title: Utilization of non-US educated nurses in US hospitals: implications for hospital mortality.
abstract: OBJECTIVE
  To determine whether, and under what circumstance, US hospital employment of non-US-educated nurses is associated with patient outcomes.
  
  
  METHODS
  Observational study of primary data from 2006 to 2007 surveys of hospital nurses in four states (California, Florida, New Jersey and Pennsylvania). The direct and interacting effects of hospital nurse staffing and the percentage of non-US-educated nurses on 30-day surgical patient mortality and failure-to-rescue were estimated before and after controlling for patient and hospital characteristics.
  
  
  METHODS
  Data from registered nurse respondents practicing in 665 hospitals were pooled with patient discharge data from state agencies.
  
  
  METHODS
  Thirty-day surgical patient mortality and failure-to-rescue.
  
  
  RESULTS
  The effect of non-US-educated nurses on both mortality and failure-to-rescue is nil in hospitals with lower than average patient to nurse ratios, but pronounced in hospitals with average and poor nurse to patient ratios. In hospitals in which patient-to-nurse ratios are 5:1 or higher, mortality is higher when 25% or more nurses are educated outside of the USA than when <25% of nurses are non-US-educated. Moreover, the effect of having >25% non-US-educated nurses becomes increasingly deleterious as patient-to-nurse ratios increase beyond 5:1.
  
  
  CONCLUSIONS
  Employing non-US-educated nurses has a negative impact on patient mortality except where patient-to-nurse ratios are lower than average. Thus, US hospitals should give priority to achieving adequate nurse staffing levels, and be wary of hiring large percentages of non-US-educated nurses unless patient-to-nurse ratios are low.
authors.affiliation: University of Florida College of Nursing, Health Professions, Nursing and Pharmacy Complex, PO Box 100187, Gainesville, FL 32610-1087, USA. dneff@ufl.edu
authors.forename: Donna Felber
authors.initials: DF
authors.lastname: Neff
authors.forename: Jeannie
authors.initials: J
authors.lastname: Cimiotti
authors.forename: Douglas M
authors.initials: DM
authors.lastname: Sloane
authors.forename: Linda H
authors.initials: LH
authors.lastname: Aiken
mesh_terms: D000328:Adult; D000368:Aged; D002055:Burnout, Professional; D005260:Female; D006742:Hospital Bed Capacity; D017052:Hospital Mortality; D006801:Humans; D007588:Job Satisfaction; D008297:Male; D008875:Middle Aged; D064700:Nurses, International / Q000706:statistics & numerical data*; D009741:Nursing Staff, Hospital / Q000706:statistics & numerical data*; D017063:Outcome Assessment, Health Care; D010351:Patient Discharge / Q000706:statistics & numerical data; D010561:Personnel Staffing and Scheduling / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D014481:United States
keywords: complications; general Methodology; health care system; health policy; hospital care; human resources; measurement of quality; mortality; nursing; patient outcomes (health status, quality of life, mortality); professions; setting of care; surveys; workforce and workload