"i want to see a real nurse!": indian immigrant nurses in u.s. urban safety-net hospitals...
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"I want to see a real nurse!": "I want to see a real nurse!": Indian Immigrant Nurses in Indian Immigrant Nurses in
U.S. Urban Safety-net U.S. Urban Safety-net Hospitals & Implications for Hospitals & Implications for
Health Disparities Health Disparities
Sheba George, PhDSheba George, PhDDepartment of Community Health Department of Community Health
Sciences, Fielding School of Public Health, Sciences, Fielding School of Public Health, UCLA & Center for Biomedical UCLA & Center for Biomedical
Informatics, Charles R. Drew University of Informatics, Charles R. Drew University of Medicine and Science, Los Angeles.Medicine and Science, Los Angeles.
OutlineOutline
Background of my workBackground of my work International health care providers in International health care providers in
the U.Sthe U.S Racial/Ethnic Health Disparities and Racial/Ethnic Health Disparities and
Social SciencesSocial Sciences ResultsResults Discussion Discussion Implications for Quality of Care and Implications for Quality of Care and
Health DisparitiesHealth Disparities
Background Of Background Of WorkWork
•When Women Come When Women Come First: Gender and First: Gender and Class in Transnational Class in Transnational Migration, Migration,
•Immigration of Indian Immigration of Indian nurse providers to the nurse providers to the U.S., and nursing U.S., and nursing shortageshortage
•Ethnographic study- Ethnographic study- participant participant observation, In-depth observation, In-depth and Focus group and Focus group interviews- 2yrs- interviews- 2yrs- U.S./IndiaU.S./India
IMGs/FENs in the U.S.IMGs/FENs in the U.S.1.1. Ongoing shortage of healthcare Ongoing shortage of healthcare
workers, continuing recruitment of workers, continuing recruitment of International Medical Graduates (IMGs) International Medical Graduates (IMGs) and Foreign Educated Nurses (FENs) and Foreign Educated Nurses (FENs)
2.2. 1/4th of U.S. medical work force are 1/4th of U.S. medical work force are IMGs IMGs
3.3. Of new U.S. nurses, 6% in 2000 and Of new U.S. nurses, 6% in 2000 and 12% in 2011 were FENs 12% in 2011 were FENs
4.4. 2/3rds of 2/3rds of IMGs/FENs are estimated to IMGs/FENs are estimated to serve in hospitals that provide care for serve in hospitals that provide care for the poorthe poor
R/E Health DisparitiesR/E Health Disparities
Definition of R/E health disparities Definition of R/E health disparities by the Institute of Medicineby the Institute of Medicine
Racial or Ethnic differences in the Racial or Ethnic differences in the quality of healthcare that are not due quality of healthcare that are not due to access-related factors to access-related factors (e.g.insurance, income) or patient (e.g.insurance, income) or patient level factors (e.g. preferences, need).level factors (e.g. preferences, need).
R/E Health DisparitiesR/E Health Disparities
Difference
Qu
alit
y o
f H
ealt
h C
are
No
n -
Min
ori
ty
Min
ori
ty
Clinical Appropriatenessand Need
Patient Preferences
The Operation ofHealthcare Systems and
Legal and RegulatoryClimate
Discrimination:Biases, Stereotyping,
and Uncertainty
Disparity
Differences, disparities, and discrimination: Populations with equal access to healthcare. (Source: Smedley, Stith, and Nelson 2003 via Gomes and McGuire 2001)
The Role of Social The Role of Social SciencesSciences
The Whitehead/Dahlgren model of health determinants(Source: Bartley, Blane, Smith 1998 via Dahlgren and Whitehead 1991)
Age, sex &heredityfactors
Age, sex &heredityfactors
International Healthcare International Healthcare providers and Health providers and Health
DisparitiesDisparities1.1. IOM study focuses on provider-IOM study focuses on provider-
patient interaction as a key to patient interaction as a key to improving quality of care improving quality of care
2.2. My work points to broader social and My work points to broader social and cultural factorscultural factors
importance of the social organization of importance of the social organization of work shaped by gender and racializationwork shaped by gender and racialization
differences in ethnic/ professional culture differences in ethnic/ professional culture & training of health professionals& training of health professionals
OutlineOutline
Background of my workBackground of my work International health care providers in International health care providers in
the U.Sthe U.S Racial/Ethnic Health Disparities and Racial/Ethnic Health Disparities and
Social SciencesSocial Sciences ResultsResults Discussion Discussion Implications for Quality of Care and Implications for Quality of Care and
Health DisparitiesHealth Disparities
ResultsResults
•Interactional ChallengesInteractional Challenges
•Differences in Professional CulturesDifferences in Professional Cultures
•Indian NursesIndian Nurses’’ responses to work responses to work challenges: challenges: ““Real nursing workReal nursing work”” vs. vs. ““charting and sweet talkingcharting and sweet talking””
Interactional ChallengesInteractional Challenges
Tremendous but expected challenges with Tremendous but expected challenges with immigrationimmigration
Unexpected challenges –the types of Unexpected challenges –the types of barriers to their incorporation and career barriers to their incorporation and career mobility in the workplaces.mobility in the workplaces.
On the ward floor, immigrant nurses On the ward floor, immigrant nurses reported facing discrimination from reported facing discrimination from patients, doctors and hospital patients, doctors and hospital administration as well as from their peers. administration as well as from their peers.
Interactional Challenges: Interactional Challenges: PatientsPatients
““Some patients don't like us- our color. Some patients don't like us- our color. When that happens, we tell the patient When that happens, we tell the patient that in all the other hospitals, in the that in all the other hospitals, in the 3(p.m.) to 11(p.m.) and the 11(p.m.) to 3(p.m.) to 11(p.m.) and the 11(p.m.) to 7(a.m.) shifts, it is only foreign nurses who 7(a.m.) shifts, it is only foreign nurses who work. There won't be any American work. There won't be any American nurses. And some patients will insist, nurses. And some patients will insist, ‘‘I I don't want you. I want a white nurse.don't want you. I want a white nurse. ’’ Then we tell them, Then we tell them, ‘‘If you want to find a If you want to find a white nurse, go ahead and look for one.white nurse, go ahead and look for one. ’“’“ Mrs. GeorgeMrs. George
Interactional Challenges: I Interactional Challenges: I want a real nursewant a real nurse
““ So he (the patient) said, ' I want to see a So he (the patient) said, ' I want to see a nurse.' We both had uniforms on. We nurse.' We both had uniforms on. We both had our identification badges. So I both had our identification badges. So I said 'We are nurses. My name is Susie said 'We are nurses. My name is Susie and this is Nanny. We are both registered and this is Nanny. We are both registered nurses.' He said 'I want to see a real nurses.' He said 'I want to see a real nurse.nurse.’’ So I said, 'We have our So I said, 'We have our registration. We are registered nurses. So registration. We are registered nurses. So I think we are real nurses.I think we are real nurses.’”’” Mrs. Eapen Mrs. Eapen
Interactional Challenges: Interactional Challenges:
Co-workers Co-workers Language fluency and accentsLanguage fluency and accents
Competency questionedCompetency questioned
Surveiled by doctors & Surveiled by doctors & ManagementManagement
Differences in Differences in Professional Culture:Professional Culture:
Not knowing patients vs. total Not knowing patients vs. total patient carepatient care
Physical and emotional distance Physical and emotional distance vs. closeness to patientsvs. closeness to patients
DoctorDoctor’’s orders vs. nursess orders vs. nurses’’ roles roles and responsibilitiesand responsibilities
Differences in Professional Differences in Professional Culture: Total Patient CareCulture: Total Patient Care
As Mrs. Thomas explained, As Mrs. Thomas explained, ““. . . Here . . . Here nursing is about total patient care, nursing is about total patient care, the total well being of the patient- the total well being of the patient- Mental and physical care of the Mental and physical care of the patient as well as the patientpatient as well as the patient’’s s family. Back home you give family. Back home you give medicines, that is all.medicines, that is all.””
Differences in Professional Differences in Professional CultureCulture
: Closeness to Patients: Closeness to Patients
Mrs.Philip noted, Mrs.Philip noted, ““Here you have to Here you have to be very polite to them and take care be very polite to them and take care of them as a close friend.of them as a close friend.””
Mrs.Thambi reflected on her work Mrs.Thambi reflected on her work experiences in India, experiences in India, ““I didnI didn’’t know t know the patientsthe patients’’ names. I didn names. I didn’’t know t know who they are.who they are.””
Differences in Professional Differences in Professional CultureCulture
: Roles and Responsibilities: Roles and Responsibilities
““Patient care managers.Patient care managers.””
TeachersTeachers
ConsultantsConsultants
FEN Response: Real FEN Response: Real Nursing WorkNursing Work
The distinction goes as follows: The distinction goes as follows:
Indian nurses are better at doing Indian nurses are better at doing the the ““actualactual”” work of nursing work of nursing”” – the – the practical work of bandaging practical work of bandaging patients, checking IVs and inserting patients, checking IVs and inserting catheters- whereas American catheters- whereas American nurses are good at nurses are good at ““charting, charting, writing and sweet talking.writing and sweet talking.””
““I see-like a couple of nurses, not everybody- just a I see-like a couple of nurses, not everybody- just a couple of nurses- they come and they sit and they couple of nurses- they come and they sit and they talk, talk, and talk. But you hardly see them moving talk, talk, and talk. But you hardly see them moving around and working- I mean, the real nursing around and working- I mean, the real nursing job. . ..job. . ..”” ““Are these immigrant nurses?Are these immigrant nurses?””““No, these are white Americans. They will flirt No, these are white Americans. They will flirt around with white doctors- Bah, bah, bah- I mean, around with white doctors- Bah, bah, bah- I mean, we don't go for all these things. We come, do our we don't go for all these things. We come, do our job, take care of our patients, say job, take care of our patients, say ‘‘Hi, I am so and Hi, I am so and soso’’ and we do our job. The Americans have a way of and we do our job. The Americans have a way of saying-saying-‘‘Hi honey, Hi sweetheart.Hi honey, Hi sweetheart. ’’ I mean, I have I mean, I have even seen nurses kissing the patients. We don't go even seen nurses kissing the patients. We don't go for all that. And the patient likes that- the patient for all that. And the patient likes that- the patient thinks 'Oh, the nurse - so wonderful she is.' You thinks 'Oh, the nurse - so wonderful she is.' You know what I mean? Those nurses can act a lot. They know what I mean? Those nurses can act a lot. They get better feedback from patients. At the same get better feedback from patients. At the same time, we may be working hard and we may not be time, we may be working hard and we may not be getting that much appreciation.getting that much appreciation.””
FEN Response: Real FEN Response: Real Nursing WorkNursing Work
““I don't like ambulatory nursing because it's I don't like ambulatory nursing because it's not really nursing- it's like more of a office not really nursing- it's like more of a office nurse type. Lot of paperwork- I really don't like nurse type. Lot of paperwork- I really don't like doing paperwork much. I like to do real doing paperwork much. I like to do real nursing. . . . Ambulatory (nursing) could be nursing. . . . Ambulatory (nursing) could be boring sometimes. Sometimes it could be so boring sometimes. Sometimes it could be so busy that it could make you confused if you are busy that it could make you confused if you are not used to it. All the patients come and so not used to it. All the patients come and so many people you have to send together to the many people you have to send together to the O.R. (Operating Room). You have to check O.R. (Operating Room). You have to check everybody. You have to be careful- anything everybody. You have to be careful- anything you didn't do and they will call you. So you didn't do and they will call you. So originally the nurses were all white- in originally the nurses were all white- in ambulatory, they are all white.ambulatory, they are all white.””
Indian Immigrant NursesIndian Immigrant Nurses’’ Experiences: A SummaryExperiences: A Summary
Difficult but expected challenges Difficult but expected challenges
Interactional difficulties on the ward Interactional difficulties on the ward floorfloor
Differences of professional culture and Differences of professional culture and differing expectations for quality carediffering expectations for quality care
FENSFENS’’ characterization of their work - characterization of their work - tthe irony of un-he irony of un-““realreal”” nurses doing nurses doing ““real real nursing worknursing work””
OutlineOutline
Background of my workBackground of my work International health care providers in International health care providers in
the U.Sthe U.S Racial/Ethnic Health Disparities and Racial/Ethnic Health Disparities and
Social SciencesSocial Sciences ResultsResults DiscussionDiscussion Implications for Quality of Care and Implications for Quality of Care and
Health DisparitiesHealth Disparities
DiscussionDiscussion
A Racialized HierarchyA Racialized Hierarchy
a.a. Racially stratified division of Racially stratified division of laborlabor
b.b. A distinct professional A distinct professional hierarchy in nursinghierarchy in nursing
Three Factors that Three Factors that Contribute to a Contribute to a
Racialized HierarchyRacialized HierarchyGendered and Racialized Expectations Gendered and Racialized Expectations
of Emotional Labor in Nursingof Emotional Labor in Nursing
Impact of professional and ethnic Impact of professional and ethnic cultures from Indiacultures from India
Racialization and Distrust of ForeignersRacialization and Distrust of Foreigners
Gendered and Racialized Gendered and Racialized Expectations of Emotional Expectations of Emotional
Labor in NursingLabor in Nursing
1.1. Emotional LaborEmotional Labor
2.2. Racialized Occupational Racialized Occupational Segregation and Emotional Segregation and Emotional LaborLabor
3.3. Nursing – Archetypal ProfessionNursing – Archetypal Profession
Differences in professional Differences in professional and ethnic cultures from and ethnic cultures from
IndiaIndia
1.1.Nursing professional skills and values Nursing professional skills and values from specific structural and cultural from specific structural and cultural contextcontext
a.a. Nurse patient ratio/Family presenceNurse patient ratio/Family presence
b.b. Broader Indian cultural norms about PDABroader Indian cultural norms about PDA
c.c. Gender based stigmas about nursingGender based stigmas about nursing
2.2.Norms of emotional labor for US nursing Norms of emotional labor for US nursing and Indian nursesand Indian nurses ’’ reticence to meet these reticence to meet these standardsstandards
Racialization and Distrust Racialization and Distrust of Foreignersof Foreigners
1.1. Racialization and FENs in urban Racialization and FENs in urban safety net work settings – left to safety net work settings – left to sink or swim!sink or swim!
2.2. Distrust of foreigners leads to Distrust of foreigners leads to questioning of their professional questioning of their professional competency competency
OutlineOutline
Background of my workBackground of my work International health care providers in International health care providers in
the U.Sthe U.S Racial/Ethnic Health Disparities and Racial/Ethnic Health Disparities and
Social SciencesSocial Sciences ResultsResults Discussion Discussion Implications for Quality of Care and Implications for Quality of Care and
Health DisparitiesHealth Disparities
Implications for Quality of Implications for Quality of Care and Health Disparities: Care and Health Disparities:
ImpactImpact Patient perceptions of quality of care Patient perceptions of quality of care
and the impact on health disparities and the impact on health disparities
Multidisciplinary teams and health Multidisciplinary teams and health disparitiesdisparities
Strengths of FENS could have Strengths of FENS could have positive impact on health disparitiespositive impact on health disparities
Implications for Quality of Implications for Quality of Care and Health Disparities: Care and Health Disparities:
InterventionIntervention1.1.US trained staff (co-workers, US trained staff (co-workers,
administrators)/ patients of the immigrant administrators)/ patients of the immigrant nurses need to be nurses need to be better informed about better informed about competencies and qualifications of FENscompetencies and qualifications of FENs..
2.2.FENs need tailored FENs need tailored orientation programs orientation programs for better integration into workplacesfor better integration into workplaces
3.3.Leverage the strengths of FENs Leverage the strengths of FENs vis-à-vis vis-à-vis their work experiences and ethnic, their work experiences and ethnic, professional cultural backgroundsprofessional cultural backgrounds
4.4.Need for Need for more research more research at the point of careat the point of care
