Onboarding internationally educated nurses in the Nordic countries

Nurse managers are facing major challenges in maintaining a high level of health care, not only due to recruitment issues, but staff retention as well. According to Shaffer et al. (2022), hospitals and healthcare systems may increasingly look to recruiting internationally educated nurses (IENs), as the shortage of nurses persists. These dynamics are clearly visible in the Nordic countries as well, where the demand for skilled nurses continues to rise (Cubelo, 2024; Lillekroken et al., 2024). Because nurse managers play a central role in shaping workplace culture, supporting competence development and ensuring safe care delivery, their understanding of the specific needs of internationally educated nurses becomes crucial for successful integration. Recruitment of IENs is not an easy task and is more complex than recruitment of nurses locally. Screening, recruitment, and onboarding practices should be sensitive and designed to meet the needs of the IENs, as IENs frequently face encounters that can lead to reduced professional development and a devaluing of their competence in host countries (Miyata, 2023). These encounters can be related to differences in nursing, adaptation to their new roles, workplace culture, as well as cultural dissimilarities. This can lead the IENs to incorporate the feeling of being an outsider and being discriminated (Balante et al., 2021; Zhong et al., 2023). Research has also found that a negative effect on the integration process and retention of IENs can be caused by their expectancies not being met, before migration (Roth et al., 2021). These challenges highlight the need for structured onboarding practices that can support internationally educated nurses throughout their transition and integration process. For new employees to successfully integrate in an organisation, as well as develop their further careers, the first element in any retention strategy is onboarding (Ogawa, 2024).

Onboarding is defined as the process that encompasses everything required when new employees start to work. It is described as more than just the legal paperwork before employment starts and also includes the process of assisting the new employee to acclimatise to the workplace (Crail et al., 2024). Poor onboarding measures can lead to an increase in staff turn-over, lower staff efficiency and productivity, and a decrease in staff engagement (Conway, 2024). Onboarding guidelines are, therefore, paramount to recruitment and retention being successful.

This blog post reports the findings from a master thesis (Husted, 2024) that explored existing research on onboarding practices for internationally educated nurses in Nordic countries with the aims to identify best practices and recommend guidelines based on global standards and the theory of organisational socialsation. The results of the thesis revealed common themes that were recommended as either an onboarding guideline, strategy or policy for IENs in the Nordic countries. When combined with the theoretical concept of organsational socialisation (Bauer et al., 2011), chosen because it offers a well-established lens for understanding how newcomers adapt to complex professional environments, five common onboarding themes were identified and suggested. These five themes are 1.) language training, 2.) bridging program and its contents, 3.) preceptorship, 4.) accessible and updated information about the qualification pathway for IENs, and 5.) information dissemination within the healthcare institute, as described below. Each of these themes aligns with core elements of organisational socialisation theory, including relationship-building, organisational support structures, clarity of expectations, and newcomer adjustment (Bauer et al., 2011).

Language training

Language training is not limited to educational institutes but encompasses the learning opportunities during clinical training which should be a priority of the employer. Language difficulties, in both educational institutes and healthcare facilities, can lead IENs to feelings of isolation, exclusion, and can negatively affect their adjustment to the workplace, specifically focusing on their level of self-efficacy and perception of their own level of competence (Eriksson et al. 2018; Eriksson et al. 2023; Högstedt et al., 2020; Högstedt et al., 2022; Högstedt et al., 2024; Lillekroken et al., 2024).

Bridging program and its' contents

Bridging programs expediate the acknowledgement and integration of IEN qualifications (Cubelo, 2024). IENs come from different backgrounds and most probably differ in their learning needs. For efficient adjustment and integration in the workplace, the elements in a bridging program should include topics about local culture and the healthcare system, opportunities to deliberate and reflect on the variances and resemblances between practices and the healthcare system with colleagues and mentors, recommending learning opportunities (Snelgrove et al., 2015), as well as language training.

Preceptorship

Preceptors are the first working relationships that IENs establish during their clinical training, which allows the IENs to experience less nervousness when supervision starts. This is supported by the study of Mikkonen et al. (2016), which states that preceptors can diminish the feelings of social isolation by creating a welcoming environment. Previous studies describe the role of preceptors as assisting and supervising IENs in their adaptation to the healthcare system in a practical setting, continuous language development, the focus of the host country’s nursing competence, and the ability to utilise reflection in nursing practice (Mikkonen et al., 2016). Therefore, a collaboration between the educational institute and the clinical training area is vital to prepare preceptors, in terms of aiding the preceptor in tailoring their supervision program and methods.

Due to this large responsibility, preparing preceptors for their role can also be considered an onboarding strategy. Preceptors need different pedagogical tools to tailor their supervision according to the IENs’ needs, which can greatly vary. Networking between preceptors can also be beneficial for both knowledge-sharing of positive and negative experiences, which can be used to further strengthen the supervision and aid in improving the bridging program at a higher organisational level (Mikkonen et al., 2016).

Accessible and updated information on the qualification pathway for IENs

The qualification pathway for IENs needs to be updated and easily accessible by the host country for potential applicants. Lillekroken et al. (2024) adds that further information on financial support during the validation process and bridging program, should also be made accessible and updated. This is further supported by the study of Cubelo (2024) and Alsadaan et al. (2021), which describes that an onboarding program should include social and welfare benefits, to make employment attractive for IENs.

Information dissemination within the healthcare institute

Feeling welcomed by a healthcare institute and employees can be considered as a foundation for the building of both social and professional relationships, which is also integral for the IEN to be able to adjust to the new workplace in the host country. This is supported by the UK study of Davda et al. (2018), which shows that cultural understanding, language proficiency and both formal and informal networks were significant to integration experiences. These practices also highlight the important role of nurse managers, whose understanding and support of the onboarding process are crucial for creating an inclusive and well-functioning work environment.

Conclusions

Expanding onboarding measures, guided by the themes identified in this review, represents a critical strategy for addressing the ongoing nursing shortage in Nordic countries. Effective onboarding not only facilitates the integration of internationally educated nurses into healthcare teams but also strengthens workforce stability and quality of care. By ensuring that these processes are systematic and supportive, healthcare systems can uphold the principles of the Nordic welfare model, equity, accessibility, and sustainability, while meeting the growing demands for skilled nursing professionals. This underscores the need for clear policy frameworks and coordinated efforts between educational institutions, employers, and national authorities to secure long-term workforce sustainability.

Authors:
Erik-Kristian Husted, Master in Healthcare, Arcada UAS
Christoffer Ericsson, Ph.D., senior lecturer, degree programme director, Arcada UAS
Jonas Danielson, Ph.D., principal lecturer, degree programme director, Arcada UAS.

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