.6%  

AEN 65.9% 65.4%       >  0.10

2010  (n  =  985)  

IEN 30.8% 32.9%  

AEN 69.2% 67.1%

      >  0.10

Results  Table  4.  Nurses  with  Multiple  Medication  Error  Incidents:  IENs  vs.  AENs

2006  (n  =  394) 1  Med  Err >  1  Med  Err p-­‐Value

IEN 38.4% 61.7%  

AEN 42.9% 57.1%       >  0.10

2010  (n  =  504)  

IEN 54.1% 46.0%  

AEN 50.8% 49.2%

      >  0.10

Results  Table  5.  Consequences  of  Medication  Errors:  IENs  versus  AENs

2006  (n  =  414) IEN AEN p-­‐Value

Error  not  reach  to  patients 6.4% 14.2%  

Error  reached  patients  but  no  harm 82.1% 74.5%

Error  reached  patients  with  harm 11.4% 11.3%

      <  0.10

2010  (n  =  556)  

Error  not  reach  to  patients 27.7% 18.9%  

Error  reached  patients  but  no  harm 64.1% 72.3%

Error  reached  patients  with  harm 8.2% 8.8%

      <  0.10

Results  Table  6.  Top  5  Drug  Categories  of  Medication  Errors:  IENs  vs.  AENs

                       Rank     IEN   AEN

2006 Analgesics 5 5 Antimicrobials 2 1 Cardiovascular 1 2 Electrolytes/Nutrition/Minerals 3 4 Endocrine/Metabolism 4 3

2010 Analgesics 4 5 Antimicrobials 2 2 Cardiovascular 1 1 Electrolytes/Nutrition/Minerals 3 3 Endocrine/Metabolism 4 Multiple  Medications 5  

Conclusions  � No  significant  differences  in  frequency  of  making  medication  errors  between  IENs  and  AENs  were  observed    

� No  significant  differences  in  making  multiple  medication  errors  between  IENs  and  AENs  were  observed    

� While  hospitals  have  improved  quality  of  care  in  the  area  of  medication  errors  (e.g.,  through  IT)  between  2006  and  2010,  IENs  seem  to  have  benefitted  more  than  their  American  counterparts  in  terms  of  making  significantly  fewer  errors  that  impacted  the  patient      

Policy  Implica4ons  � Continuous  improvement  in  quality  of  care  is  important,  especially  for  IENs  who  have  received  significant  benefits  from  it  

�  IENs  are  able  to  provide  comparable  quality  of  care  as  AENs,  which  may  play  an  import  role  in  alleviating  the  problem  of  increasing  healthcare  provider  shortage  during  the  implementation  of  the  Affordable  Care  Act