Experiences of migrating nurses

This section has explored an important topic of how the migrating nurses perceive different aspects of their migration. Before the year 2008, the personal experiences of migrating nurses were not explored as often as was the efficacy and ethics of migration (Buchan et al., 2005), (Bach, 2008). Within the last decade, there has been a wealth of research mapping the experiences of migrating nurses and the aspects of a successful adaptation period for migrating nurses. Thus, Kingma´s complaint from 2001 - that some areas of nursing migration are under-researched (Kingma, 2001) - is not completely valid anymore.

Overwhelmingly negative and excessively difficult beginnings in the most popular destination country were described by the participants in Jose´s phenomenological study, when migrating nurses realized that migrating for work to the USA was much harder than they had imagined it would be. They felt that there was nobody to help them, and no orientation to the issues they struggled with was provided (understanding slang, understanding the health care system, using technologies, coping with cultural diversity) and they were demotivated by the fact that their native colleagues viewed them as incompetent. These feelings eventually changed when the nurses adapted to their new environment (Jose, 2008). Similarly, Kingma suggested that the first two years of migration are the most difficult ones (Kingma, 2006).

44

Other authors suggested that the process of integrating an internationally educated nurse15

into a host country nursing system can span from 12 months to 10 years (Yi and Jezewski, 2000).

Jose created six themes from her in-depth interviews with migrating nurses. These themes were chronologically ordered and named: Dreams of a better life, Difficulties of the journey, A

shocking reality, Rising above the challenges, Feeling and doing better, and Ready to help others (Jose, 2008). The above-mentioned themes are very similar to the five themes later developed by Newton from a comprehensive review of the recent literature on nursing migration (Reasons for and challenges with migration, Cultural displacement, Credentialing

problems and deskilling, Discrimination and Successful strategies for transition) (Newton et

al., 2012). Both sets of themes manifest a deep insight into the world of migrant nurses and they offer interesting information about the transformative path of the migrating nurse. Kawi and Xu, in their integrative review, explored facilitators and barriers to the adjustment of migrating nurses. According to the authors, the facilitators of adjustment are: being hardworking and persistent, being a perfectionist (the wish to prove that she/he is a “good” nurse), getting support from their friends and learning to be assertive (Kawi and Xu, 2009). The barriers were similar to those mentioned by Moyce in a later study (the communication barrier, the differences in nursing practice, presence of serious discrimination and racism, the lack of support for the newly arrived nurses, and insufficient and unspecific orientation). Also, the solutions suggested by Kawi and Xu seem to be similar to Moyce´s, which could result from the fact that the two literature reviews partly overlapped (Moyce et al., 2015).

We are now aware that the credentialing procedures are demanding and lengthy before even migrating; once in the destination country, migrating nurses typically struggle with the following: communicating in the foreign language, learning different approaches to nursing, understanding the autonomy of patients and sometimes with discrimination.

15_{The term internationally educated nurses (IENs) was selected among the many terms currently used (e. g.}

overseas nurses, foreign educated nurses, foreign trained nurses, foreign nurse) (as evidenced in the insightful concept analysis by Freeman et al. (2012a). This term seems to appropriately, and without a negative connotation, characterize nurses that were educated in one country and are/were practicing the nursing profession in another country.

45

Communication

The most important problem reported by migrating nurses in many studies was the limited communication ability due to the language barrier which caused the nurse to feel “like an outsider” (Magnusdottir, 2005), (Tregunno et al., 2009), (Newton et al., 2012). Adequate language skills in the nursing profession go beyond a mere proficiency in the language; appropriately using and understanding voice tone, stressing certain parts of a word, using silence, gestures, getting jokes - that all requires advanced knowledge of the language and of sociocultural context (Tregunno et al., 2009), (Blythe et al., 2009). In the urgent, global need for nurses in destination countries, only minor attention was paid to the deeper-lying issues of cultural adaptation (Buchan, 2008b), (Habermann and Stagge, 2010). Further, colloquial expressions, medical abbreviations and telephone interactions were difficult for the nurses migrating to the USA (Davis and Nichols, 2002). Even nurses who successfully passed the licensing examination in Canada had not achieved basic proficiency in the English language, and this has obvious implications for safe care (Tregunno et al., 2009).

Similarly, the language barrier was bigger than expected for European nurses migrating to Iceland. Even after the nurses could hold a basic communication in Icelandic, any deeper communication was not as accurate as they would want it to be, which caused them serious stress. As above, telephone communication also caused fear, due to the lack of nonverbal cues to enhance understanding (Magnusdottir, 2005). The nurses from the Philippines and India working in Ireland, who participated in Troy´s study, did not have a strong desire to integrate into the culture of the host country, preferred to retain their culture in spite of the fact that they often did not plan to return to home country. They also reported communication difficulties on their arrival (Troy et al., 2007). The perioperative nurses migrating from undisclosed countries to practice in Ireland also reported language problems, as well as problems being sufficiently assertive (Cummins, 2009).

Migrating nurses who did not speak the local language well experienced barriers to professional advancement and worked more often in the stigmatized geriatric care (Kingma, 2006). However, from the perspective of patients´ safety, a nurse needs to be very proficient in the local language, especially in a fast-paced hospital environment.

46

Differences in nursing practice

The different approach to nursing in the destination country was another reported obstacle. In a qualitative study, Tregunno interviewed 30 randomly selected internationally educated nurses working in the Ontario region in Canada, with the goal of exploring barriers and challenges to a smooth transition into the new workforce. Two participants came from Central and Eastern Europe (CEE). While twenty-nine participants stated that they migrated to find a better quality of life, all of the nurses described the nursing practices in the host country as different from those in their home country. The biggest identified differences were listed as: carrying out more responsibilities and fully respecting clients’ autonomy (Tregunno et al., 2009).

Similar results were found by Adhikari when researching Nepali nurses practicing in the UK (Adhikari, 2013), as well as in a quantitative study with 113 participants, where 49% of the migrant nurses working in perioperative settings in Ireland found the work practices different from those in their home country (Cummins, 2009). Also, the internationally educated nurses in an Australian qualitative study were reported to be surprised that they were expected to know about all of the specialized health services, that a holistic and patient-centered care was being practiced and that clients were involved in their own care. They had difficulties with complex discharge planning, time management, making priorities and negotiating with other team members (Smith et al., 2011). Knowledge of the system, and especially of policies related to confidentiality and documentation, and working with technologies and modern drugs, a fast work tempo and practicing autonomously in the destination country were other differences in nursing practice that hampered a quick and smooth integration of migrating nurses (Newton et al., 2012). This issue was generally highly relevant, considering that before 2004, about 5.1% of the total nursing workforce in the USA had been internationally educated, but by 2008 it was already 8.1% (U.S. Department of Health and Human Services, 2010).

One qualitative study explored the challenges that influence a smooth transition of internationally educated nurses into the US nursing system. Twenty-one nurses and ten nurse managers were interviewed. An interesting detail is that even though the migrating nurses

47

were from seven different countries, their nursing training was provided in English. As in previously mentioned studies, the theme of different nursing practice in the host country occurred, specifically regarding nurse autonomy, responsibility for physical assessment, and the use of technologies. Spousal support and spiritual support were strategies for easing the transition during the orientation period (Sherman and Eggenberger, 2008). A special orientation/adaptation period for the migrating nurses is considered to be highly beneficial for everybody and necessary for a provision of safe care (Buchan and Perfilleva, 2006a). Over 90% of the respondents in the Irish study on perioperative nurses found the preceptor and the orientation programs valuable for their integration. Eighty percent of the respondents felt that they were given sufficient time (6 weeks) of adaptation and support to achieve competence (Cummins, 2009).

Discrimination

Recently some studies reported discriminatory practices in the destination countries and even racism (Tregunno et al., 2009), (Cuban, 2010), (Newton et al., 2012), (Moyce et al., 2015). Discriminatory practices were an important issue in the study conducted on internationally educated nurses working in Saudi Arabia, as such practices (not surprisingly) greatly contributed to work dissatisfaction of the studied nurses. The discrimination was financial, personal and involved limited use of certain benefits such as higher standard living arrangements (Mitchell, 2009).

A qualitative study from England described the brain wasting of qualified oversees nurses in England. These migrating nurses felt exploited by the system, where never-ending additional charges for their “further professional education” were required by the manipulative recruiting agencies, but career advancement opportunities were not available. If the nurses finally managed to have their qualification recognized and were promoted from previous auxiliary posts, which often combined caring and domestic work, their salary increased minimally. For that reason they often kept both positions and alternated working as, for instance, a health care assistant and a RN. This study further demonstrates the strategies which the migrating nurses used to cope with their situation (Cuban, 2010).

48

Apart from describing discriminatory practices at the hand of colleagues, auxiliary personnel and patients, Sherman also suggests a few strategies to facilitate a smoother transition to the new nursing system. For example, the possibility of the nurse to choose in which area of nursing she/he wants to practice16_{, to attend accent reduction classes, and to use an}

experienced nurse migrant for helping a new nurse migrant with her/his transition. The authors present a recommendation for a curriculum for internationally educated nurses in their paper, which covers fundamental clinical areas of nursing practice, seminars on American idioms, culture, and critical thinking, practicing nursing skills, simulating scenarios such as physical assessment, and a seminar on the role of nurses in the USA, including legal regulation (Sherman and Eggenberger, 2008), (Kawi and Xu, 2009), as well as lessons on local cultural and work values (Davis and Nichols, 2002), (Kingma, 2006), (Bieski, 2007). Additionally, Moyce suggests including information on discrimination policies into the orientation program (Moyce et al., 2015). The researchers call for stronger support of internationally educated nurses at each stage of their migratory process, and extended workplace orientation to fully utilize the professional skills of migrating nurses (Blythe et al., 2009).