Foreign educated nurses’ work experiences and patient safety—A systematic review of qualitative studies

Abstract Aim The aim of this systematic review was to identify the evidence contributed by qualitative research studies of foreign educated nurses’ work experiences in a new country and to link the results to patient safety competencies. Design A systematic literature review of qualitative studies. Methods Electronic searches in the Ovid MEDLINE, Embase, PsycINFO, Cochrane Library and Cinahl databases and additional manual searches in five scientific journals. A content analysis of 17 qualitative articles was conducted. Results The analysis revealed one main theme: “Being an outsider at work” and two themes: “Cultural dissonance and Unfamiliar nursing practice. Two sub‐themes emerged from the first theme; Loneliness and discrimination” and “Communication barriers”. The second theme was based on the following two sub‐themes: “Handling work‐related stress” and “Role uncertainty and difficulties in decision‐making”. A better prepared and longer orientation period with continual clinical supervision including systematic reflection on practice experiences is needed to support foreign educated nurses in the transition period and strengthen their Patient Safety Competencies. Nurse Managers have an important role in ensuring the inclusion of foreign educated nurses and providing desirable working conditions.


| INTRODUC TI ON
The migration of nurses due to nursing shortages has been considered a global concern (An, Cha, Moon, Ruggiero, & Jang, 2016). In 2013, the International Council for Nurses Workforce Forum found that most industrialized countries were or would be facing a shortage of nurses due to increased demands for health care (Li, Nie, & Li, 2014). In this review, the term foreign educated nurses (FENs) refers to nurses who were born, raised and educated in another country to that where they work. FENs constitute a significant proportion of the nursing workforce in many Western countries (Bae, 2012;Cutcliffe, Bajkay, Forster, Small, & Travale, 2011). The healthcare sector has often relied on FENs to fill nursing vacancies (Larsen, 2007;Victorino Beechinor & Fitzpatrick, 2008). There has been a rise in the number of FENs in hospitals and especially in the longterm care of the elderly and home-care facilities (Brush, 2008).

| Background
The World Health Organization (WHO) has proposed a Global Code of Practice on the International Recruitment of Health Personnel.
It contends that if recruitment is properly managed, the international migration of health personnel can make a sound contribution to developing and strengthening health systems (WHO, 2010). The WHO emphasizes that all migrant health personnel should be offered appropriate orientation programmes that enable them to operate safely and effectively in the health system of the country where they work.
Recruitment ethics is a central issue, also in terms of safeguarding the rights of health personnel. The International Council of Nursing (ICN) Position Statement on Scope of Nursing Practice (ICN, 2013) states that employers have a responsibility to support nurses in practicing within their full scope of practice. This includes not placing nurses in situations where they are asked to practice beyond their level of competence or outside their legal scope of practice and providing practice environments that support safe and competent care. Jeon and Chenoweth (2007) point to the many unresolved issues associated with the employment of FENs worldwide, such as treatment and rights in recruitment processes, equal opportunity in the workplace and the challenges and experiences of FENs, particularly during the transition period. FENs bring a wealth of experience, knowledge, skills and many personal attributes to their new country, but migration is not without challenges for the nurses themselves.
They have to face a period of integration and adaptation as well as continual professional development (Hancock, 2008).
Nurses migrate not only for better pay, but also for an improved quality of life and better working conditions or opportunities for professional development, (Nichols, Davis, & Richardson, 2011).
According to nursing researchers (Batnitzky & McDowell, 2011;Lum, Dowedoff, Bradley, Kerekes, & Valeo, 2015), very little academic attention has been paid to the challenges faced by FENs in their working lives. However, there is a growing body of literature pertaining to FENs (Okougha & Tilki, 2010). Research from the UK shows that FENs are often subjected to stereotypical and normative assumptions about their attributes and skills from colleagues, managers and patients that undermine their self-confidence and may cause them to suffer stress (Alexis, Vydelingum, & Robbins, 2007;Allan, Cowie, & Smith, 2009).
With an increasingly diverse workforce, there is a need for healthcare organizations to address the challenges of skill transfer, role definition and communication. Ensuring safety is the cornerstone of the credentialing process for FENs, but nursing licensure requirements vary between countries (Sherwood & Shaffer, 2014;Sochan & Singh, 2007;Xu & He, 2012). For example, FENs in Canada reported that the credentialing process was inefficient, timeconsuming and expensive (Sochan & Singh, 2007). In Europe, the European Economic Agreement (EEA) provides for the free movement of persons, goods, services and capital in the European Single Market. The EEA member states have established mutual agreements that govern the recognition of professional qualifications (van Riemsdijk, 2010).
The Commission of European Communities (2008) defined patient safety as the prevention of unnecessary or potential harm associated with health care. Other definitions are related to the dynamic system of health care and focus on the interaction of several elements (WHO 2008; WHO, 2010). These definitions assume that incidents are the result of ineffective interaction between the actors involved (Wiig & Lindøe, 2009). Patient safety requires qualified and committed nursing staff competent in skills and effective in communication (Nease, 2009).
Patient safety culture is a subset of organizational culture specifically relating to the values and beliefs associated with patient safety (Feng, Bobay, & Weiss, 2008). Mustard (2002) defines patient safety culture as "a product of social learning, ways of thinking and behaving that are shared and that work to meet the primary objective of patient safety" (Mustard, 2002, p. 112).
Nurses are in a key position to improve the quality of health care through patient safety interventions and strategies (Mitchell, 2008). A large body of literature on evidence-based improvement strategies has been developed to enhance the quality of care and strengthen safety culture. Habermann and Stagge (2010) explored the impact of FENs on nursing care and professional standards.
They concluded that the recruitment of FENs has not yet taken quality and safety issues and indicators in healthcare settings into consideration to the necessary extent.
In the context of preventing harm attention to non-technical skills is crucial, defined as an array of cognitive, social and personal resource skills that compliment technical skills (Flin, O'Connor, & Crichton, 2008). According to The Canadian Patient Safety Institute, non-technical skills comprise six core competency domains that reflect the knowledge, skills and attitudes that enhance patient safety across the continuum of care (Frank & Brien, 2008).
The domains are: "Contribute to a culture of patient safety, work in teams for patient safety, communicate effectively for patient safety, manage safety risks, optimize human environmental factors and recognize, respond to and disclose adverse events." (Frank & Brien, 2008, p. 4).
Examples of non-technical skills often include being able to understand the situation, decision-making, professional performance, interpersonal, leadership, team work and ethical skills (Mitchell et al., 2011;Yule, Flin, Paterson-Brown, & Maran, 2006). It is estimated that between 70% and 80% of healthcare errors can be attributed to a breakdown in these skills (Flin et al., 2008). There is a continuum of processes and techniques between traditional literature reviews and systematic reviews. Systematic reviews involve a protocol, search, appraisal and synthesis, making them more likely to be rigorous and unbiased than a traditional review (Pawson & Bellamy, 2006).

| ME THOD
The search strategies were designed in collaboration with a specialized librarian. The inclusion criteria were: Peer-reviewed articles in the English language based on original empirical studies. The articles should focus on the FENs' perspective on their work experiences.
After the initial search, the criteria were limited to qualitative articles published after 2005. The following search words were selected: Foreign, immigrant, ethnic, international, multicultural, cross-cultural, abroad, nurse, nursing, cultural competency, cultural diversity, cultural sensitivity and patient safety. Electronic searches were conducted in the Ovid MEDLINE, Embase, PsycINFO, Cochrane Library and Cinahl databases and resulted in a total of 1,054 matches. This was reduced to 116 after reading the titles. Further reduction took place after all three authors had read the abstracts. Reasons for excluding articles were reviews, the absence of primary data and quantitative methods.
Following closer examination of 43 articles, 38 were excluded and five were selected for further analysis. The reason for excluding these articles was that they did not focus on FENs' perspective. Further manual searches were conducted in Swemed and in five scientific journals, resulting in the inclusion of an additional 11 articles.
Through the process of reading, the authors were able to select more specific search words and an updated search was performed in December 2016 in the same databases, plus Web of Science and ProQuest. The search words were: Foreign or international, nurse, job or work experience. Seven articles were found, of which six were duplicates from the first search, thus one new article was included (Smith, Fisher, & Mercer, 2011). This gave a total of 17 articles for review ( Figure 1).

| Quality appraisal of the included articles
The methodological quality of the included studies was assessed and rated according to the Critical Appraisal Skills Program (CASP), a methodological checklist of key criteria relevant to qualitative studies (CASP, 2013). The three authors (BV, EMS, AL) assessed the quality of the studies together. Consensus was achieved by discussing the studies in the light of the various criteria. It was finally agreed that six studies were of moderate methodological quality, while 11 studies had high methodological quality (Appendix 1). No studies were excluded due to low quality.

| Analysis and synthesis of the included studies
The included studies employed different qualitative approaches such as individual interviews, reflective diaries, world café, focus groups, narratives from guided interviews and a single-case study.
A thematic analysis was performed, which includes different steps (Thomas & Harden, 2008). In the first step, the authors individually read the studies using free line by line coding, followed by discussions to achieve consensus and strengthen validity. The second step involved organizing the codes into descriptive themes. The authors agreed on a classification system for sorting and analysing the content of the articles at a descriptive level. They spent time discussing and comparing the different types of evidence as a further step to a synthesis of the FENs' work experiences. The synthesis was finally achieved when the authors reflected on the content, abstracted it and after a discussion agreed on the theoretical themes (Thomas & Harden, 2008). A new interpretation, which goes beyond the original studies was formulated.

| Ethics
Ethical approval was not required (Table 1).

| RE SULTS
The included studies covered FENs of many nationalities working in different countries such as the UK, USA, Iceland, Saudi Arabia and Australia. They mainly described experiences of nurses from Asia and Africa. Only a few of the articles dealt with the situation of nurses from European countries. Although the FENs' experiences varied according to their country of origin and destination, there were nevertheless many similarities.
The analysis revealed one main theme: "Being an outsider at work" and two themes: "Cultural dissonance" and "Unfamiliar nursing practice". Two sub-themes emerged from the first theme: "Loneliness and discrimination" and "Communication barriers". The second theme had the following two sub-themes: "Handling workrelated stress" and "Role uncertainty and difficulties in decisionmaking" (Table 2).

| Main theme: Being an outsider at work
The main theme was identified as Being an outsider at work. Feelings of being an outsider meant not being accepted and recognized by peers as a valuable and contributing team member. The feeling of otherness and uncertainty due to the new nursing practice had a negative impact on FENs' work performance (Tregunno, Peters, Campbell, & Gordon, 2009).

| Theme I: Cultural dissonance
Cultural dissonance occurred when FENs met a new professional environment with a different culture. Recruiting agents had provided them with limited or no information concerning the cultural requirements of the host country (Allan, 2010). There was a tension between the FENs' desire to hold on to their old selves and the need to conform to the new society and working conditions (Zhou, 2014).
The experiences of cultural dissonance compelled FENs to reflect on their identity as cultural beings, leading to (un)learning or reaffirming who they are (Xu, Gutierrez, & Kim, 2008). Feelings of loneliness, discrimination and profound communication barriers are all part of the cultural dissonance.

| Loneliness and discrimination
Unexpected changes in FENs' social and cultural environment created a feeling of loneliness and discrimination (Alexis, 2013; Allan, 2010;Almutairi, McCarthy, & Gardner, 2015;Connor & Miller, 2014;Jose, 2011;Xu et al., 2008). The nurses described "a sense of loss", "being thrown into an unfamiliar world" and being situated as "the other" (Magnusdottir, 2005;Tregunno et al., 2009;Xu et al., 2008;Zhou, 2014). A social psychological distance between the FENs and their colleagues functioned as an invisible wall, resulting in feelings that "we are among but we are not in" (Zhou, 2014, p. 4). Some FENs said that they felt lonely in the workplace because they usually found the topics of conversation unfamiliar and uninteresting, in addition to the fact that they did not engage in the same social activities as their colleagues. It could also be difficult to balance family and work life because the FENs lacked the support they would have had in their home country (Connor & Miller, 2014).
Many FENs perceived being discriminated against and that the other nurses resented their being hired (Connor & Miller, 2014;Estacio & Saidy-Khan, 2014). They perceived mistreatment, intimidation and a lack of respect from others throughout the settlement process (Allan, 2010;Lin, 2014;Wheeler, Foster, & Hepburn, 2013;Xu et al., 2008). A nurse reported being bullied by being assigned the "hardest" patients to "see if she could survive" (Connor & Miller, 2014, p. 509). FENs could also experience contemporary forms of racism that were considered covert, subtle and sometimes unintentional. Patients also exhibited this form of racial microaggression by declining services offered by FENs. Colleagues used exclusion to make their targets feel unwanted and excluded from the group (Estacio & Saidy-Khan, 2014). Some FENs developed strategies to overcome discriminatory remarks such as remaining silent and not complaining (Allan, 2010).
When moving to a new country, many FENs hoped to further their education (Kishi, Inoue, Crookes, & Shorten, 2014). However, the reality was often quite contrary to what they expected.
Institutional racism could hinder their opportunities for further training and promotion, for example the lack of clear rules and resources to accredit FENs' expertise (Xiao, Willis, & Jeffers, 2014).
Some nurses described being treated like students and felt devalued (Alexis & Shillingford, 2011).
Despite the difficulties and unmet support needs, FENs demonstrated great strength and resilience (Zhou, 2014

| Communication barriers
The challenge of learning the language and overestimation of their language fluency made the nurses feel anxious and insecure because they considered that it adversely influenced the quality of care they could provide (Almutairi et al., 2015). Both lack of language proficiency and different communication styles could lead to difficulties forming interpersonal relationships and adjusting to new environments (Magnusdottir, 2005). Passing a language test did not guarantee successful communication in the workplace. Intercultural New ways of interacting with colleagues could also be quite frustrating for the FENs. Nurses who were used to only receiving written orders from the doctors in their home countries found verbal and telephone orders distressing and frustrating (Jose, 2011;Liou & Cheng, 2011;Xu et al., 2008).

| Theme II: Unfamiliar nursing practice
FENs experienced an unexpected unfamiliar nursing practice.
Although nursing may be considered universal, many FENs were poorly prepared for a new nursing practice culture (Alexis, 2013; Kishi et al., 2014;Xiao et al., 2014). The transition created workrelated stress as well as role uncertainty and difficulties in decisionmaking. FENs faced challenges adjusting to the healthcare providers and the healthcare system (Zhou, 2014). Some FENs stated that nursing principles were viewed similarly, but that nursing practice differed.

| Work-related stress
Inadequate orientation before coming to the new country and inconsistent support at the workplace were common among FENs (Jose, 2011;Zhou, 2014). Some nurses described the immigration process as long and difficult and wished they had received more help from the recruiters (Jose, 2011). Other FENs felt a lack of support from hospital managers (Almutairi et al., 2015). In the USA, several FENs were concerned about litigation and could behave in a certain way to protect their nursing license .
The new work environment was experienced as very stressful (Kishi et al., 2014). Some described "shocking workplace realities", including demanding patients, high-tech equipment and expanded nursing responsibilities. As already stated, they could experience communication problems, discrimination and alienation, which interacted with intensified work-related stressors (Connor & Miller, 2014).
Stressors also came from some peers who criticized the FENs and saw their difficulties as incompetence rather than inexperience with a new system (Jose, 2011). For example, FENs working in a neonatal department were unfamiliar with family-centred care and the need to communicate and provide parents with information, which caused stress (Alexis & Shillingford, 2011). On the other hand, having a new emotional connection with their patients and the patients' families could reduce the work-related stress (Lin, 2014).
The multicultural work team placed additional stress on both host nurses and FENs (Xiao et al., 2014). Many FENs had little former exposure to other races and ethnicities (Connor & Miller, 2014). They were therefore challenged by working with people from diverse cultures, each with their own pattern of behaviour, value systems and beliefs (Almutairi et al., 2015). Many FENs obtained support from colleagues of the same nationality to handle the work-related stress, thus helping each other to adjust to a new culture (Alexis, 2013;Alexis & Shillingford, 2011). Some also obtained support from other colleagues as well as from their managers, which enabled them to become more confident in their work environment and was of the utmost importance for coping with work-related stress (Alexis & Shillingford, 2011;Jose, 2011;Liou & Cheng, 2011;Magnusdottir, 2005).

| Role uncertainty and difficulties making decisions
It has been reported that FENs may "take a u-turn" from clinical expert to cultural novice when they enter practice in a new country (Tregunno et al., 2009). Some had agreed to work outside their area of expertise to obtain an employer-sponsored visa (Xiao et al., 2014). Many FENs did not have the knowledge required to care for specific populations and had to learn about, for example elder care, in preparation for the national registration examinations (Tregunno et al., 2009 • Work-related stress • Role uncertainty and difficulties in decision-making TA B L E 2 Overview of the interpreted main theme, themes and sub-themes country of origin, as the nurses in their new country were often expected to be more assertive, assume greater responsibility for patients and be more involved in decision-making (Tregunno et al., 2009). Nurses were also expected to have more egalitarian relationships with physicians, while the culture in their country of origin was more oriented towards nurses just following orders. The FENs could feel "overwhelmed" because they had to learn to provide total patient care for a certain number of patients while they were accustomed to working in a team of several nurses, who shared the responsibility and decision-making . Other nurses felt uncomfortable at the beginning due to the informality and lack of hierarchy among colleagues. They believed that there was inadequate discipline and that the response to mistakes was too mild. Some concluded that the quality of care was affected by this easy-going culture, which led to role uncertainty (Magnusdottir, 2005). For example, in their country of origin the activities of daily living were mainly performed by family members who were at the bedside, while in the new country these activities were the responsibility of the nursing staff. It was difficult for some FENs to accept washing, toileting and feeding as part of a nurse's role (Smith et al., 2011;Zhou, 2014).
They had to learn that patients were at the centre of health care and that patient satisfaction with health care was emphasized (Alexis & Shillingford, 2011;Lin, 2013;Tregunno et al., 2009). The FENs had to change both their practice and the power relationship between themselves and their patients. The consumer-centred approach was highlighted and patient education assumed a prominent role in nursing practice (Smith et al., 2011;Tregunno et al., 2009).
The FENs had to learn to make decisions autonomously while providing direct patient care (Lin, 2013). They could be reluctant to make decisions because they expected no protection in the event of making an incorrect judgement. For some FENs, the desire to appear competent and not lose respect rendered it difficult to disclose lack of knowledge and seek support. They therefore concealed and underplayed their doubts and attempted to work as normally as possible (Zhou, 2014). In the later stages of their adaptation to their new surroundings, FENs began to interact and communicate confidently as professionals, for example with doctors (Lin, 2013).

| D ISCUSS I ON
The aim of this systematic review was to identify the evidence contributed by qualitative research studies of FENs' work experiences in a new country and link the results to patient safety competencies. The main theme Being an outsider at work and two themes; Cultural dissonance and Unfamiliar nursing practice that emerged from the analysis revealed that the experience of being an outsider at work makes FENs uncertain in their new practice environment, which has an impact on patient safety.

| Cultural dissonance
The theme Cultural dissonance involves the FENs' self-confidence, their way of being and how reactions from others affect their communication and teamwork. The theme contains two sub-themes: Loneliness and discrimination and Communication barriers. The difference between FENs' own cultural background and the culture in the new country creates a feeling of loneliness. In addition, they are exposed to discrimination from colleagues and patients, which can undermine their self-confidence and professional effectiveness (Larsen, 2007). Kingma (2008) contends that discrimination and marginalization of FENs threaten patient safety and disrupt the cooperation dynamic required to advance the delivery of care. Healthcare professionals should be mindful that members of the healthcare team need support when responding to adverse events (Frank & Brien, 2008).
Teamwork and communication are two of the main patient safety competency domains (Frank & Brien, 2008). Discrimination and challenges in communication can make the FENs feel devalued and reduce their personal and professional confidence (Alexis et al., 2007).
This in turn affects the way they interact with colleagues and patients and how they carry out their daily tasks. Teamwork is of the utmost importance for preventing patient safety risks and should receive special attention when employing FENs. One of the patient safety competencies is effective and appropriate participation on an interprofessional healthcare team, which requires a shared vocabulary to facilitate adequate communication in the team (Frank & Brien, 2008).
Lack of language proficiency affects FENs who work in a country with a very different language from their own, but can also apply to FENs who speak English in an English-speaking country.
Colloquial expressions, medical terminology, abbreviations and names of medication and equipment can differ in the new country (Jeon & Chenoweth, 2007 Requesting support when appropriate is another of the key safety competencies (Frank & Brien, 2008). Habermann and Stagge (2010) assume that differences in education levels, language abilities and maladjustment to the cultural context can constitute a challenge to the safety of patients and the quality of care. Interaction in the staff room is especially important in multicultural groups as it fosters group cohesion and makes space for the host nurses and FENs to learn from each other (Xiao et al., 2014). A way of supporting FENs who feel alienated from their colleagues and lack a social network is described in a cultural education programme (Xiao et al., 2014). The authors explain that because of the lack of cultural sensitivity in nurse-nurse intercultural encounters in one hospital, they held a forum where they asked several immigrant nurses to tell their stories and describe the culture and practice in their home countries. The involvement of both host and immigrant nurses in the forum supported the two-way approach of learning in multicultural settings. These learning outcomes will probably affect the patient safety culture, such as attitudes and values.
The cultural dissonance that FENs experience is related to both their work and their social life, which may affect their risk management. When FENs are subjected to discrimination or lack of support from their leaders or worry about their license, it can make them reluctant to disclose adverse events (Connor & Miller, 2014;. The facilitation of continuity of care is of the utmost importance for patient safety. However, the results of this review revealed that it is a demanding area for new FENs.

| Unfamiliar nursing practice
The theme "Unfamiliar nursing practice" is related to what the FENs do and how they practice nursing in a new environment. The two sub-themes are "handling work-related stress" and "role uncertainty and difficulties in decision-making". New nursing roles that emphasize a consumer-centred approach and patient education were found to be unfamiliar to many FENs, while the demand for independent decision-making led to uncertainty and indecision. If FENs do not ask questions or refrain from telling someone about their uncertainties, not only will teamwork and collaboration be affected, but the management of safety risks could be impaired.  (2017) found that reflection is a crucial part of nurse specialist students' professional development towards ensuring patient safety and clinical supervision is an essential prerequisite for learning and acting in a reflective, professional manner (Jokelainen, Turunen, Tossavainen, Jamookeeah, & Coco, 2011;Woodbridge & Bland, 2010). As FENs come from a diverse range of educational and cultural backgrounds, reflective skills provide an opportunity to clarify their own values as well as learn some of the professional values in their new practice. Clinical supervision has been defined as a learning, supportive and monitoring process and therefore suitable for meeting these needs (Cutcliffe, Hyrkas, & Fowler, 2010;Woodbridge & Bland, 2010). Continual reflective activity will increase nurses' self-awareness and provide them with more options for dealing with unfamiliar patient situations and thinking critically about their own practice (Ekebergh, 2007).
Providing resources such as a mentor or supervisor who can help clarify certain information will facilitate FENs' success in and satisfaction with their job performance (Reyes, 2013). However, Ginsburg et al. (2015) contend that internal reflection is not enough to foster self-improvement. A learner also receives feedback from external sources. Both organizational structures and the work environment can therefore be linked to patient safety (Richardson & Storr, 2010).
The importance of a supportive professional practice environment and organizational structures for integrating FENs should therefore be emphasized. Access to the necessary resources to do the job and having the opportunity to work and grow will empower employees to accomplish their duties in a meaningful way (Laschinger, 2008). For all nurses and especially FENs, system-level interventions such as increasing nurse staffing and creating a better work environment have been associated with improved patient safety outcomes and a higher degree of nurse well-being (Aiken et al., 2012;Bruyneel et al., 2013).
The full utilization of FENs knowledge and skills will depend to a large extent on their integration into the healthcare team (Allan, 2007;Buchan, 2006). The cultural diversity of the healthcare workforce poses a risk to patient safety. Quality and safety competencies may be interpreted differently across cultures and systems and these differences may challenge the safe integration of FENs into nursing practice (Sherwood & Shaffer, 2014). A challenge for many countries is ensuring that FENs receive equal treatment to nurses from the host country. It is important that healthcare institution managers are aware of the cultural and professionals needs of FENs and take appropriate action. When the FENs' needs are met, they are better able to perform and provide safe, high quality patient care (Reyes, 2013). Victorino Beechinor and Fitzpatrick (2008) (Raghuram, 2007). A two-way approach where receiving healthcare institutions apply a culturally sensitive perspective seems to be of importance. Such a perspective should therefore be included in transition programmes for newly recruited FENs (Adeniran et al., 2008;Nease, 2009;Sherman & Eggenberger, 2008).

| Methodological considerations
The When conducting a systematic review, data are decontextualized and removed from their original context, implying the risk that important findings in the primary research may be overlooked.

| CON CLUS IONS
The fact that FENs perceive themselves as outsiders in their new country can affect their self-confidence and professional nursing practice and pose a threat to patient safety. Nursing performance and skills are not universal, but linked to differences in culture and social norms. There is diversity in nursing practice and FENs should be supported to strengthen their patient safety competencies. A better prepared and longer orientation period and continual clinical supervision with systematic reflection on practice experiences is needed to support the transition of FENs to a new practice environment and to ensure patient safety. It is important that measures are taken both at individual and system level. Nurse managers are vital for ensuring the inclusion of FENs, involving them in decisionmaking and providing appropriate working conditions, which will contribute to better quality of care and safeguard patients.

ACK N OWLED G EM ENTS
The authors wish to thank specialized librarian Hege Sletsjø for her valuable contribution to the electronic search for articles. We would also like to thank Monique Federsel for reviewing the English language.

CO N FLI C T O F I NTE R E S T
The authors declare that there are no conflicts of interest.