• Donna Felber Neff, Jeannie Cimiotti, Douglas M Sloane, and Linda H Aiken.
• University of Florida College of Nursing, Health Professions, Nursing and Pharmacy Complex, PO Box 100187, Gainesville, FL 32610-1087, USA. dneff@ufl.edu
• Int J Qual Health Care. 2013 Sep 1;25(4):366-72.

ObjectiveTo determine whether, and under what circumstance, US hospital employment of non-US-educated nurses is associated with patient outcomes.DesignObservational 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.ParticipantsData from registered nurse respondents practicing in 665 hospitals were pooled with patient discharge data from state agencies.Main Outcomes Measure(S)Thirty-day surgical patient mortality and failure-to-rescue.ResultsThe 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.ConclusionsEmploying 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.

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