According to the World Health Organization (2020), internationally educated nurse (IEN) migration has become a steadily increasing trend in recent years. Large numbers of IENs entering the workforce have created an educational gap in transition to practice (TTP) as most programs are geared toward the novice nurse or new graduate nurse (NGN). Balancing the education requirements of an experienced nurse with the needs of nurses new to the United States created an opportunity to develop a focused transition to practice program specifically targeted for IENs.

International Transition to U.S. Practice

MultiCare Health System, in partnership with Insight Global Health, developed an international TTP program that onboarded over 70 IENs across the organization in 2024. While the nurses were already successful and thriving in their new careers, there were lessons learned in how the nursing professional development (NPD) team could better meet the challenges that IENs face in the initial phases of entering U.S. acute care practice. The initial orientation model was successful, but there was not a consistent length of precepted time—some nurses were precepted in seven weeks while others took up to 12. There was also inconsistency in what the prepared-to-be-independent IEN looked like. While most IENs felt prepared to practice, some felt challenges due to a lack of socialization to the U.S. health care system.

Recognizing the need for a standardized onboarding process in a large health care system and the influx of IENs starting in the new year, the NPD team swiftly developed a structured orientation approach. This project was piloted in three hospital’s medical-surgical departments in two distinct regions of Washington state. The faster-than-expected approval of visas for 62 nurses, and earlier-than-anticipated arrival of nurses in the U.S. required expedited planning and prompt implementation of the precepting model.

Our team was not just preparing for new hires or for the large numbers of IENs, we were preparing to honor the lived experiences, grit, and dedication of each person. We wanted to ensure that every IEN arrived feeling welcomed, valued, and set up for success. Evidence shows that structured TTP programs and comprehensive clinical orientation support successful IEN integration into a completely new health care environment (Thomas & Lee, 2024). Intentional support for IENs centers around recognizing that this group of nurses faces unique challenges—which include communication, clinical practice differences, team dynamics, and technology. The scope of practice is much more limited and task focused, often under the supervision of the physicians. Independent nurse's roles are less common, and clinical decision-making authority is more constrained (Roth et al., 2021; Shoki et al., 2023). Our NPD team saw the opportunity to leverage this experience while bridging the gap to U.S. nursing practice. We recognized that it was crucial to be intentional during the onboarding and orientation phases to help our IENs navigate the challenges. To support this goal, our NPD team—comprised of unit-based and system-level NPD practitioners—set out to implement a precepting model that better addressed the challenges for an IEN.

Putting a Plan Into Action

We created a tiered skill precepting approach designed to enhance critical thinking and move away from task management. Building from the Tired Skills Acquisition Model (TSAM) by Joswick (2018), we created an accelerated integration model (AIM). With this model, the orientee provides care for the full patient assignment, alongside a preceptor, delivering care around core focus areas. Skill and knowledge acquisition are gained incrementally while being exposed to a wider range of patient populations and clinical circumstances which our team felt was key for the IEN. With a focus on skill and knowledge acquisition, this model has been shown to increase competency and confidence gains sooner than prior precepting models (Joswiak, 2018). The NPD team implemented the model as follows:

This approach lays the foundations for patient care and team integration from the start. Alongside a preceptor, there is greater exposure to tackle the top challenges the IEN faces such as communication, patient assessment, and technology differences.

To facilitate this shift in precepting, the NPD team developed a multi-modal approach to equip department leaders and preceptors to support the IENs and implement the new precepting model. A live virtual class, recorded class, and an LMS-based module were developed to cover the International Transition to Practice (ITTP) program and preparation; IEN cultural considerations; TTP challenges; tiered skill precepting model; considerations on how to implement this model in the day-to-day of patient care; and learning/teaching strategies specific to the IEN population. The IENs were also prepared prior to their start date on what to expect during their onboarding and orientation phases, including an introduction to the tiered skill precepting model. Expectations were reviewed on what the NPD team expected from them, and what they could expect from us.

A printed guide, titled “Internationally Educated Nurse Orientation Toolkit” was developed by the NPD team to steer the orientee and preceptor through the phases of the preceptorship. This toolkit provides guidance for a midpoint and end of precepted time assessment. Both the midpoint assessment and the final assessment of readiness for independent practice were determined through six domains: clinical knowledge and judgement, critical thinking, management of responsibilities, communication, technical skills, and professionalism (Paiewonsky, 2024). A preceptor guide was created to educate and support assessment of the six domains through key performance indicators (KPIs) and guided questions aligned to assess IEN performance. The NPD and leader teams rounded closely and intentionally with the preceptor and IEN pairs to reinforce the precepting model, answer questions, and provide ongoing support during this transition period.

 

Outcomes and Discussion

Sixty-two IENs have completed this tiered skills precepting model since January 2025 in three hospitals, and two regions in Washington state. Implementing system-level changes across a large geographic area provided a challenge for system-level NPDs to ensure the unit-based NPDs had the proper training and support. By working collaboratively, ensuring strong communication, and utilizing a shared framework for preceptorship, the team was able to solicit positive feedback from preceptees, preceptors, and leaders that highlighted the success of this model.

Leaders have stated that they’ve witnessed a significant shift in confidence between the first week and the midpoint assessment of the precepted time—IENs feel more certain in their practice and are quickly building trust in the team around them. Using the KPIs, leaders were able to identify opportunities for improvement and give actionable feedback to the IENs.

One clinical nurse manager shared “It’s been fun to watch them going through the precepted weeks, and all of a sudden, we see those lightbulb moments where they realize it’s all going to be okay. The IENs describe to me how much pride they take in caring for our patients, and I can see that it brings them a lot of satisfaction and joy.” 

The toolkit provides updated information for position-specific onboarding that was more encompassing than the traditional unit checklist. The feedback from the preceptors has been that the toolkit offers a guide to create focused, competency-oriented opportunities intentionally designed to meet the weekly areas of practice development for the IENs. The IENs report that they have been able to reinforce what they learned and use the toolkit to solidify their understanding of nursing practice. Another IEN highlighted the frequency of exposure to different patients and how they expanded their knowledge of providing care to different types of patients.

By using this precepting model, data analysis showed we were able to reduce the average precepted time by two weeks, increase preceptee readiness for practice, and provide a successful transition into the U.S. health care system compared to the IENs who came before 2025. The cost savings for one hospital was over half a million dollars, and for the first time since the pandemic, the hospital is fully staffed, thus reducing overtime, travelers, and short-staffed units.  

Looking Ahead

Given the positive feedback from leaders and preceptors, the reduced precepted time, cost avoidance, and increased confidence of the IENs, MultiCare Health System is looking at piloting expansion to other specialties. The medical-surgical NPD practitioners expanded this model to the med-surg nursing residents and fellows for the fall cohorts, utilizing a similar rollout of the preceptor training plan. The work done by the medical surgical team took the six-week model and expanded it to 14 weeks, aligning with the American Society of Medical Surgical Nurses (ASMSN) and American Nursing Association (ANA) standards and competency.

Additional data is being analyzed to explore competency gains and opportunities to evaluate and perfect this precepting model. At the same time, the team will continue to evaluate the precepting model and toolkit to provide the right support for future cohorts of IENs entering MultiCare.

References

Booth, A. T., Robinson, K. L., & Pyles, A. L. (2025). The Experiences of Internationally Educated Nurses Transitioning to U.S. Nursing Practice. Journal for Nurses in Professional Development, 41(2), 97–101. https://doi.org/10.1097/NND.0000000000001101

Joswiak, M. E. (2018). Transforming orientation through a Tiered skills acquisition model. Journal for Nurses in Professional Development, 34(3), 118–122. https://doi.org/10.1097/NND.0000000000000439  

Paiewonsky, A. (2024, July 10). How to evaluate the readiness of new graduate RNs. The Advisory Board. https://www.advisory.com/topics/nursing/2024/07/evaluate-readiness-new-graduate-rns

Roth, C., Berger, S., Krug, K., Mahler, C., & Wensing, M. (2021). Internationally trained nurses and host nurses’ perceptions of safety culture, work-life-balance, burnout, and job demand during workplace integration: a cross-sectional study. BMC Nursing, 20(1), 1–15. https://doi.org/10.1186/s12912-021-00581-8

Shoki, R., Suzuki, H., & Ota, E. (2023). Training programs to promote the nursing practice skills of overseas qualified nurses: A scoping review. Pacific Rim International Journal of Nursing Research, 27(2), 286–302. https://doi.org/10.60099/prijnr.2023.262038

Thomas, J., & Lee, M. (2024). Factors influencing the transition of foreign‐educated nurses to the US healthcare setting: A systematic review. International Nursing Review, 71(3), 440–456. https://doi.org/10.1111/inr.12862

World Health Organization. (2020). State of the world's nursing 2020: Investing in education, jobs and leadership. World Health Organization (WHO). https://www.who.int/publications/i/item/9789240003279