the transitioning of internationally educated nurses...

THE TRANSITIONING OF INTERNATIONALLY EDUCATED

NURSES (IENS) INTO THE CANADIAN HEALTHCARE

SYSTEM

Partners in Education and Integration of IENs – 8th

Annual Conference 1-2 May 2014

Ontario Network of Educators and Supports of

Internationally Educated Nurses

In the keynote address today:

• Review the literature in respect of the transitioning

of IEN’s into new ethno-cultural context

• Share findings from a study conducted in Western

Canada

• Followed by time for questions and discussion.

What do we know?

• In 2006 the International Council of Nurses warned in a heraldic message the impending global shortage of nurses

• Many developed countries Australia, Canada, the United States (US) and the United Kingdom (UK) sought to address deficits in the nursing workforce via international recruitment (Dywili 2012, Alexis 2013, Newton, Pillay & Higginbottom 2012, Allan & Dongzia et al 2014, Larsen 2003, Buchan & Calman 2004)

A Complex Ethical Scenario

Some countries may be educating more nurses than required as a development strategy

Countries may have a low ratio of nurses: per head of population creating a substantial drain (Zu & Yang 2005)

Some countries, notably the UK have ethical clauses preventing the direct recruitment of nurses from specified nation states (Newton, Pillay &Higginbottom 2012)

These phenomena are significantly manifested in Canada – a country founded on immigration.

Are professional nursing competencies directly

transferable to a new ethno-cultural context?

• Health care systems evolve in respect of a given

set of socio-economic, political, and cultural

circumstances

• There may be wide variation in the context of

health care delivery and education – including

nursing

http://www.dreamstime.com/stock-images-

frustrated-nurse-image8679614

Transferability of core competencies

• Core professional competencies may or may not be

directly transferable

• New IENs may need considerable support in transitioning

• We conducted a review of transitioning issues in 2012:

The migration and transitioning experiences of

internationally educated nurses: a global perspective

(2012) Journal of Nursing Management, 20, 534-550 (Newton S, Pillay J & Higginbottom GMA, 2012)

VV

REVEW PAPER

Key themes identified in our review

• Reasons for and challenges with migration

• Cultural displacement

• Language and communication barriers on arrival

• Feeling like an outsider

• Differences in nursing practices

• Credentialing and de-skilling process

• Discriminatory experiences

• Strategies which assist transitioning

Economic advantage

(Dywili 2013, Kingma 2006, Palese et al 2007, Aboderin 2007)

Career and lifestyle opportunities (Dywili 2013, Dicicco-Bllom 2004, Aboderin 2007)

Marriage and spousal employment (Dywili 2013, de Verr 2004)

Length of immigration process (Dywili 2013, Pitman et al 2012, Palese et al 2007)

Reasons for and challenges with migration

Language and communication barriers on arrival

Professional nursing practice is premised on the notion of clear

and accurate communication (Terry et al 2013, Belay 2013)

Language challenges a significant barrier (Carter et al 2013, de Veer et al 2004, Jeans et al 2005, Magnusdottir 2005, Xu et al

2008)

English as a first language – nurses more likely to secure

employment in the preferred speciality (Brunero et al 2008)

Preferred speciality does impact upon job satisfaction and

retention

Feeling like an outsider

Dominant psycho-social theme of cultural dissonance

(Liou et al 2013, Xu et al 2008)

Disillusionment if lack of success in meeting a the receiving

country’s standards (Sochan & Singh 2007)

Cultural displacement ranging from mild homesickness to extreme

cultural dissonance (Lio et al 2013)

A perception of mistrust by colleagues and managers (Alexis et al 2007, Magnusdottir 2005)

Differences in nursing practices

A lack of knowledge of the new system

(Pitman et al 2012, Xu et al 2008, Sherman & Eggenberger 2008)

A strong fear of litigation and law-suits (Sherman & Eggenberger 2008)

Differences in autonomy in relation to nursing practices (O’Brien 2007)

Shift in professional identity

Lack of familiarity with newer technologies and

information management (Palese et al 2007)

Credentialing and de-skilling process

Discovery the qualifications do not meet the

standards in the destination country (Jeans et al 2005, Smith et al 2006, Aboderin 2007, Larsen 2007, Xu et al

2008)

MOST PREVALENT THEME – DIFFICULTIES WITH

LICENSURE AND REGISTRATON

Discriminatory experiences

Multi-dimensional discrimination in the workplace (Pitman et al 2014, Wheeler 2014 et al, Smith et al 2006)

Lack of recognition and valuing of professional skills (Wheeler et al 2013, Larsen 2007)

Fractured career trajectories (Salma et al 2012)

Nursing homes vs acute units

Hostility from colleagues (Wheeler et al 2014, Gerrish & Griffin 2004)

Limited opportunities for promotion (Wheeler 2013, Xu & Kwak 2007)

Strategies which assist transitioning

Greater investment in the human potential (Xu & He 2012)

Successful acculturation positively correlated with job satisfaction (Emerson et al 2008)

Employment in speciality of experience (Brunero et al 2008)

Mentorship, supportive leaders and management (Gerrish & Griffin 2004, Bozionelos 2009)

Combating discriminatory practices at the organizational level (Wheeler et al 2014, Pitman et al 2014)

The Migration and Transitioning of

Internationally educated Nurses into the

Canadian Health Care: Perspectives from a

Western Canadian Province

Acknowledgements

• Prairie Metropolis Centre for funding the study

• The IENs who participated in this study

• Study advisory board members Arturo del Rosario (Filipino Nurses Association), Jean Farrar (CARNA), Betty Sawchenko (AHS), Cathy Giblin and Cesar Sandoval (Capital Health)

• The research team – Dr Rwamahe Rutakumwa, Shirley Mogale, Shireen Bell and Eileen Omosa

Introduction

• Global nursing shortages

• Contextual differences

• Complexities of IENs www.medicusmundi.org/en/topics/human-resources/migration

• Costs and retention

• Supports for IENs

http://nursinglicensemap.com/nurses-immigrating-u-s

Background – Research Context

• Recruitment drives in Australia, India, the UK and the Philippines.

• In 2008, there were 1000 contingent job offers to IENs but the economic downturn in 2009 meant that many positions were frozen – Marxist analysis – disposable workforce.

Research Questions

Overarching research question:

How do IENs transition into the

Alberta health care system?

Subsidiary research questions

were grounded in the findings of

international research studies

exploring the experience of

IENs.

Research Questions (Continued)

• Phase 1 - A critical review of the global literature on transitioning of IENs (Newton, Higginbottom & Pillay, 2012)

• Phase 2 - A qualitative approach, focused ethnography (Higginbottom 2013, Cruz &

Higginbottom 2013) utilizing semi-structured interviews of IENs at 1-3 months & 9-12 months post-relocation

• The interview topic guides for both interviews were developed with help of an advisory group of key stakeholders within Capital health, AHS and CARNA.

Methods

• IENs recruited at the Alberta Health Service Orientation

Program after presentation of the study

• Via Filipino Nurses Association, Edmonton

• 23 IENs participated in 31 interviews 14 IENs were not

available for follow-up interview due to reorganization of

health authority and relocation

• Philippines, New Zealand, Australia, UK and India

often ‘chain migrants’ who have worked in several countries prior to re-

location

Recruitment & Sample

• Motivation and Decision to Relocate

• Experiences of Recruitment, Reception, Salary & Support on Arrival (Expectations vs Reality)

• Healthcare System Nursing Work Environment

• Discrimination in the Professional Lives of IENs

• Qualifying as a Registered Nurse

• Life Beyond the Nursing Setting

• Strategies IENs Learned to Overcome Challenges

Findings

Finding 1: Motivation and Decision to Relocate

For a better life…basically for my children, yeah, considering the fact that, uh, we are

experiencing some problems in the Philippines. (Participant 2)

I think Canada is a better place because I can learn more … In the Philippines we are

lacking of supplies. I must admit that we are not doing good in procedure or something

because we are lacking of supplies. We let [patients’] relatives buy supplies. Let’s say we

are going to do one dressing. We will ask relatives to buy supplies, like gauze. And even

syringes.... (Participant 13)

Finding 1: Motivation and Decision to Relocate

We worked in the United Kingdom a few years ago, and we just wanted to have another

travel work experience. We like the outdoors and things like that so we wanted to have a

look at the mountains and animals, and I like fishing and things like that so. Really, other

than that, there was no real intention. (Participant 10 – Australian)

Yeah to be honest with you the UK is a nice place, you know. It’s just the cost of living is too

high. So that’s the other reason why I came here [Canada]. Because the salary that they

gave me is a little bit higher than what I am earning in the UK .. That’s one motivation.

(Participant 5 – IEN Philippines)

Experiences of Recruitment, Reception, Salary &

Support on Arrival (Expectations vs Reality)

[On arrival] I was told to get a taxi. Well of course,

you’re in a new in a country… I complained about that

with my agency…I’ve never been to the place and

[you] ask me to take a taxi? (Participant 5 – IEN

Philippines)

http://blackburnnews.com/chatham/chatha

m-news/2013/12/18/reviewing-accessible-

taxis-in-ck/

The first impression was Canadians made me feel that they are doing me a favour for

me…because I come from a Third World country. I’ll be earning more. (Participant 7 – IEN

Philippines)



The six weeks accommodation gave me freedom…It’s wonderful most of the

nurses that were in the hospital stayed for the entire 45 days. (Participant 3 –

IEN Philippines)

Accommodation-wise I had a problem with that

because … I was expecting it would be close to the

hospital… I did not finish the 45 days because I can’t

stand it anymore. It’s too far. (Participant 5 – IEN

Philippines)



We were told that ... you will always work in your area

of specialty which has turned out to not be true. They

guaranteed that you would always, if you are specialized

in an area, then that is where you go. ... they kept

changing what they wanted to do with me every five

minutes. And then two weeks before I left to come over

here, like I was supposed to go to Emergency (I was

trained in Emergency and that is all I have ever done)

they say “oh, there is no positions anymore. You have to

work on a medical ward.” (Participant 10 – Australia)





To me it was more suicidal than anything... the contract

was that um, temporary full-time for one year... almost all

Internationally Educated Nurses who came, who didn’t

really understand what that entailed until we got here...

given all those years of experiences of working in the

NHS no one would have swapped that for a temporary

one year position ...then because they used an agency, the

people that they employed at the agency themselves didn’t

really understand that. (Participant 14)



More unmet expectations…





And more unmet expectations…

• Different entry-to-practice

requirement previous RN

education ≠ Canadian BScN

• Graduate nurse status

• Financial issues

Healthcare System Nursing Work Environment

In New Zealand, we actually wash our patients but they [Canadians] spend more time

on a computer…So you establish more rapport than here. You tend to talk more with

your patient, know your patient.

(Participant 7 – IEN New Zealand)

I thought that the [Canadian] Healthcare system would be really advanced… I

thought it would make Australia’s healthcare system look really old-fashioned…

thought I would come over here and there would just be all this whiz/bang

technology, and all these different practices and I wouldn’t understand and I thought

I’d have lots and lots to learn. But that hasn’t ended up being a really accurate idea

that I had.

(Participant 11 – Australia)

Healthcare System Nursing Work Environment

I think they are a little bit foolish doing what they’re doing. I think they are

chopping themselves off at the head by doing it. As an educator in New Zealand ...

we had lots of international nurses come through the unit. And I loved the fact that

they brought skills to New Zealand that we didn’t have in New Zealand. You know,

and everybody brought something. Canada’s not about that unfortunately, or not so

far. It’s about their way is the right way.… (Participant 4 – New Zealand)

• Assignment of tasks

unrelated to nursing, eg.

dishwashing and vacuuming.

• Allocation of accommodation

– “ethnicity-determined”.

• Country of origin though to

determine whether or not

they were able to relocate

with their family members.

Discrimination in the Professional Lives of IENs

http://www.trecebits.com/2011/02/18/cuantos-mas-amigos-en-facebook-mas-

posibilidades-de-sufrir-estres/

Conclusion

• Clear communication and transparent expectations need to be

delivered from the employing health authority to the recruiting

agencies, to enable accurate information of the credentialing

process and orientation structure.

• Orientation/bridging/retraining programs need to consider

findings from this and other studies which indicate that IENs require

extensive orientation (up to 6 months) and that which considers

wider social and economic dimensions of integration into a new

ethno-cultural context.

• Since language and communication problems are paramount for credentialing and transitioning of many IENs, programs which assist with acquiring skills for communication within the Canadian healthcare System should be offered at the recruitment stage.

• Nurse managers need to be provided with comprehensive training programs on cultural competency (of their employees) and empowering their units to embrace and celebrate diversity and the contributions IENs make to the healthcare system.

Conclusion (Continued)

Higginbottom, G.M.A. (2011). The transitioning experiences of

internationally educated nurses into a Canadian health care system: A

focused ethnography. (2011). BMC Nursing, 10(1), 14-26.

doi:10.1186/1472-6955-10-14

Newton, S., Pillay, J., & Higginbottom, G. (2012). The migration and

transitioning experiences of internationally educated nurses: a global

perspective. Journal of Nursing Management, 20(4), 534-550.

doi:10.1111/j.1365-2834.2011.01222.x

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Thank you!

Dr. Gina M.A. Higginbottom Professor and Canada Research Chair in Ethnicity and Health

Email: [email protected]

Websites: http://www.nursing.ualberta.ca/Staff/Faculty/GHigginbottom.aspx

http://www.cresh.ualberta.ca/

mailto:[email protected]

http://www.nursing.ualberta.ca/Staff/Faculty/GHigginbottom.aspx

http://www.nursing.ualberta.ca/Staff/Faculty/GHigginbottom.aspx



the transitioning of internationally educated nurses...

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