Foreign Born Nurses

The care of patients in hospitals today has become increasingly more complex for nurses, because they must contend with increases in medical technological capabilities, changes in health care consumer demands, changes in the allocation of health care resources and changes in the legal system governing nursing practice such as withholding or withdrawing life support (Annas, 1990). As new complexities develop surrounding the medical and nursing care of severely ill individuals, nurses may become more involved in situations in which being an advocate for the patient may conflict with loyalty to the institution, physicians, family and others.

Conflicting loyalties can create conflicting options in the resolution of the problems of patient care, which in turn, can create ethical dilemmas for nurses. From the critical perspective, many factors can influence the way in which nurses respond to medical dilemmas, including prior knowledge of the dilemma, the conception of the nurse’s role in the dilemma and congruence between the ideal resolution and the realistic resolution of the dilemma (Ketefian & Ormond, 1988). The influence of one’s culture on medical practice in nursing may also affect responses to ethical dilemmas.

Fabrega (1990) suggested that culture is closely linked with moral behavior and medical practice since “each culture and tradition of medicine is held to stipulate a moral way of looking at illness and a moral way of conducting medical practice” (p. 595). Hence, analyzing and describing modes of healing among any group of people may, in part, describe their “medical ethics” (Fabrega, 1990). This paper aims to describe and analyze cultural differences existing among American nurses and foreign born or educated nurses.

According to recent issue of Business Week the number of foreign nurses within the total registered nurse workforce in the United States has tripled since 1994 (Business Week, 2009). With an increasing number of foreign nurses being employed in the American health care system, there is a need to determine how culturally perceived values influence patient care. Thompson and Thompson (1985) stated that while some ethical principles may be universal among cultures, “the shoulds and the should nots vary within and between cultures” (p.

58). Bleich (1989) described differences between Jewish laws and Christian traditions regarding prolongation of life issues, and Jakobovits (1986) described differences in truth-telling between Catholics and Jews (Thompson and Thompson, 1990). Meleis and Jonsen (1983) described differences in value systems, perceptions of expectations, style of expression and behavior between Middle Eastern and Western cultures during a medical and nursing ethical crisis (Thompson and Thompson, 1990).

Minami (1985) reported that confusion occurred in Japanese nurses who had been influenced by post-World War II Western educational philosophies regarding ethical issues taught in nursing school and the traditional Eastern philosophies taught in the home (Thompson and Thompson, 1990). There have been very few empirical studies utilizing culture as the major focus of research on medical practice in nursing. Davidson, Vander Laan, Hirschfeld, et al.

, (1990) described differences among Australian, Chinese, Canadian, Finnish, Israeli, Swedish and American nurses on decisions to feed or withhold feeding from a terminally ill, elderly cancer patient in a hypothesized situation. They found that all subjects from China decided to feed the patient in the situation while the majority of the subjects from the other countries decided not to feed the patient. Justification for the Chinese position was given by the use of the underlying principle of beneficence by one-third of the subjects and by a philosophy of life prolongation which guides the Chinese culture.

Although Cox (1985) did not specifically look at culture in his study of medical decision making among hospital nurses, the study examined the responses of a small number of nurses whose educational preparation for practice occurred outside of the United States. Eighteen (7. 8%) out of 231 subjects were foreign educated and 14 out of the 18 were Filipino. Cox developed the Ethical Behavior Inventory (EBI) which was a multiple choice, self-administered test with a short “ethical dilemma” followed by 3 or 4 forced-choice answers.

The EBI was based on the Code for Nurses and only one answer was “correct” in that it followed the tenets of the Code. Cox found that Code congruency was lower in registered nurses educated outside of the United States. Cox (1985) did not suggest reasons for this finding but did recommend that nursing administrators should screen foreign nurse-applicants “to ascertain the types of ethical decisions made and… [provide] programs to socialize them into the values of nurses in the United States” (p.

49, 50). Literature describing differences between European nurses and American nurses, with regard to ethics and ethical decision making, has been scarce. Researchers have reported studies describing differences in political attitudes, ideas about illness among the elderly and care and health patterns (Thompson and Thompson, 1990). One study was found which described American and European responses among physicians and nursing internists on ethical dilemmas.

Secundy (1985) surveyed 98 family physicians, nurses and nursing internists. Secundy used seven vignettes to describe ethical dilemmas ranging from disclosure of a venereal disease to the spouse of a patient who requests such information be withheld to prolonging the life of a terminally ill patient who was 80 years old versus one who was 25 (Secundy, 1985). Secundy found no significant differences between American and European physician and nurses responses.

Many responses were similar and upheld the institutional policies or legal requirements in the situations. The literature on medical practice in nursing showed limitations in clear delineations between the constructs of moral reasoning and ethical practice. Many authors have chosen to define medical practice in specific ways to allow for a broader picture of the phenomena involved. There have been few empirical studies examining the relationship between culture and ethical decision making in nursing.

Authors described differences in decisions to feed or withhold feeding among nurses in different countries and differences in Code congruency. Evidence has suggested that cultural differences may influence medical decision making and ethical actions in health care and nursing. These cultural differences often incorporate differences in values or value systems. Thus, when faced with procedural or ethical dilemma, nurses may use cultural values or values with which they are most familiar in the resolution of medical conflicts.


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Norwalk, CT: Appleton-Century-Crofts

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Ketefian, S. & Ormond, I. (1988). Moral reasoning and ethical practice in nursing

practice: An integrative review. NY: National League for Nursing

Cox, J.L. (1985). Ethical decision making hv hospital nurses. Doctoral dissertation, Wayne

State University, Detroit, MI

Secundy, M.G. (1985). Ethical dilemmas in office practice: Physician response and

rationale. Journal of the National Medical Association. 22(12), 999-1007

Herbst D. (2009). Immigration: More Foreign Nurses Needed? Business Week, June 2009

Retrieved from <> July 4, 2009

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