The experience of China-educated nurses working in Australia: A symbolic interactionist perspective Yunxian Zhou BN (Nursing), MM (Medicine) A thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy School of Nursing and Midwifery, Faculty of Health Institute of Health and Biomedical Innovation Queensland University of Technology Brisbane, Australia February 2010
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The experience of China-educated nurses working in Australia: A symbolic interactionist perspective
Yunxian Zhou
BN (Nursing), MM (Medicine)
A thesis submitted in partial fulfilment of the requirements for the degree of
Doctor of Philosophy
School of Nursing and Midwifery, Faculty of Health
Institute of Health and Biomedical Innovation
Queensland University of Technology
Brisbane, Australia
February 2010
I
Abstract Transnational nurse migration is a growing phenomenon. However, relatively little
is known about the experiences of immigrant nurses and particularly about non-
English speaking background nurses who work in more economically developed
countries.
Informed by a symbolic interactionist framework, this research explored the
experience of China-educated nurses working in the Australian health care system.
Using a modified constructivist grounded theory method, the main source of data
were 46 face to face in-depth interviews with 28 China-educated nurses in two major
cities in Australia.
The key findings of this research are fourfold. First, the core category developed in
this study is reconciling different realities, which inserts a theoretical understanding
beyond the concepts of acculturation, assimilation, and integration. Second, in
contrast to the dominant discourse which reduces the experience of immigrant
nurses to language and culture, this research concludes that it was not just about
language and nor was it simply about culture. Third, rather than focus on the
negative aspects of difference as in the immigration literature and in the practice of
nursing, this research points to the importance of recognising the social value of
difference. Finally, the prevailing view that the experience of immigrant nurses is
largely negative belies its complexities. This research concludes that it is naïve to
define the experience as either good or bad. Rather, ambivalence was the essential
feature of the experience and a more appropriate theoretical concept.
This research produced a theoretical understanding of the experience of China-
educated nurses working in Australia. The findings may not only inform Chinese
nurses who wish to immigrate but also contribute to the implementation of more
effective support services for immigrant nurses in Australian health care
organisations.
II
Key Words Immigration
Nurses
Immigrant nurses
Chinese nurses
Experience
Australia
Symbolic interactionism
Grounded theory
III
Table of Contents Abstract........................................................................................................................ I
Key Words .................................................................................................................. II
Table of Contents.......................................................................................................III
List of Figures.........................................................................................................VIII
Statement of Original Authorship..............................................................................IX
As some have argued, the decision to immigrate is often made in a family context
with consideration to maximise expected incomes and minimise risks (Massey et al.,
1993; Stark & Bloom, 1985). In addition, personal health, personal wealth, potential
cultural and psychological costs to the migrating person also influence whether
immigration can and will take place. More importantly, immigration is not merely a
14
matter of choice. Immigration policies in the potential receiving country are
influential in determining immigration flow and the type of immigration that takes
place (Arango, 2004).
2.1.3 Global situation of labour migration As noted, the level of international migration has grown markedly. Data from the
United Nations highlight that there was an estimated 191 million international
migrants worldwide in 2005, an increase from 176 million in 2000 and 75 million in
1960 (United Nations, 2006). International migrants consist of nearly 3 per cent of
the global population, up from 2.9 per cent in 1990 (United Nations, 2006). Relative
to the total population, Oceania has the largest share of international migrants (15.2
per cent), followed by Northern America (13.5 per cent) (United Nations, 2006). The
US is the largest recipient of international migrants, having 38.4 million migrants in
2005 (United Nations, 2006).
A feature of this migration trend is the growing proportion of skilled migration from
developing to developed countries (also known as the “brain drain”). It is estimated
that, in 2001, nearly 1 in 10 tertiary educated adults born in the developing countries
resided in North America, Australia, or Western Europe (Lowell & Martin, 2005).
About 30 to 50 per cent of people in developing countries trained in science and
technology live in the developed world (Lowell & Martin, 2005). Taking Australia
as an example, its recent immigration policy has targeted the “skilled worker”
immigrant. Since 1997-1998, permanent arrivals through the Skill Stream of the
Migration Program have been consistently larger in number than through other
programs, accounting for 45 per cent of all permanent arrivals to Australia in 2005-
2006 (Australian Bureau of Statistics, 2007).
Although both men and women immigrate, the immigration of women has been
traditionally viewed as passive and secondary. One reason is that child-raising
responsibilities have severely restricted the career mobility of women. Today, by
contrast, women represent a growing share of immigrants, rising from 47 per cent in
1960 to 49.6 per cent in 2005 (United Nations, 2006) and the proportion has grown
15
to 51 per cent in more developed regions (Martin, 2005). In part this has occurred
because of the increasing demand for immigrant women to perform domestic work
and child and elder care services as more and more women in developed countries
have entered the labour force (Martin, 2005). The feminisation of immigration is
also significant in that many women are immigrating as primary wage earners, rather
than as accompanying family members.
2.2 Nurse migration Part of the phenomenon of expanding international labour migration is nurse
migration. This migration has several features: it is voluntary in nature (voluntary
migration instead of forced migration); it is skilled migration; and it involves women
as the primary migrants (instead of men).
Kingma (2001) has proposed several reasons for the global movement of nurses that
include both push and pull factors. First, nurses migrate in search of professional and
educational opportunities not available in their home countries. Second, nurses seek
better wages and living or working conditions than exist at home. The third reason is
that nurses seek work situations associated with less risk (biological, chemical,
physical, and social) to personal safety. Personal safety is an increasingly strong
contributing factor to nurse migration and “may be motivated by circumstances
within the health sector or the external environment” (Kingma, 2001, p. 207). This
factor is evident in African countries where there are high rates of HIV/AIDS and
other infectious diseases (Kline, 2003). It is argued that it is pull rather than push
factors that exert most influence on the size of nurse migration (Royal College of
Nursing, 2003). In moving beyond push and pull factors others have argued for a
broadening of analysis to incorporate distinctive historical and political contexts
such as post-colonialism (McNeil-Walsh, 2004). However, a shared element across
theoretical perspectives and in the current context is the extent of the global nursing
labour shortage, an examination of which follows.
2.2.1 Nurse shortage The impact and implications of nurse shortages is evident at both the global and
16
national levels. Policies adopted to address the shortages are somewhat similar
worldwide, with international recruitment becoming an increasingly prominent
approach.
2.2.1.1 The global situation There has been an unprecedented global shortage of nurses in recent years (Oulton,
2006). Both a decreased supply and an increased demand have contributed to the
shortage, making it more complex, serious, and enduring than previous shortages
(Hassmiller & Cozine, 2006). Quantifying the global nurse shortage is difficult
because of varying definitions of the shortage and problems of access, currency, and
quality of data (Oulton, 2006). However, the following statistics provide a general
picture of the extent of the shortage.
Research published by the Canadian Nursing Association predicted that Canada will
face a shortfall of 78,000 RNs by 2011 and the number may expand to 113,000 by
2016 (Nelson, 2004). In April 2006, officials from the US Health Resources and
Services Administration projected that the US nurse shortage would grow to more
than 1 million by the year 2020 and all 50 US states will be experiencing a shortage
of nurses to varying degrees by the year 2015 (HRSA, 2006). In Europe, Germany
and the Netherlands are both in need of 13,000 nurses and Switzerland is lacking
3,000 nurses (International Council of Nurses, 2003). In France, 18,000 nurses leave
public hospitals every year (International Council of Nurses, 2003). In 2025, the
small country of Denmark will face a projected shortage of 22,000 nurses
(International Council of Nurses, 2003) and it is estimated that New Zealand has a
shortfall of 2,000 nurses (Hulbert, 2005).
Shortages are also occurring in developing countries. The situation in Africa is
particularly serious. Across Africa, there are on average fewer than 50 nurses per
100,000 of the population, less than half the number required to deliver even basic
health care (Eastwood et al., 2005). Yet, these African countries face increased
demand for nurses as they struggle to provide anti-retroviral treatment and care to
HIV/AIDS patients (Eastwood et al., 2005). A report (Friedman, 2004) noted that in
17
Malawi only 28 per cent of nursing positions were filled in 2003 and in South Africa,
32,000 nursing positions were vacant in the same year. One hospital in Zambia was
reported to have only one-third of the 1,500 nurses required to function well
(Trossman, 2002). In the case of the Philippines, the country which supplies the
largest number of nurses to the US and the UK, the nurse shortage has reached 6 per
cent and is projected to increase to 29 per cent by 2020 (Marchal & Kegels, 2003).
2.2.1.2 The Australian situation Australia is no exception to the global nurse shortage situation. Unless remedial
measures are put in place, it is estimated that Australia will be faced with 40,000
nursing vacancies by 2010 (Karmel & Li, 2002). According to the Council of Deans
of Nursing and Midwifery data (Preston, 2006), in 2006 Australia as a whole had a
shortfall of 3,243 RNs (or 1.6 per cent of the RN workforce).
Where Australian states are concerned, the Australian Nursing Federation reported
that in Tasmania, nursing shortages had resulted in a large number of elective
surgery cancellations (Australian Nursing Federation, 2005a) and unacceptable
vacancy levels at major hospitals (Australian Nursing Federation, 2006b). An annual
increase of about 200 RNs will simply maintain the Tasmanian RN workforce at its
current level (Preston, 2006). In 2005, New South Wales figures indicated a shortage
of 1,750 nurses but this has not taken into account shortages in the private sector
(NSW Nurses’ Association, 2005). In Queensland, a shortage of 1,461 (3.8 per cent
of the workforce) nurses by 2010 is projected. If existing low staffing levels in
Queensland are progressively improved to a level equivalent to that of Australia as a
whole, then the projected shortage in this state almost doubles (to 2,849 or 7 per cent
of the workforce) (Preston, 2006). In Western Australia, if the staffing levels
improved to the national equivalent, it will have an approximate shortfall of 377
nurses by 2010 (Preston, 2006). In Victoria, it is estimated that 5,000 full time
equivalent or 6,050 additional RNs will be required by 2011 to 2012 (Department of
Human Services Victorian Government, 2004). In South Australia, between 650 and
1,350 new graduates per year are required to maintain the RN workforce at the
current size (Parliament of Australia Senate, 2002).
18
As a result of the growing evidence of a nursing labour crisis, the Australian
government in 1999 identified nursing as a national priority area (Heath, 2002) and
the Department of Immigration and Multicultural Affairs has since listed the RN on
the Migration Occupations in Demand List, which means that nurses receive bonus
points for migration (Department of Immigration and Multicultural and Indigenous
Affairs, 2005).1 All of these data reflect a serious problem of a growing shortage of
nurses in Australia.
2.2.1.3 Strategies to address the nurse shortage Strategies used to counter the shortage are similar across countries and include
increasing nursing education enrolment, seeking to recruit unemployed nurses,
improving retention and overseas recruitment. Each of these strategies is addressed
in turn.
Increasing nursing education enrolment
Increasing the number of people entering nursing education is identified as a
potential long-term solution to nurse shortage. Nursing education programs are
being provided to a broader range of recruits including mature age entrants, entrants
from ethnic minorities, and those with vocational qualifications or work-based
experience (Buchan & Sochalski, 2004). It is argued that special effort should focus
on attracting more young people, more men, and more members of minority ethnic
groups to the nursing profession to make the workforce more diverse and
representative of the population makeup (Goodin, 2003). A further position is that it
is essential to market a positive image of nursing to children at an early age because
they have decided by fifth grade on what are desirable and undesirable careers
(Cluskey, Jackson, Brubaker, Cram, & Awl, 2006). It should be noted that these are
not innovative ideas but have long been integral to campaigns to increase levels of
nurse enrolment.
1Since 1999, where the nominated occupation of an applicant is on the Migration Occupations in Demand List at the time an application is lodged or assessed, the applicant becomes eligible for “occupation in demand/job offer” points on the General Skilled Migration points test. An applicant receives extra points if he/she has a job offer from a suitable Australian employer.
19
Reaching unemployed nurses
Programs to encourage a return to the profession of licensed RNs who are
unemployed or working in non-nursing fields have been implemented in countries
such as the UK and Australia. Yet it is pointed out that the number of RNs interested
in returning to the profession is limited (McIntosh, Val Palumbo, & Rambur, 2006)
and the effectiveness of re-entry programs is questionable as they fail (much like the
marketing strategies suggested above) to address the underlying reasons why nurses
left the workforce (Cowin & Jacobsson, 2003).
Improving retention
The cost of turnover extends well beyond the fiscal cost of losing an individual. The
turnover of effective staff members leads to decreased morale and a sense of
rejection in those left behind (Manion, 2004). Hence how to nurture a culture of
retention is considered to be the key to easing the nurse shortage (Manion, 2004).
But as Buchan and Sochalski (2004) argued, the importance of retention is not
widely recognised and/or acknowledged.
Overseas recruitment
In the absence of alternative effective policies and as the demand for RNs continues
to grow and the RN workforce ages, the strategy of overseas recruitment is gaining
momentum (Buchan & Sochalski, 2004) and many developed countries are
increasingly relying on overseas RNs to fill vacancies. Although overseas
recruitment may not always be the most cost-effective solution, at a time of shortage,
it offers a relatively quick and sometimes the only solution. In the foreseeable future,
overseas recruitment will continue to play a significant part in supplementing
nursing numbers in many countries.
The UK recruits more nurses from developing countries than any other Western
nation. In 2002 alone, 16,155 foreign-trained nurses2 were recruited (Aiken, Buchan,
2 There is a range of terms used when referring to nurses from overseas in the literature such as foreign-trained nurses, foreign-educated nurses, and foreign-born nurses. This review adheres to the terms as used in the literature.
20
Sochalski, Nichols, & Powell, 2004). In the year to March 2005, a total of 11,477
overseas nurses were admitted to the UK from non-European countries and between
April 2005 and March 2006, another 8,673 were admitted (Aiken et al., 2004). This
recruitment strategy appears to have alleviated the UK nurse shortage to a great
degree and this, combined with a tightening of health funding, has meant that the
UK no longer recruits nurses in these numbers (Buchan & Seccombe, 2006). Yet the
aging population and an increasingly aging nursing workforce remains a challenge
to overcome. Overseas recruitment was initially presented as “a quick fix” to solve
acute nurse shortage in the UK but has now become an essential and recurrent
strategy in the overall nurse recruitment policy (Royal College of Nursing, 2003).
The number of foreign-educated nurses moving to the US more than tripled from
4,000 in 1998 to 15,000 in 2004 (Llana, 2006). This cohort now accounts for 14 per
cent of the current nursing workforce, up from less than 9 per cent in 1994
(Auerbach, Buerhaus, & Staiger, 2007). In fact, employment of foreign-born RNs
accounted for nearly one-third of the total growth of RN employment in the US
nursing labour market during 2002-2003 which means that the trend towards
increased reliance on foreign-born RNs has accelerated (Buerhaus, Staiger, &
Auerbach, 2004). As a result, some people have argued that the reliance on overseas
RNs to fill gaps is no longer a short-term solution but has become an entrenched
government strategy in some developed countries.
In response to the nurse shortage, the Australian government has introduced a
number of initiatives, one of which is attracting overseas RNs. Australia received
11,757 foreign nurses between the years 1995 and 2000 (Hawthorne, 2001). In
addition, the number of overseas RNs in Australia almost tripled from 1,188 in 2000
to 3,233 in 2004 (Jeon & Chenoweth, 2007). Almost 30 per cent (1,732) of nurses
obtaining initial registration with the Nurses Board of Victoria in 2004 were from
overseas (Australian Nursing Federation, 2005b). In Queensland alone, the number
of license applications from overseas nurses and midwives increased by 40 per cent
in 2006 (Queensland Nursing Council, 2006) and in New South Wales, aggressive
recruitment brought in over 1,000 overseas nurses in the same year (Lawson, 2005).
21
For the foreseeable future, international recruitment will continue to play a
significant part in boosting nursing numbers in Australia (Jeon & Chenoweth, 2007).
2.2.2 China as a source for nurse recruitment It appears that the dominant sources for nurse migration are developing countries
(Buchan & Sochalski, 2004) and with a 1.3 billion population, China represents one
of the world’s largest reservoirs of human resources. As Xu (2006, p. 131) argued, in
the context of the widening gap between the global demand for and supply of nurses,
it is not a question of “if” but “when” Chinese nurses will become a major
component of the global nurse market.
In 2004, the number of working RNs in China was 1.3 million, with just over one
nurse per thousand people (Jiang, Shen, & Yan, 2004). Yet, because of inadequate
government funding in health care, the level of unemployment and
underemployment of nurses in China is very high (Xu, Gutierrez, & Kim, 2008). As
a result, both the Chinese government and the Chinese Nursing Association openly
support the export of Chinese nurses (Xu, 2004; Xu & Zhang, 2005).
International migration of Chinese nurses began in the 1990s when the Chinese
government organised groups of nurses with good English skills to work in
Singapore and Saudi Arabia for determined periods of time. Most of those
employment contracts were arranged by government agencies (Fang, 2007). During
the last five years or so there has been a similar increase in the number of nurses
who have migrated to Australia and England, although most of these were arranged
by private companies rather than government agencies (Fang, 2007). However, the
exact number of Chinese nurses migrating overseas is unknown.
In a situation of increasing global demand for nurses and a shrinking of the
traditional supply markets such as the Philippines, commercial and government
recruiters have expressed a strong interest in the recruitment of nurses from China
(Fang, 2007). In 2006, the Australian Nursing and Midwifery Council met with three
Chinese delegations of officials and expressed an interest in further promoting
22
Chinese nurse migration to Australia (Australian Nursing and Midwifery Council,
2006). As Xu and Zhang (2005) argued, compared to those countries which are
opposed to the migration of their nurses, China is perceived to be a more ethical
source for recruitment. Several authors have assessed the potential for nurse
migration from China and have concluded that with its very large labour resource,
China will become an increasingly important supplier of nurses in the future
1975; Musolf, 2003). The work emanating from the Chicago School at the
University of Chicago, which has continued the classical tradition of Mead and
Blumer, has been by far the most influential. It is this latter body of knowledge
combined with the work of Erving Goffman that is theoretically pertinent to this
38
research.
SI also reflects a range of intellectual influences which makes it problematic to
summarise concisely. Yet, regardless of the varying ways in which SI has been
interpreted, most of those identifying with this approach trace its principal origins to
pragmatism and related intellectual influences (Meltzer et al., 1975; Reynolds,
2003a, 2003b) each of which is now addressed in turn.
3.2 The pragmatist tradition It is generally accepted that, as an American philosophy, pragmatism exerted the
greatest influence on the development of SI (Reynolds, 2003b).3 The close
association between pragmatism and SI is evident in the fact that some refer to the
pragmatists as early interactionists (Musolf, 1989). The pragmatist influence
emerged largely from the writings of Charles Sanders Peirce (1839-1914), William
James (1842-1910), James Mark Baldwin (1861-1934), Charles Horton Cooley
(1864-1929), John Dewey (1859-1952), William Isaac Thomas (1863-1947), and
George Herbert Mead.
As the father of American semiotics (the study of signs), it was Charles Sanders
Peirce who first invented the term pragmatism (Page, 2000). In rejecting the idea
that mind and physical processes are separate, Peirce (1955) argues that mental
activities correlate with the underlying physiological activities of the brain.
According to Peirce (1955), consciousness and thinking are made possible through
signs (language) which represent reality. The existence of consciousness and the
ability of mind to manipulate signs is a result of evolution.
For Peirce (1955), the meaning of an object is embedded in the perceived effect of
an object on humans and in the response of humans to an object. More importantly,
as Peirce (1955) pointed out, signs were not neutral, but associated with sensations
(emotions). Signs and the associated sensations combined act as a means of guiding
3 The term pragmatism was first used in 1878 by Charles Sanders Pierce who argued that to understand the meaning of thought we need first to determine what action the thought will produce.
39
conduct.
Named as the father of American psychology, William James is a further noted
pragmatist. Three concepts of James proved to be central to the development of SI:
habit, instinct, and self. According to James, habits arose from past experiences
through repetition and served to modify and inhibit instincts (Meltzer et al., 1975).
Therefore, it is habits rather than instincts which function to maintain social order.
The view that human behaviour is not instinctive is even more obvious in James’s
conceptualisation of a social self distinct from the material and spiritual selves in
human beings. Social self is the desire to receive recognition from and to make an
impression on significant others (James, 1890). In James’ terms, an individual has
different social selves in different contexts and these selves function to influence
human behaviour. In addition, self and others are distinct but they do not exclude
each other (James, 1890). People and things in the environment belong to the self, as
far as they are felt as “mine” (James, 1890). In this sense, self is considered as a
product of interaction with others.
Furthermore, James was critical of the “reflex-arc” concept which reduced
behaviour to basically a nerve response and argued instead that interest and attention
affect human actions (James, 1890). This provided the beginning of a non-mechanic,
non-reductionistic view of human behaviour. It also meant that human beings were
perceived as distinct from the physical world in the sense that they can instil the
meanings of objects in their minds and thus render the social world subjective rather
than objective (James, 1890).
Named “the father of American social psychology”, James Mark Baldwin also
attacked biological determinism and advanced James’s concept of habit to make it
more social than psychological (Musolf, 1989).4 To Baldwin, habit is socially
learned and individuals cannot be separated from society (Noble, 1967). One can
only develop selves through imitation and interaction with others and thus society
4 James’ concept of habit was tied to his theory of instinct and was thus psychological.
40
influences the kind of person one becomes (Baldwin, 1894).
The importance of the relationship between the individual and society was pursued
further by Charles Horton Cooley who is well known for his concepts the primary
group, sympathetic introspection and looking-glass self (Cooley, 1983; Meltzer et al.,
1975; Reynolds, 2003a). The primary group is a small number of significant others,
such as family members and peer groups, with whom one has frequent face-to-face
interaction (Meltzer et al., 1975). Cooley argues that through one’s primary group,
basic behaviour is formed and the individual becomes a socialised member of
society (Meltzer et al., 1975).
The emphasis of the role of emotion and sentiment in human behaviour is reflected
in Cooley’s concept of sympathetic introspection (Cooley, 1983). As Cooley argues,
people use sympathetic introspection to imagine situations as perceived by others.
Individuals spend much of their lives living in the minds of others (without knowing
it) (Cooley, 1983, p. 208). This implies individuals are influenced by others (Cooley,
1983).
From here Cooley (1983) drew the concept of the looking-glass self to depict the
formation of the individual’s sense of self based on the perceived response of others
and particularly within the context of primary group. As Cooley (1983, pp. 182-185)
articulated, there are three components of the looking-glass self: the imagination of
our appearance to the other person; the imagination of his/her judgment of that
appearance, and some sort of self-feeling, such as pride or mortification. These
theoretical tenets added force to the proposition of the individual and society as
inseparable: there can be no individual apart from society; and society is a product of
the individual mind.
In considering the relationship between the individual and society (or social groups),
John Dewey returned to the concept of habit. However, in contrast to James, the
essence of habit for Dewey is not repetitious individual behaviour but “acquired
predispositions to ways or modes of responses” (Dewey, 1957, pp. 40-41). As such
41
and in echoing Baldwin, the conditions which constitute habit have their origins not
in the individual, but in the social order (Meltzer et al., 1975; Reynolds, 2003b).
Dewey also replaced the concept of instinct with impulse. In his view, instincts were
not the cause of social behaviour. Rather, it was impulse that gave new direction to
old habits and gave rise to new behaviours (Dewey, 1957).
Dewey moved on to argue that individuals always act based on deliberation. As
Dewey stated, “…Deliberation is a dramatic rehearsal (in the imagination) of various
competing possible lines of action…” (Dewey, 1957, p. 179). In other words, as
human beings attempt to complete a course of action, they go through a process of
deliberation whereby they respond to the environment selectively.
Dewey’s concept of mind as a function and minded activity as adaptive behaviour in
an ever-changing environment is also significant. According to Dewey, mind
occurred through the process of communication and specifically through the
employment of language (Meltzer et al., 1975). In his revolutionary article titled The
reflex arc concept in psychology, Dewey (1896) extended James’ critique of the
reflex arc conception of human behaviour5 and gave emphasis to the role of
interaction in explaining human and social behaviour. Mead wrote that:
For Dewey the distinction between the organism and the environment is only a
distinction in phases of the process, whether this process is called psychological or
biological…The organism determines its environment as genuinely as the
environment determines the organism (Mead, 1936, pp. 69-70).
Several contributions from Thomas are also of relevance in the evolution of an
interactionist perspective, the most notable being the definition of the situation
concept. In rejecting Watson’s radical behaviourist idea6 that humans simply respond
5 The stimulus-response conception of human behaviour as either purely physical or purely psychological “whichever being selected being an arbitrary matter of personal taste” (Dewey, 1896, p. 370). 6 This view, associated with Pavlov, emphasised physiology and the effect of external stimuli on human behaviour. Watson argued against the use of references to mental status and held that psychology should study observable (overt) behaviour (Watson, 1914).
42
to the objective features of a situation, Thomas argued that “if men (sic) define
situations as real, they are real in their consequences” (Thomas & Janowitz, 1966, p.
301). In other words, the importance of situational influence on behaviour is evident
in that our definition of a situation motivates us to act in a particular way consistent
with the definition (Musolf, 1989). As Thomas pointed out, definitions of the
situation preceded all behaviour:
Preliminary to any self-determined act of behaviour there is always a stage of
examination and deliberation which we may call the definition of the situation
(Thomas, 1931, p. 41).
The importance of understanding why others define situations in a way that leads to
a particular behaviour is that it allows us to understand the subjective meanings of
actions (Meltzer et al., 1975; Musolf, 1989). Definitions of situations may reflect
imbalances of power, but they also imply that one is not totally determined by the
social structure. Thus, some emphasis on subjectivity is needed to explain and
conceptualise the exclusively human behaviour (Meltzer et al., 1975; Musolf, 1989).
The varied theoretical arguments noted above provided a foundation for Mead who
was by far the most influential pragmatist. He is also widely regarded as the true
originator of the Chicago School of SI with his emphasis on linguistically mediated
knowing and acting.
3.3 Intellectual influence of Mead To understand the general positioning of the symbolic interactionist perspective, it is
necessary to address not only the pragmatist influence on Mead’s work but the
influence of Darwinism, German idealism, and behaviourism, all of which remain
central to SI (Charon, 2007).
That Mead was a pragmatist is evident in the key assumptions that underpin his
work. The first is that human beings are active and creative; they influence the world
they live in which, in turn, shapes their behaviour (Charon, 2007; Mead, 1934).
Second, for the human being, truth exists in its usefulness; that is we learn and
43
remember what is useful to us (Charon, 2007). Third, we are selective in what we
notice in every situation. Thus, we see and define objects in our environment
according to their usefulness (Charon, 2007, p. 32). Meaning, then, is not inherent to
objects (Mead, 1934), but lies in the effect they produce. Fourth, action and
interaction, rather than person or society, should be the focus when studying social
In addition to pragmatism, Mead was inspired and influenced by the work of Charles
Darwin on the theory of evolution (Mead, 1934).7 Darwin was a naturalist and
argued that we must understand the world we live in without appeal to a supernatural
explanation (Charon, 2007, p. 33). All behaviour then is considered a constant
adjustment or adaptation to the natural environment. Mead too argued that human
beings must be understood in natural terms (Charon, 2007; Mead, 1934). Thus,
Darwin influenced Mead in thinking of social life as a process, in the state of
becoming, unfolding, and emerging (Charon, 2007).
But Mead went further than Darwin in some key aspects. In Darwinian terms,
evolution in animals is a passive process. Yet, Mead stated that once humans were
formed, language and the ability to reason resulted in human beings becoming active
participants in their environments (Charon, 2007; Mead, 1934). In other words,
echoing Dewey, organisms and environments mutually determine each other (Mead,
1934). Further to this, Mead argued that the ways in which humans act in relation to
a particular situation were learnt through social interaction (Blumer, 1969; Mead,
1934).
An additional influence was German idealism which informed Mead’s theorising in
several ways. One doctrine of German idealism is that the world we live in is self-
created and human beings respond not to the world per se but to their own working
definitions of that self-created environment (Reynolds, 2003b). This notion is crucial
7 Darwinism (evolution through adaptation) differs from Social Darwinism where social inequality was considered the result of natural selection and philanthropic or state interventionism to help the less fit would only do more damage to society than good. Mead was a strong critic of Social Darwinism.
44
to SI. The Darwinian premise that the world evolves and that reality is in a process
of evolution was also reinforced by the German idealists (Mead, 1936). In addition,
Willhelm Wundt, a direct descendant of German idealist thought, influenced Mead
through his writing on gestures and language (Miller, 1973).
Scientifically, Mead was a social behaviourist (Mead, 1934). He argued that as social
beings, humans must be understood in terms of what they do rather than who they
are (Charon, 2007; Mead, 1934). Mead’s (1934) thoughts were indeed always
concerned with action or behaviour. Behaviours from Mead’s (1934) perspective are
social acts that include not only physical behaviour, but also behaviour that takes
place internally and is not directly observable. What we then draw from Mead is that
to understand human overt action, we must comprehend human action as it involves
understanding, definition, interpretation, and meaning (Mead, 1934). We also
recognise these processes as explicitly social.
3.4 Mead and mind, self, and society In 1894, Mead joined the faculty of the University of Chicago where he taught for
his remaining 37 years. Interestingly, Mead never authored a book in his lifetime.
Following his death, his students compiled and edited his lecture notes, unpublished
papers, and manuscripts into a series of four books: The philosophy of the present
(Mead, 1980), Mind, self, and society: From the standpoint of a social behaviorist
(Mead, 1934), Movements of thought in the nineteenth century (Mead, 1936), and
The philosophy of the act (Mead, 1938). Among them, Mind, self and society was the
most influential and contains the most complete exposition of SI.
In this latter work, Mead considered that mind, self, and society were closely
interrelated and social interaction (via language/symbols) accounted for the
development of mind and the presence of self (Mead, 1934). Two forms of human
social interaction are identified by Mead: the conversation of gestures and the use of
significant symbols. For Mead, gestures do not carry ideas with them and thus the
conversation of gestures is a simple stimulus-response and non-significant (Mead,
1934). In contrast, the use of significant symbols involves interpretation of the action
45
(Mead, 1934). This means that human beings engage frequently in the conversation
of gestures as animals do, but their distinctive mode of interaction is at the symbolic
level (Blumer, 1969).
Gestures become significant symbols when individuals who make gestures respond
in a way that is the same as they seek to elicit from the respondents (Mead, 1934). In
other words, the meanings of significant symbols are shared (Mead, 1934). True
communication is thus realised among humans through the use of significant
symbols.
In much the same way, the vocal gesture is significant because “it affects the
individual who makes it just as much as it affects the individual to whom it is
directed” (Mead & Strauss, 1964, p. 36). We respond to our own speech as others do;
its meaning is the same for us as it is for others (Musolf, 1989, p. 383). An extension
of this concept is that the vocal gesture allows us to take into account the attitude of
the person to whom we are addressing our gestures (Musolf, 1989).
Mind, which Mead calls the “reflective intelligence of humans” (Mead, 1934, p. 118)
arises out of the process of social interaction where, as noted above, language plays
a crucial role in its development (Mead, 1934). In Mead’s words:
Mind arises through communication by a conversation of gestures in a social
process or context of experience--not communication through mind (Mead, 1934, p.
50).
The brain and mind are thus not identical. The brain is a human organism while the
mind is a process which is essentially social (Mead, 1934). Mind allows for self-
indication, internally organising our act, and making a delayed response. That is to
say, it is an internalised symbolic covert interaction towards oneself (Mead, 1934).
Following directly from the above and as an object of one’s own awareness, self, too,
is a social construct that does not exist or develop apart from society (Mead, 1934).
The self is distinctively different from the body as self is not there when we are born
46
but appears as a part of social experience (Mead, 1934).
In Mead’s terms, the self consists of I and me. The I is the response of the actor to
the attitudes of others, a more impulsive, psychological and acting part of ourselves;
and the me is the organised set of attitudes of others which one assumes from the
outside world and from others, and is the more reflective and socially aware side of
our selves (Mead, 1934). Put differently, the I represents a selected line of action and
the me represents one’s awareness of social expectations (Charon, 2007; Mead,
1934). What appears in consciousness is always the self as an object, as a me (Mead,
1934). A self exists when one takes on the attitudes of others and can act towards
oneself as others might act (Charon, 2007; Mead, 1934). This is the point at which
we are “aware of another self as a self” (Mead, 1913, p. 377).
Thus, becoming aware of the role of others is an essential mechanism in the
development of self. According to Mead, a child first learns to pretend to be certain
individuals around him/her, deliberately taking on their roles, imitating their
behaviours, seeing him/her self from the perspective of them, and acting towards
him/her self as they do (Mead, 1934). As the child develops, he/she takes the roles of
many others with whom he/she associates and develops a generalised other
(society’s attitudes, viewpoints and expectations) that incorporates the common
responses of those around him (Mead, 1934). To Mead, it is from this perspective,
from the generalised other, that a person develops a complete self.
Self and society are made only possible because of communication (Mead, 1934). To
communicate requires one to see things, including oneself, from the other’s
perspective. Here again the theorising draws on the inseparability of the individual
and society. Humans live in groups, groups of individuals form society, and it is
within a social process that an individual’s mind and self emerges (Blumer, 1969;
Mead, 1934). In other words, individuals act with one another in the mind, take
account of one another as they act, symbolically communicate, and interpret one
another’s acts (Charon, 2007; Mead, 1934).
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The significance of this theorising is in explaining social order which requires
cooperative actions based on shared meanings, common understandings, and
expectations (Charon, 2007; Mead, 1934). Over time, this cooperative symbolic
interaction necessarily creates a shared symbolic representation of the generalised
other among its members or what we call a culture (Mead, 1934). Culture means the
consensus of the group and the pattern of what people do. Within a culture (or
group), individuals see their actions through the perspectives of generalised others
and use this consensus to guide their own behaviour and also to judge the behaviour
of others (Charon, 2007).
By virtue of ongoing symbolic interaction, society is thus not to be considered as a
set of fixed institutions or structure. Instead, it is a formative process through which
society is constantly constructed and reconstructed (Blumer, 1969; Mead, 1934).
This view of society as continuous action is of paramount importance to SI.
3.5 Blumer and SI Following Mead, the three premises of SI were set down by Blumer. The first is that
human beings act towards things, whether physical objects, other people, social
institutions, ideas, activities, and situations, on the basis of the meanings that those
things have for them (Blumer, 1969, p. 2). That is to say, we assign meanings for
things and those meanings determine how we will act in regard to those things.
Human behaviours are thus not products of various factors such as motives, attitudes,
personality, or role requirements that play upon human beings. Instead, meanings
that things have for human beings are central in the formation of people’s behaviour
and attitudes (Blumer, 1969). This meaning establishes the way a person interprets
something, the way an individual comes to act towards it, and the way he or she is
prepared to talk about it (Colomy & Brown, 1995, p. 22). For instance, if I define a
chair as something to sit on, I will act towards a chair as such and use it as an object
upon which to sit. Someone else may define a chair as a kind of weapon and respond
to it by throwing it towards others.
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The second premise concerns the source of meaning. It is argued that meaning arises
in the process of interaction (communication, broadly understood) with other people
(Blumer, 1969). That is to say and reminiscent of Dewey, our meaning for a thing is
not intrinsic or inherent in the thing itself, nor is it merely an expression of
psychological elements. Instead, our meaning comes from our interactions with
others. As people interact, they use their own meanings for things in the interactions
with others. As the interaction continues, however, the meaning of the thing may
remain constant, may change, or may alter in some way.
Blumer insisted that social interaction is of vital importance in its own right. It is a
process that forms human conduct instead of merely a means or a setting for the
expression of human conduct (Blumer, 1969). The meaning of a thing for a person
grows out of the ways in which other persons act towards the person with regard to
the thing (Blumer, 1969). Thus, I was not born knowing that a chair is something to
sit on. Someone had to show me or tell me its function. If I had to determine its use
on my own, it could only be through an internal conversation I had with myself.
Last, these meanings are handled in, and modified through, an interpretive process
used by the person in dealing with the things one encounters (Blumer, 1969, p. 2).
As we experience things we adapt and modify our understanding of the things. This
process involves communicating with oneself and indicating to oneself the meaning
of the thing towards which one is acting via symbols. At first, I defined a chair as a
sitting object. However, later I saw someone throwing a chair at another which
caused me to re-evaluate my understanding of the possible use of a chair.
Blumer’s other major contribution to SI was the development of a naturalistic
research methodology. According to Blumer (1969), traditional methodology and
their methods and techniques (such as the survey) did not put enough emphasis on
the importance of the meaning that things had for a person in shaping behaviour.
Instead, meaning was viewed as innate to the object itself and thus a dismissible
factor. Although Blumer (1969) believed that an object had an independent empirical
existence, he proposed that sociologists should seek to understand, rather than
49
predict or control, human behaviour.
In understanding, Blumer (1969) started with an interpretive approach to human
nature. Humans do not simply react to another human’s actions; they interpret and
define actions and respond based on the meaning of those actions. A research
methodology must therefore be able to capture information on the meanings and
interpretations held by the individual. This, according to Blumer (1969), can only be
achieved through direct examination of the empirical world.
In summary, from a symbolic interactionist perspective, objects do not have inherent
meanings but assume meanings as people act towards them and these meanings are
then constructed and reconstructed through ongoing social interaction. Realities are
thus the product of processes of interpretation and negotiation. The study of minded
behaviour involves the study of active, interpreting, and interacting individuals. Thus,
in understanding human behaviour, James’ (1890) social self, Cooley’s (1983)
sympathetic introspection and looking-glass self, Dewey’s (1957) notion of
deliberation, Thomas’s (1931) definition of the situation, Mead’s (1934) awareness
of the role or attitude of others, and Blumer’s (1969) human action based on
meaning all suggest that it is fundamental to understand, as best as we can, the
subjective meanings of the actor.
3.6 Critics and contemporary development of SI SI is a perspective. Like all perspectives it is limited because it must focus on some
aspects of the world while ignoring or deemphasising others (Charon, 2007). And as
with all theoretical propositions, SI has been subjected to criticism from both within
and outside the knowledge area (Meltzer et al., 1975). Criticism of SI is directed
primarily at the capacity, or lack thereof, of SI to acknowledge and address social
structures and culture, give consideration to human emotions and unconscious
elements, and to locate any interpretations of society within the macro world of
power, organisations, and history (Fine, 1993; Gusfield, 2003; Kemper, 1978;
In summary, the view of SI in this study draws not only on the tenets of the classic
Chicago School of SI but also on structural and emotional factors as informed by the
more recent theorising on SI. Finally, the key concepts applied in this research are
addressed below.
3.7 Key concepts drawn from SI This study was informed by the following symbolic interactionist “way of seeing”
and “way of thinking”. The human being is considered an active actor in the
environment, with a self. To understand a social phenomenon, it is necessary to
focus on human action and interaction. These are ongoing dynamic processes
wherein situations are defined and meanings are interpreted. The meanings of
objects, in turn, are made possible by symbols. The emotions associated with
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symbols and the concerns of impression and face are sources of motivation of
human behaviour. During interpretation, actors take into account structural factors
such as power, organisations, and culture. The interpretation is also based on the past
experiences of actors and their anticipation of the possible consequences in the
future.
The key concepts applied in the theoretical framework underpinning the research are
humans as actors, self, meaning, symbols, emotions, interpretation, action and
interaction, process, situation, social structures, and history.
From the SI perspective, human beings are actors with selves and thus are able to be
symbolic objects of their own actions and to act towards themselves as they might
act towards others (Colomy & Brown, 1995). This capacity of self-interaction
(through defining the situation) gives human action a reflective character and also
considerable autonomy. Thus, the human being is not a passive, conforming object
of socialisation, but an active, creative organism who constructs his or her social
world (Mead, 1934). In other words, human beings construct actions on the basis of
what is taken into account and not simply as a response to external factors (Blumer,
1969; Mead, 1934). From this perspective, action is understood from the position of
whoever is forming the action and the researcher needs to see the situation as it is
seen by the actor. In this study, China-educated nurses were considered actors who
actively constructed the meaning of their experiences and acted upon the basis of
those meanings. A researcher studying the experience must, as much as possible, see
it from the perspective of the actors rather than others.
The self of the human being is a social product (Mead, 1934). It emerges not just
from the individual, but how others perceive the person, and how the person
responds to this perception (Mead, 1934). In other words, self is not fixed, but
constructed and reconstructed through social interaction with others (Mead, 1934).
In this study, the researcher paid attention to how the selves of the China-educated
nurses were constructed and reconstructed and how their identities were negotiated
in the Australian context.
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In acting, humans act on the basis of the perceived meaning of objects, events, other
people, self, and ideas (Blumer, 1969). Meaning is, therefore, not fixed and intrinsic
to the object but rather socially created (Blumer, 1969). This must mean, indeed, that
events, objects, and situations have a multiplicity of possible meanings (Gusfield,
2003) and these meanings change over time and vary from group to group. Thus, a
researcher cannot simply assume the meaning an object or a situation has for the
participant (Gusfield, 2003). To explore the experience of the China-educated nurses,
it was necessary to understand the meanings that they gave to events and situations
and how they were constructed, maintained, and negotiated over time.
This is also true of the human environment. The nature of one’s environment is not
so much determined by its objects,8 but the meanings those objects have for
individuals (Blumer, 1969). People assign different meanings to the same objects
and thus individuals who live in the same area (physical world) may have, indeed,
quite different environments. As Blumer (1969, p. 11) noted, “people may be living
side by side yet be living in different worlds”. We see from this point that in order to
understand the experience of the participants, it is necessary for the researcher to
understand the world of socially defined objects upon which the action is based.
Although working in the same physical context as their Australian colleagues, the
China-educated nurses may exist in a different world of mental objects. To grasp this
world, we need to identify the underlying meanings that are assigned to objects in
the Australian health care system by the nurses.
The meanings of things, other people, the self, and various ideas are made possible
through symbols which arise in the social interaction process and are shared among
social groups (Blumer, 1969; Mead, 1934). The important significant symbols of
human beings are language. As a meaning-making entity, human beings use
language as the dominant medium for communication and meaning construction
(Mead, 1934). Through the use of language, an individual might see him or herself
8 Blumer defines an object as “anything that can be indicated or referred to” (Blumer, 1969, p. 11).
56
as an object, imagine how the self is perceived by others, and regulate his or her
conduct accordingly (Mead, 1934). Symbols and their meanings allow individuals to
carry out distinctively human action and interaction. To study human action,
researchers must pay attention to the symbols participants use and the meanings they
stand for. In this study, the researcher focused on the words (through in-depth
interviews) and their meanings (by interpretation) expressed by China-educated
nurses when describing their experiences.
Every symbol has an emotional component and emotion is increasingly recognised
as no less important than symbols in guiding human conduct (Franks, 2003). As
Shott (1979) argued, “role taking emotions”, such as embarrassment and shame,
motivated people to avoid deviant behaviour. From the SI perspective, emotions are
socially constructed with certain normative standards (Franks, 2003). In this study, it
is acknowledged that human action is based on the meaning of symbols and
associated emotions. Some attention was given to emotion when interpreting how
China-educated nurses made sense of their experience, how they presented themself
when interacting with others and how they were motivated to act in a particular way.
Instead of a conventional stimulus-response sequence (in Darwinian terms), Mead
(1934) argued that human action is a stimulus-interpretation-response sequence.
Human action is not caused by certain factors such as motives, attitudes, role
requirements but rather it is built up and constructed by the individual based on
meaning (Blumer, 1969). The meanings of things, other people, self, and various
ideas are formed through an ongoing interpretive process that occurs during
interaction with others, self, and objects (Blumer, 1969). Thus, meanings are
negotiated and constructed over time and are subject to change. It is the
interpretation process that is unique to human beings and it is the interpretation
process that this research seeks to explore. This means getting inside the defining
process of the actors in order to observe what they take into account and how they
interpret what is taken into account in order to understand their actions. In this study,
to understand why China-educated nurses act as they did, the researcher sought to
explore how they interpreted the objects and events they encountered.
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It has been argued here that human society consists of people engaging in action
(Blumer, 1969). This means that the life of any human society consists of an
essential and ongoing process of fitting together the activities of its members
(Blumer, 1969). Joint actions are characteristic of social interaction and rest on the
ability of actors to take on a role, to grasp the other’s perspective, and to see what
their actions might mean to the other actors with whom they interact (Blumer, 1969).
In other words, actors constantly adjust their behaviour to the actions of others.
Fundamentally, human groups (or society) exist in action and must be seen in terms
of action (Blumer, 1969). This view contrasts with a more dominant perspective
which considers society composed of cultural or social structures. Yet, the
determinism of the structural position leaves little room to conceptualise the active
person who shapes society. In studying the empirical social world, therefore, a
researcher needs to trace the ways in which actions are formed. In this study, the
processes that underpin the experiences of China-educated nurses are the focus of
the inquiry and it is through an understanding of actions that these processes are
revealed.
This requires an understanding of human activity as an ongoing stream of action
whereby humans engage in covert and overt forms of actions (Blumer, 1969; Charon,
2007) and where decision making is constantly influenced by our interaction with
others and with the self (Charon, 2007). Through socialisation, individuals learn to
think and interact with others based on symbols and shared meanings (Mead, 1934).
This points to the fundamental tenet of this study which is that human beings
construct their realities in a process of interaction with others. To understand human
behaviour, it is important to understand how the process of definition and
interpretation of the situation redirects and transforms behaviour (Benzies & Allen,
2001). The actions of China-educated nurses are constantly influenced by social
interaction. To understand these actions, we need to understand that process of social
interaction.
Action is paramount but it also takes place in a context. An individual forms action
58
based on the interpretation of persons, places, and events (Blumer, 1969). Action
thus is the here (context) and now (present) (Gusfield, 2003) and so it is situational.
To understand human action, researchers must know the situation of the actor and
the actor’s definition of that situation (Gusfield, 2003). In this study, it is necessary
for the researcher to understand the situation of the participants and how they define
that situation.
When we interpret the context, we take into account social structures such as power,
gender, race, ethnicity, organisations, and culture. As Blumer (1969) has argued, it is
undeniable that human behaviour occurs within structural (such as power and
organisations) and cultural (such as social expectation, norms, and values)
constraints. Macro-like structures continually affect how individuals define a
situation and actors draw upon their understandings of these structures to develop
their respective lines of actions (Blumer, 1969). We acknowledge, therefore, the
place of structural conditions in providing a social context for interaction. Yet, social
structure, while effectual, is never strictly considered as causal. It does not determine
the action but rather, influences meaning construction (Blumer, 1969). In this study,
it is assumed that social structures shape the actions and experiences of China-
educated nurses through meaning construction and definition of situation.
In the same sense, every action has a history and must be seen within a historical
context. During the interpretation process, actors draw upon their past experiences in
defining the present situation. Although the past is used to guide action in the present,
our histories do not cause what we do in the present (Charon, 2007). The future is
also very important in our definition of a situation because what we do in the present
depends in part on our consideration of the consequences for the future (Charon,
2007; Mead, 1934). We understand from this premise that the actions of China-
educated nurses are caused by their definitions of the here and now. Yet, both past
experience and future anticipation may influence those definitions and thus actions.
In summary, SI provides a persuasive theoretical perspective for studying how
individuals interpret objects and people in their lives and how this process of
59
interpretation leads to action in specific situations (Benzies & Allen, 2001). SI
emphasises the importance of defining the situation through symbols; the centrality
of meaning to human interaction; the necessity of understanding the subjectivity and
human agency of the actor; and a focus on interactive indeterminacy, contingency,
and emergence in human behaviour (Blumer, 1969; Mead, 1934). In addition, the
criticisms of SI were given due consideration in relation to this study. On the issue of
structure and agency, this study tended to focus more on China-educated nurses as
agents who interpreted and thereby constructed their experience. But it was also
concerned with explaining how social structures (such as power, history, social
organisation, culture, and gender) and emotions shaped individual behaviour. It is
the combination of these tenets that situate the study theoretically.
3.8 Summary This chapter has constructed and justified the theoretical framework to be applied in
this research. As background, the chapter provides insight into the range of
intellectual ideas that ultimately shaped the Chicago School of SI. Of these traditions,
pragmatism and the works of Mead have been by far the most influential. Blumer
followed, not only to name SI, but also to extend Mead’s theoretical perspective and
develop it into a distinctive research methodology. This study draws predominantly
on the theoretical tenets of Mead, Blumer, and Goffman. However, the theoretical
perspective also acknowledges criticisms surrounding SI because of its astructural
bias and neglect of emotions. Thus, the key concepts that underpin this study are
humans as actors, self, meaning, symbols, emotions, interpretation, action and
interaction, process, situation, social structures, and history. We turn now to a
detailed exposition of the study methods which is the focus of Chapter 4.
60
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Chapter 4 Methods 4.0 Introduction While theory refers to a way of thinking about and studying social phenomenon,
method is a set of procedures and techniques for gathering and analysing data
(Strauss & Corbin, 1998). The purpose of this chapter is to describe and justify the
GT methods employed in this study. Although a concurrent process of sampling,
data generation, and data analysis is characteristic of the GT approach, for ease of
description, each method is considered sequentially. In addition, the relevant ethical
issues are addressed and issues of rigour examined.
4.1 Justification of GT methods The value of a qualitative study is that it delves in-depth into complexities and
process (Marshall & Rossman, 1995) whereas quantitative approaches may
oversimplify the complex nature of real-world experiences (Patton, 1990). The
nature of the research question (how and why China-educated nurses give meanings
to the experience of working in Australia) and the fact that the area of research
interest has not been adequately addressed previously calls for a qualitative
exploration.
The methods of GT were chosen for this study because it is generally acknowledged
that the philosophical underpinnings of GT are informed by SI (Charmaz, 2006;
Strauss & Corbin, 1990, 1998). The SI emphasis on language, meaning, self,
interaction, and process complement a GT study (Charmaz, 2006).
A further reason for selecting an inductive approach is that theory building in this
area of knowledge has been largely absent. GT methods allow for an uncovering of
the underlying social processes that are grounded in empirical data (Glaser, 1998).
The main purpose was to generate a theoretical understanding rather than simply
describe the study phenomenon (Glaser & Strauss, 1967). The use of GT methods is
more likely to offer insight, enhance understanding, and provide a meaningful guide
to action (Strauss & Corbin, 1998).
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4.2 GT methods As its name implies, GT moves from data to the development of theory; it is both an
interpretive and an inductive process (Glaser & Strauss, 1967). In this study, GT
provides a constant comparative method for the generation of a theoretical
understanding of the experiences of China-educated nurses working in Australia.
4.2.1 Background of GT GT was first developed in the 1960s by Barney Glaser and Anselm Strauss as a
systematic method of research designed to generate rather than test theory (Glaser &
Strauss, 1967). At that time, grand theory (logic-deductive theorising) and theory
testing (verification) were the predominant approaches to knowledge development
(Glaser & Strauss, 1967). The intention of Glaser and Strauss was to close (what
they argued was) an existing gap between theory and empirical research by turning
the focus to the discovery of concepts and hypotheses relevant to a study area
(Glaser & Strauss, 1967).
Following the initial publication on GT9, Glaser and Strauss parted in their
methodological approaches (Glaser, 1992).10 Glaser remained consistent in his
vision of GT as an objective method of discovery (Charmaz, 2006). This objectivist
approach is founded in the belief that researchers should remain impartial and
objective during data collection and analysis (Charmaz, 2000, 2006). For objectivists,
categories emerge from the data and hold explanatory and predictive power across
different times, spaces, and individuals. Strauss (1987) and his subsequent co-author
Corbin (Strauss & Corbin, 1990, 1994, 1997, 1998) moved the method towards
verification with an emphasis on technical procedures. Yet, just as significantly, the
Strauss and Corbin (1990, 1994, 1998) approach extended the focus of the classic
micro-social processes of GT to include the macro-social dimensions and their effect
on people’s actions.
9 The discovery of grounded Theory: Strategies for qualitative research was published in 1967 (Glaser & Strauss, 1967). 10 There has been much debate surrounding this parting of the approaches, but a discussion of this area is beyond the scope of this chapter (see Duchscher & Morgan, 2004; Corbin, 1998; Glaser, 1992; Heath & Cowley, 2004; Kendall, 1999; Locke, 1996; Melia, 1996; Rennie, 1998a, 1998b; Walker & Myrick, 2006).
63
In recent years, a growing number of scholars have moved GT away from the
objectivist and towards the constructivist position (Annells, 1996; Bryant, 2003;
Charmaz, 2000, 2006). According to Charmaz (2000, 2006), a constructivist view
places emphasis on how data are interpreted. This latter perspective acknowledges
that a neutral position is impossible and hence that data collection and analysis are
influenced by the researcher’s theoretical beliefs and interactions with participants
(Charmaz, 2000, 2006). For constructivists, meaning is the centre of inquiry and the
results are contextualised. In other words, the theoretical concepts serve as
interpretive frameworks and offer an abstract understanding rather than a tidy theory
for explanation and prediction.
4.2.2 Modified constructivist GT The methods applied in this study depict a modified constructivist GT approach
informed by a combination of the Glaserian and constructivist positions (Charmaz,
view becomes problematic if it moves us to an absolute position where all views of
the same situation are considered equally valid (Fox, 2001; Olssen, 1996) and thus
where anything goes.
The position of this study, therefore, lies somewhere between Strauss and Corbin
and Charmaz. It accepts Charmaz’s distinction between reality and truth. It also
acknowledges a constructivisitic epistemological premise that the researcher and the
researched influence each other during interaction (Charmaz, 2000, 2006).
Knowledge is therefore created and constructed during the research process among
the researcher and participants. As a result, research inquiry is necessarily value-
bound and a certain degree of bias and subjectivity is unavoidable (Charmaz, 2000,
2006). My personal experience, in combination with my cultural background, gender,
racial and social affiliation, impact upon the way I make sense of the world.
But importantly the study also adheres to the view that although we may not entirely
know reality, we must presuppose reality for otherwise we drift into solipsism (Fox,
2001; Olssen, 1996). We therefore accept the assumptions of a constructivist GT
apart from the relativist ontology of some constructivist works. In adopting a
modified constructivist GT approach, the researcher can move GT methods further
into the realm of interpretive social science consistent with a Blumerian emphasis on
meaning and the existence of a real world (Charmaz, 2000).
The following outlines the research process and engages with key concepts critical
to the GT methods. While the sampling and data generation process as articulated
here appears linear, it was recursive in its application. Also, it is worthy of note that
in a GT study this process evolves in accordance with the data generated and the
proceeding analysis.
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4.3 Recruitment procedure This research was conducted in two major cities in Australia: Brisbane and Adelaide.
The study participants were recruited using the same approaches in both regions: a
call for participation and snowballing.
First, a call for participation was advertised in the publications of the Queensland
Nursing Union (see Appendix A) and the Australia Nursing Federation (see
Appendix B). The initial notice included the possibility of a focus group. Focus
groups were ultimately not used as a data generation strategy. Furthermore, nurses
born and educated in Taiwan were included in the recruitment advertisement but it
was subsequently decided to confine the sample to Mainland China due to social and
economic differences. Interested participants were asked to contact the researcher.
Appointments for the interviews were negotiated with potential participants
following initial contact. Second, snowball sampling was undertaken to recruit
further participants. This was done by requesting participants to refer people they
know who might be interested in participating to the researcher.
Gaining trust from potential participants is essential in the recruiting process. On
most occasions, initial contact with potential participants was via email or telephone.
Detail matters in gaining trust and thus much attention was paid to factors such as,
how participants would be approached, how I presented myself as a researcher, and
how the research project was explained.
Snowball sampling proved to be successful and 15 out of 28 participants were
recruited through this strategy. To further develop the categories, 18 of the initial
participants were invited and agreed to undertake second interviews. Recruitment of
study participants took place over a 13 month time frame, resulting in 22 interviews
with 13 participants in Adelaide and 24 interviews with 15 participants in Brisbane.
4.4 Ethical considerations Ethical approval for the study was granted by the Human Research Ethics
Committee of the Queensland University of Technology. When a potential
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participant demonstrated interest in participation by contacting the researcher, he/she
was screened for inclusion criteria and then given the information sheet (see
Appendix C) and consent form (see Appendix D). Prospective participants were
given time to read and think about the study before making a final decision to
participate.
Prior to the interview, the study was explained to the participant, including the
purpose, the procedures for data collection, potential risks and benefits, time
commitment, the rights of the participant, and strategies to protect privacy and
anonymity. Also, an opportunity to ask questions was given prior to signing consent
form to ensure the participant was fully informed.
Participation in this study was voluntary and participants were free to withdraw at
any time without penalty. A decision to participate or not would in no way impact
upon the work situation of a participant. No coercive or deceptive tactics were used
to encourage participation. Participants were recruited through their professional
organisations and personal contacts rather than their employers.
In the snowball sampling the researcher asked the initial participants, on the basis of
their own experience of being interviewed, to consider if they could recommend the
research to others who might be interested in participating. If agreed to, the
participants were requested to give the information sheet about the research to the
potential participants. The researcher did not seek any information about the
potential new participants but waited until they made contact in relation to the
research.
Privacy and anonymity of participants were ensured by the development of a master
list that identified participants by an assigned code. This list was kept separately in a
locked filing cabinet away from the transcripts and audio-records. Only the
researcher had access to the key and the list. The master list and electronic
recordings will be destroyed at the completion of the research. No names or other
identifiers such as place of employment or geographic region appeared in the
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transcripts, field notes, reflexive journal, memos, or presented data. All electronic
transcripts, field notes, reflexive journal, and memos were stored in a password
protected computer accessible only to the researcher. The researcher was responsible
for transcribing all interviews.
No physical risk to the participants was anticipated. It was possible that participants
might feel emotional or psychological discomfort in reflecting upon their
experiences during or following interviews. A plan for risk management included
continuous assessment of a participant’s level of comfort and anxiety throughout the
interview, terminating the interview, rescheduling it for a later time if discomfort or
anxiety occurred, and a referral of participants to a free counselling service at the
Queensland University of Technology if they so desired. In addition, participants
were informed that they could refuse to answer any question at any point in the
interview. None of the participants experienced emotional distress and no referrals
were required in this study.
4.5 Sampling strategy A GT sample is not entirely pre-determined as is the situation in quantitative
research where participants are ideally statistically representative of a broader
population. The sampling strategies applied in this study were purposive sampling
and theoretical sampling.
Purposive sampling was used at the start of the research to select participants who
met the following inclusion criteria. Each participant had:
• been born in Mainland China;
• studied nursing in Mainland China, registered as a nurse and had work
experience in Mainland China; and
• migrated to Australia and worked in the Australian health care system as an
RN for at least six months.
For the purposes of this study, only nurses from Mainland China were included in
acknowledging that the health care systems of Taiwan and Hong Kong are
69
significantly different and warrant separate examination. The six month time frame
specified in the inclusion criteria was to ensure that the participants had a reasonable
amount of exposure to the study phenomenon. Diversity of demographic
backgrounds for participants was preferred to maximise variation and thus enhance
transferability of the study findings.
For ease of organisation, the first few interviews were conducted in Brisbane where
the researcher was studying. Those China-educated nurses who worked in Brisbane
and contacted the researcher after seeing the advertisement were the first few invited
to participate.
As the analysis proceeded, theoretical sampling11 was employed based on the
emerging analysis. Theoretical sampling is a distinctively GT method. It is a process
whereby concepts, categories, and conceptual ideas are elicited from raw data
through constant comparison and used to direct further data generation (Glaser,
1978). In other words, it is the means by which a researcher develops categories and
builds theories. Unlike other sampling techniques, the researcher who uses
theoretical sampling cannot know in advance precisely what to sample for and where
the sampling will lead because of the emergent nature of this method (Glaser, 1978).
Strauss and Corbin (1990) make the important point that theoretical sampling is not
only about the selection of participants, but also about the selection of incidents by
way of altering the interview questions. This form of sampling is thus based on
incidents and not on individuals per se (Strauss & Corbin, 1990). Alteration of the
interview questions to meet the needs of the ongoing theory development was
widely used in this study.
In addition, the researcher also used theoretical sampling to select participants with
particular experiences or characteristics to meet specific needs identified through
data analysis and relevant to the theory development. One example was the
11 Theoretical sampling considers what is theoretically relevant, what is absent (Strauss, 1987), analytic sampling of incidents and maximisation sampling to elaborate the theory (Glaser & Strauss, 1967).
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revelation, after the initial analysis of the first eight interviews, that marital status
had a considerable influence on participant experience. As such, the researcher
sought China-educated nurses who were married and with their partners living in
Australia, to further refine the theory.
A further point to consider was that theoretical sampling may include sampling
within and outside a substantive research area. In this study, the sampling was
limited to the substantive area because the researcher intended to develop a focused
theory applicable to one substantive group only (Glaser & Strauss, 1967). Indeed,
the extent to which it is necessary for a researcher to go outside the substantive area
is debatable (Glaser, 1978, p. 51). As Glaser (1978) has argued, sampling outside the
substantive area before an emergent theoretical framework is stabilised may
undermine theory relevance.
For Glaser and Strauss the process of theoretical sampling continues until the point
of theoretical saturation is reached. Saturation means that no additional data are
being found whereby the researcher can develop properties of the category (Glaser
& Strauss, 1967). Yet, making a theoretically sensitive judgment about saturation is
always subjective and never precise (Glaser & Strauss, 1967, p. 64). Rather, the
decision is “a matter of degree” in that:
It is more a matter of reaching the point in the research where collecting additional
data seems counterproductive; the “new” that is uncovered does not add that much
more to the explanation at this time (Strauss & Corbin, 1998, p. 136).
Although the point of saturation is open to interpretation and criticism,12 the concept
was used to guide this study. After 39 in-depth interviews, a reasonable degree of
theoretical sufficiency had been achieved and there was no new information
emerging in the form of category, sub-category and property. Aware that saturation is
always provisional and tentative and that enough data is needed in order to be
persuasive, participant interviews were continued to strengthen the abstract
12 See for example Morse (1995) and Suddaby (2006).
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connections between categories. This resulted in a total of 46 interviews with 28
China-educated nurses who work in Australia.
4.6 Participant demographics Basic demographic information was collected from each participant using a pre-
designed questionnaire (see Appendix E). The demographic data acquired for the 28
participants in the study is as follows. Although gender was not specified as an
inclusion criterion, all participants were female. The age distribution was 20-30
years (16 participants); 31-40 years (10 participants); and 41-50 years (2
participants). Among the 28 participants who were interviewed, 4 held a three-year
diploma in nursing, 18 held a baccalaureate degree in nursing, and 6 had a
postgraduate qualification. As to marital status, 15 were single, 11 married, 1
divorced, and 1 separated.
Participants in this study came from nine provinces and three municipalities in both
the northern and southern parts of China: Beijing city, Shanghai city, Chongqing city,
The situation in China is like this. After working for many years, many nurses feel
that they just do what doctors ask them to do. Even if they have their own ideas, it
is the doctor who makes the final decision. (Participant 1, Interview1)
However, it is also important to note that nurses in China, if in a somewhat invisible
role, are decision-makers. Nurses observe patient conditions, draw upon various
forms of knowledge and experiences to inform doctors and shape their decisions.
This universal dilemma of the invisibility of the nurse has been subject to much
theorising. In the 1960s, Stein (1968) used the concept of the doctor-nurse game to
explain a complex relationship whereby nurses provide information for and pose
recommendations to doctors in such a way that does not challenge the existing
power structure. For the game to be successful, nurses must adopt a passive position
in presenting information so that it appears doctors fully own decisions (Manias &
Street, 2001). For Stein (1968), the authority of doctors was reproduced and
sustained through such interactions. Some decades later, Manias and Street (2001)
argued that this strategy had a positive dimension in enabling nurses to contest the
dominant practices that marginalised nursing knowledge. Nonetheless, where the
input of nurses was invisible, the outcomes of their decisions remained hidden
(Manias & Street, 2001; Porter, 1991). For the participants, the work of Australian
nurses conformed far less to the doctor-nurse game.
Generally speaking, nurses here are more independent. They don’t rely on doctors
totally. They can have their own thoughts and make decisions on the caring of
patients. (Participant 4, Interview 4)
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Here doctors and nurses each have their own administrative hierarchy. They don’t
interfere with each other’s business. Doctors do not have power over nurses just
because of their education. (Participant 7, Interview 7)
This perception of autonomy is related to the extent of the professionalisation of
nursing. The notion of a “profession” initially appeared as a demarcation issue; that
is, drawing a boundary between “special” and “ordinary” occupations (Lamont &
Moln´ar, 2002). From this view, professions are those occupations that have
successfully claimed and received special advantages and rewards (Shaffir &
Pawluch, 2003). In China, nursing is distinguished more so as an occupation than a
profession.
Nonetheless it is the case that boundary building between nursing and medicine is, at
its root, a process of social interaction (Abbott, 1988). Occupational boundaries are
not self-evident but have to be negotiated constantly within a system of work. While
the status of nurses is stronger in Australia, status differential still exists as the
following quote suggests:
I feel that the status between nurses and doctors here still differs…I feel the respect
is not so much about nursing as a profession, but nurses as human beings
generally…Not that the medical system in Australia considers nurses as someone
high in status, not so from my point of view. (Participant 1, Interview 1)
While nurses are increasingly recognised, there is still a discrepancy between the
image of nursing in rhetoric (as an independent profession) and the realities of
nursing practice. In the 1970s, Hughes (1971, p. 308) made the point that “ the
[nurses’] place in the division of labour is essentially that of doing in a responsible
way whatever necessary things are in danger of not being done at all”. More than
four decades later, the point remains relevant.
May and Fleming (1997) further allude to this point in arguing that the profession of
nursing has been more concerned to construct occupational differences than to
compete on the same terms with medicine. While the emphasis of medicine is on
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scientific treatment, the argument is that nurses care about patients (May & Fleming,
1997). Hence, the nursing profession has grounded its jurisdictional claims in the
language of care in order to establish professional autonomy (Allen, 2001). Yet, the
difficulty with the May and Fleming (1997) argument is that the
“professionalization” discourse (and not nurses) dictates the grounds on which this
struggle is played out. This is equally the case in China and Australia. It appears that
nurses in Australia and even globally, are still struggling to improve their image and
status.
Apart from medical dominance, the organisation of nursing work is a further factor
that constrains nurses’ decision making in China. To maximise efficiency and to
cope with the level of work, nursing work in China is often routinised.
Nursing work in China is basically routine, task by task. Nurses are not caring for
the patient, but fulfilling tasks. (Participant 12, Interview 12)
In contrast, the delivery of nursing care is perceived to be more individualised in
Australia indicating a different philosophy of care and better staffing resources. The
participants thus perceived that they had more freedom in decision making
concerning care delivery in Australia.
Health care organisations in China are also strictly hierarchical. Hospitals set down
rigid rules and regulations to which nurses are required to adhere. Nurse managers
implement surveillance strategies and constantly scrutinise the work of individual
nurses. As one participant said:
In China, nurse managers spend all day looking at you and checking your
work…Have you done this? Have you done that?…You should not sit there and
chat. You should not sit there and drink, and so forth. (Participant 3, Interview 3)
In contrast, the role of nursing management in Australia is one of overall
coordination.
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That is to say, unlike in China, nurse managers here coordinate and manage the
ward comprehensively, and not just spend time looking at you as an individual.
(Participant 3, Interview 3)
It should also be noted that nursing in China is not a unified entity. Nurses are as
much subordinated by management groups in nursing as they are by medicine. In
that context, the authority of individual nurses determines the level of involvement
in decision making. In a ward hierarchy, what we might refer to as thinking is the
responsibility of top level nurses, while doing is the role of bedside nurses. Where
the rules are laid down and there are superiors who make decisions, bedside nurses
are expected to follow the rules and listen to nurse managers. Constrained by a
system that gives priority to rules and routine, Chinese nurses have little decision
making power and are seldom required to think independently. Indeed, their capacity
to think becomes invisible or obscured over time.
In Australia, judgments made by nurses are well respected. Along with increased
autonomy comes additional responsibility. Yet, although decision making implies
greater power and higher status, the participants were uncomfortable with being held
accountable for their decisions.
The prn order is here, but whether to give the medicine or not, how much to
give? …To a large extent, you as a nurse need to assess the patient’s condition and
decide on that. The doctor’s order is like that, it gives you a right, but when you
execute the right, you need to think a lot...At the beginning, I was scared. Why I
should take this responsibility? It should be a doctor’s responsibility. (Participant
6, Interview 6)
Without doctors available in the ward, the administration of pro re nata (prn) drugs is
often the sole responsibility of nurses in Australia. While this reflects autonomy of
practice (Usher, Baker, Holmes, & Stocks, 2009), the participants were not fully
confident in clinical judgment. They thought that their nursing knowledge might be
inadequate and they needed to know more in order to better execute that autonomy.
It is probable that this is a perceived rather than actual knowledge deficit (Bucknall
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& Thomas, 1997). The nurses may also have reverted to the novice role in a new
context and thus looked to rules in decision making. A further reason is related to the
foreign status of the participants. They were reluctant to make decisions as they
feared that there would be no protection in the case of a wrong judgment.
The level of decision making involved in nursing work is shaped by many factors
such as the practice context, type of knowledge, and power. Clinical judgement is
considered to be a largely intuitive skill, honed and refined through adopting
strategies that work and avoiding those that do not (Usher et al., 2009). Over time
the participants gained more experience in decision-making and became increasingly
confident. A further concern of difference related to what was described as basic
nursing care.
5.1.2 More basic nursing care The China-educated nurses perceived that basic nursing care constituted a great deal
of the daily work of nurses in Australia. From their perspective, nurses undertook
too much of this form of care.
Nursing here is different from in China, such as we don’t have much basic nursing
care. As to the basic nursing care, in China, we only learn its theory, not practice;
here the basic nursing care is (widely practiced). (Participant 9, Interview 9)
It is very different...Nurses here are required to do basic nursing care whereas in
China we are usually not. The family does that. (Participant 14, Interview 14)
From the SI perspective, each task has its meaning for those who perform the task
(Shaffir & Pawluch, 2003). The meaning of basic nursing care for the China-
educated nurses differed from that of the local nurses. In China, RNs typically do not
provide direct care (Xu et al., 2008). Rather, families or personal carers accompany
patients in the ward and provide all the required basic care (Lee, 2001).
Several factors contribute to this constructed reality. First, direct care is often of an
intimate and private nature. Patients in China, therefore, prefer to retain some
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privacy in hospital and are reluctant to be cared for by a nurse. Second, a moral
obligation to look after a sick family member is embedded in Chinese culture.
Meeting basic needs through the provision of direct care is seen as a way of
demonstrating care and affection (Haley et al., 2008).
In addition, nursing in China is often understaffed because of lack of recognition and
funding (Haley et al., 2008). During a day shift, a nurse may care for an average of
15-20 patients and this number increases on public holidays (Ma, 2005). Thus
realistically, nurses are often too busy to meet the direct care needs of patients. In an
effort to redress the nursing labour issue and to contain health care costs, the
boundaries between waged and unwaged care are necessarily blurred.
It is also the case that in China nursing is considered a semi-skilled job and nurses
are of low social status. The media portrayal of nurses gives people an impression
that nurses do little other than the “hard and dirty work” (Pang, Arthur, & Wong,
2000). Consequently, nurses in China are concerned to set down a boundary between
nursing work and the work of a servant (Pang et al., 2000). A distancing from basic
nursing care is one way to protect professional integrity and gain social respect for
nurses in China (Pang et al., 2000).
Even where nurses embrace the caring aspect of the profession they do not want to
be solely acknowledged for that attribute, particularly when their knowledge and
expertise are overlooked (Dombeck, 2003). This constructed meaning shapes how
China-educated nurses react to basic nursing care. As nurses ascend the professional
ladder, they distance themselves further from “dirty” work.
Although the participants accepted the concept of patient centred care, they found it
hard to accept the washing, toileting, and feeding of a patient as part of the role of
the RN in Australia. As one participant indicated:
Here, nurses need to do the bathing and toileting. I feel that is very hard for me. I
swore that I would never work there again after the 6 weeks clinic practice in the
medical unit. That is too much. I have never done anything that dirty and that tiring
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in my nursing life...Although I have heard of this situation before (I came), it was
still very hard for me to face it in real life. (Participant 22, Interview 22)
Goffman’s theorising on stigma has relevance for this analysis. If basic nursing care
carries stigma, it is a social process constructed from the experience, perceptions,
and anticipation of negative social acceptance and judgements about such work
(Goffman, 1963). People who carry out such stigmatised work are envisaged as
undesirable in the view of others and are devalued by society (Goffman, 1963).
Work that is, or that people think is, stigmatised is held in secret. As one participant
demonstrated:
I feel it is not good if people in China know that I am doing this kind of work here
since we seldom do it (basic nursing care) in China. However, we have had to do it
after we came to Australia. (Participant 14, Interview 14)
Another participant put it this way:
I feel too embarrassed to tell people (the fact)…If I tell my family that a nurse in
Australia needs to shower the patient, I think even my family would find it very
hard to accept. (Participant 16, Interview 16)
Goffman (1963) contends that it is a constant effort for those who are stigmatised to
manage and control social information about themselves. They actively engage in
what he refers to as impression management to shape how they are seen by others
(Goffman, 1959). Where fear of disclosure might have brought embarrassment and
loss of face, participants chose not to inform families and friends at home that they
were undertaking such work in Australia. The stigma connotes a mark of disapproval
and disgrace and has significant psychological consequences for those stigmatised
(Goffman, 1963). One participant purposefully chose not to work in hospital settings
in Australia in order to avoid such stigma.
Because I feel that if I choose to work in a nursing home, I don’t need to do that
(body care). There are carers there to take care of that. If I work at a hospital, I
feel (I cannot get away from that). (Participant 16, Interview 16)
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The tension here was between being a professional and yet doing what was
considered “unprofessional”. The relocation of nursing education from hospital-
based to higher education institutions upgraded the image of nurses and improved
the professional status of nursing. However, the historical “service” version of
nursing remains (Allen, 2001).
To cope with basic nursing care, the nurses tended to distance themselves from the
identity that accompanied that work (that is, low status worker). As Goffman (1961)
points out, one is not “just the role” in which one has been cast. The role is not
playing the individual, but the individual is “playing with the role” (Goffman, 1961).
Through this role distancing, the participants were able to effectively separate
themselves from what the work implied of them.
A further coping strategy was the use of methods to neutralise stigma and to
rationalise or justify actions to others as well as to themselves. Indeed, during the
interviews, the participants spent much time explaining how they made sense of
basic nursing care. It appears that they were making sense of this work more for
themselves than the researcher. The fact that the nurses were so clear in their
articulation of the issue also indicates a high level of reflection.
The rationalisation is evident in the detailed accounts provided by participants about
why basic nursing care was better performed by RNs. To begin with, there was some
professional knowledge involved in basic nursing care to perform it safely. Health
care assistants were not educated to observe and interpret patients’ conditions. The
day-to-day realities of health care in hospital settings also afforded RNs very little
opportunity to supervise the work of care assistants. And basic nursing care provided
nurses an opportunity to assess the patient completely and also in context.
Part of the rationalising strategy was recreating the meaning of basic nursing care.
The reality that local nurses did basic nursing care willingly helped the participants
gradually reconstruct their perceptions of basic nursing care. The appreciation and
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positive feedback from patients further reinforced the legitimacy of the new meaning.
Using the reactions of others (their looks, their words, and their emotions), the
participants reshaped their views of basic nursing care.
The nursing concept here is very good…It is not a wrong thing for nurses to
provide basic nursing care as nursing should be human centred. (Participant 7,
Interview 42)
A closely associated difference was, as termed by the participants, technical nursing.
5.1.3 Less technical nursing In combination with the focus on fulfilling the basic care needs of patients, nursing
in Australia is perceived to be less technical. Overall, the participants were
unimpressed with the technical skills of local colleagues.
But what do nurses here actually do? They do not even do the IV, the cannulation
and so forth. All these are doctor’s job. What do nurses here do? After I think
carefully, I find the only specialised skill for most nurses in medical/surgical wards
is medicine administration. (Participant 1, Interview 1)
I want to mention the advantage of nursing in China, which is we are more solid in
technical skills. Here I feel generally nursing care has no large component of
technical skills. (Participant 7, Interview 7)
The importance the participants attached to technical nursing skills can be
understood historically. The traditional skills hierarchy in China accords the highest
status to medically derived technical work. The commercialisation of health care
also means that technical nursing attracts greater monetary return. Nurses in China
prefer to perform technical work because it symbolises professionalism and is more
socially prestigious.
However, the participants were prevented from using some technical skills acquired
in China and which they were perfectly capable of performing. They had to prove
their competence within the Australian system by attending courses and proving
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competence. This was considered a process of deskilling although far less so in
technically oriented departments such as intensive care units than others such as
rehabilitation wards. However, since many participants found it difficult to secure a
job in the highly technical areas, they considered their skills and expertise were
wasted or underutilised.
The perception that nursing care in Australia is less technical may create a sense of
loss since they could not demonstrate their superior technical skills which may have
engendered greater respect. This situation also created a form of moral dilemma for
the nurses where patients had to wait for procedures or where they received “sub-
standard” care. A common observation was of a doctor failing to successfully insert
an intravenous cannula into a patient with “poor veins” and the obvious pain it
caused to the patient. The nurses were of the view that they were better skilled and
yet were frustrated because they were not permitted to apply those skills.
5.1.4 No need to consider the cost Nursing care in Australia is also perceived to be far better resourced. It appeared that
Australian nurses could use resources at will. Yet in China, budgeting is a serious
concern where nurses must count equipment and material each shift and charge the
patient who is the recipient of those resources.
Because of the medical service here is paid by the government, you don’t need to
consider the money issue. You only need to consider…the patient’s conditions and
what care you need to provide. (Participant3, Interview 3)
In China, if you work in a big hospital, you need to consider the bonus…When you
use something for a patient, you need to think of how to save more and how to
achieve the best value. (Participant 9, Interview 9)
Since the early 1980s, China’s heath care system has undergone massive
restructuring (Haley et al., 2008) and the government’s share of national health
spending has steadily decreased (Lague, 2005). This has meant that hospitals have
been forced to introduce fee-for-service systems (Browne, 2005). As part of the
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market economy, hospitals also link the staff bonuses to the amount of income they
generate (French, 2006). This bonus scheme provides a strong incentive for nurses to
offer cost effective care. Indeed, one of the major tasks for nurse managers in China
is to be creative in saving. The priority given to nursing care quality is thus reduced.
Faced with the dilemma of sustaining organisational profits and patient health,
nursing care in China is complex.
The focus on cost containment also creates potential conflict in nurse-patient
relationships since patients and families tend to oversee nursing work closely (and it
may be easier to oversee nursing work than medical work). This not only
undermined the fulfilment that nurses drew from their work but also contributed to
high levels of occupational stress and consequent “burn-out”. This is evident in the
following reference to the nursing situation in China:
Because many patients pay for the medical services themselves, they pay a lot of
attention to that. Some even to the degree…to record everything nurses do for them
each day, such as how many times you take their temperature…It is very detailed.
It brings you lots of invisible pressure. (Participant 3, Interview 3)
Many Chinese find themselves without access to any type of comprehensive health
insurance. In China, around 56 percent of health care costs are paid for directly by
patients (Powell, 2005). Low income families find it difficult if not impossible to
afford health care (Wang, Xu, & Xu, 2007). Mostly because of the issue of cost,
Chinese patients and their families will look for faults in health care which
contributes to further stress for nurses.
Nurses are under constant psychological stress. They are not getting paid much,
because patients always make trouble, big or small. They know that they can get a
refund from the hospital if they can make some noise. (Participant 6, Interview 6)
In the Chinese context of a nascent market economy, nurses are now encouraged to
view their patients as “consumers” or “clients”. The “buying” of a service by health
care users implies increased consumer expectations. The frequent media portrayal
105
about inadequate service also challenges nurses’ authority and increases tension
between nurses and patients. As one participant stated:
In China, it is rare that patients say “thank you” to nurses. Rather, it is common
that patients get angry with you. (Participant 7, Interview7)
Australia has a national health insurance scheme and patients either enjoy largely
free health care or have private health insurance. There appears to be less conflict of
interest between nurses and patients. In this respect, the participants perceived
patients in Australia as pleasant and nursing work in Australia as more rewarding.
In China, nurses need to consider a lot the money issue. I feel working as a nurse
in Australia is a big improvement in quality for me. I can feel the essence of
nursing more from my daily work. (Participant 22, Interview 22)
More decision making, more basic nursing care, less technical nursing, and no need
to consider the cost are characteristic of nursing work in Australia. The work
environment and the organisation of nursing work differ to China from the
perspective of participants.
Most importantly, the system is different! The whole system cannot compare, they
are totally different. (Participant 1, Interview 1)
In migrating to Australia, the China-educated nurses brought certain meanings and
perspectives about what nursing is and how nursing care should be undertaken.
When confronted with nursing in Australia, the participants sought to make sense of
the new experience and did so by perceiving it as different from nursing in China.
While acknowledging the difference, it is important to note that the difference
reflects the perceptions and interpretations of the reality from the perspective of
participants rather than a matter of objective truth. In addition, the participants’
comments on nursing in China were historical rather than contemporary.
It is also the case that health care organisations are not rigid, fixed entities, but
106
dynamic arrangements of intricate social relationships (Charmaz & Olesen, 2003).
The organisation of nursing work is different in Australia and China but both are
what Allen (1997) refers to as negotiated orders. On one hand, the participants may
be motivated to immigrate because of the difference; on the other hand, these
perceived discrepancies might also mean that they are not clinically well prepared
for the realities of the nursing world in Australia. This point is further illustrated in
the next sub-category this is the Western way.
5.2 This is the Western way This is the Western way points to the discrepancies between China-educated nurses
and their colleagues in perceptions on what was real nursing work and how one
should engage with others. The participants’ emphasis on harmonious relationships
and respect for elders also made delegating tasks to enrolled nurses and carers
problematic.
After immigration, the participants found not only a change in the nature of nursing
work in Australia, but also the ways nursing care was delivered. It appeared that the
local nurses concentrated more on communication through talking and yet the
participants were more concerned about “real nursing work” through doing.
I don’t know what they (local colleagues) are doing, chatting with doctors-- a
waste of time from my perspective. (Participant 26, Interview 40)
The concept of real nursing work is constructed in a particular social context and
thus is not static. In China, the implementation of the market economy delineates
nursing care as a commodity with a price tag. Physical labour is the most visible
aspect of nursing care in the sense of paid work because one is doing something. In
contrast, the invisible nature of soft nursing work (emotional labour of caring)
renders its cost imperceptible and economic compensation difficult (Reverby, 1987).
The staffing shortage also prevents the provision of thorough social and
psychological care in the Chinese context. The nurses are encouraged to appear busy
in terms of observable, physical work. The talking domain of nursing care thus
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remains largely unrecognised and undervalued.
The cultural definition of what constitutes real nursing work shaped the
communication between the nurses and patients, which was usually brief,
predominantly task-oriented, and concerned with physical care.
Our communication with patients is limited to the functional level. There are few
in-depth communications between us. (Participant 7, Interview 42)
Apart from less emphasis on talking as nursing work, it is also possible that the
participants talked less because they were less capable of doing so. They consciously
played down the talking component.
Chinese nurses are very diligent and hardworking. But they don’t talk much with
others and they don’t like to talk due to inadequate language skills. (Participant 14,
Interview 14)
There was not only less communication but different communication. For example,
due to a lack of understanding about English expression, requests tended to be
articulated through direct Chinese translations which were often perceived as rude
and impolite by local colleagues.
Although she (a Chinese nurse) did a lot of physical work, she talked to colleagues
like this: I do this and you do that. Colleagues perceived this as an order…and not
being given a chance to express their opinions…They felt annoyed being told by a
newcomer. (Participant14, Interview 14)
Many Chinese are not used to saying “thank you”. It sounds as though one regards
others as outsiders. However from a local’s viewpoint, you are very rude by not
saying “thank you” or “please”. (Participant 10, Interview 10)
Language is the symbol used for communication which stands for shared meaning
within a given community (Mead, 1934). The expression of politeness is socially
constructed and not a self-existing entity with an intrinsic nature (Blumer, 1969).
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Once the consensus of politeness has been agreed upon, it is taken for granted as a
routine by members of a community to sustain some social order. People who
conform are considered polite while those who breach the rules are seen as acting
impolitely.
The participants acted on the basis of their previous definitions of politeness and
encountered resistance in the interaction. This further reflects the view that the
meaning of politeness does not reside in the intentions of the actor, but depends on
the response of others (Blumer, 1969). Problematic situations required the nurses to
reflect on the definition of the situation and construct new actions instead of
responding in pre-established ways. One such example is that the nurses found it
necessary to appear warmer, softer and more suggestive in posing requests.
When communicating with others, I tried to learn how to be polite so as to be more
acceptable by others. Sometimes, my words sound too formal and impolite, but I
found others can put it in a softer and more acceptable way. (Participant 12,
Interview 31)
Interestingly, the participants also perceived the more direct style of Western
communication as rude and impolite. They were easily hurt because of the
insensitive and sometimes even aggressive words of local colleagues.
When working with each other, local colleagues tend to be very direct. They do
what they want and they point out what they dislike about you directly, not being
concerned whether it would hurt you or not. (Participant 1, Interview 43)
As noted earlier, the rules of communication are socially situated. The Western style
of communication tends to be direct and straightforward, not giving people “face”.
The Chinese form of communication, by contrast, is more indirect and implicit in
order to maintain harmony. It is not uncommon for a Chinese to dwell on thoughts
for a long time before speaking out for fear of hurting others or causing conflict.
These social norms of communication are culturally embedded and dictate how one
presents oneself in a particular situation.
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Here you need to ask for what you want directly, let alone being polite in saying no
when being asked…If they didn’t tell you to take a break, you needed speak out
yourself: it is time for me to have a break. (Participant 1, Interview 43)
With the passage of time, the participants learned not to take a colleague’s comments
personally and to accept what was said as simply the “Australian” way.
As a senior nurse, I was in charge sometimes. I found local colleagues wouldn’t
mind being told by a senior on how to appropriately undertake a task. They would
accept your suggestion happily and would not remember the incidence afterwards
or give you a hard time in return. Vice versa, when you are being told, you should
not take it personally either. (Participant 12, Interview 31)
Differences in communication were also reflected in the way nurses addressed a
patient in Australia.
Here every nurse calls everyone sweetie, love, things like that. It is totally different
from us. We call everyone by name… I have never thought of addressing a patient
so intimately. It is hard for us because we don’t feel this way. (Participant 20,
Interview 41)
Such norms of addressing are also socially constructed. The symbolic action of
addressing a patient becomes a ritual through ongoing professional socialisation. In
the Chinese context, nurses are encouraged to address a patient in a way similar to
addressing a neighbour or friend. The “Australian” form of addressing a patient as
love or sweetheart was alien to the participants.
In Chinese culture, words such as sweetheart and love are used only when people
address someone who is very close and usually in private (Gao & Liu, 1998).
Intimate relationships are demonstrated by doing things for each other or by hints
and little gestures. Verbal expressions are less important (Gao & Liu, 1998). To be
explicit with someone not close sounds not only unnecessary but also disingenuous
(Gao & Liu, 1998). It is difficult emotionally for the participants to adopt the
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practice of addressing a patient intimately. However, the nurses saw a need to do so
in order to conform to the normative expectations of the work setting.
…but I think gradually we need to learn from local nurses. Anyway, do in Rome as
the Romans do...As an Asian, local people will regard you with special respect
when they hear you speak good English and see you behave like an Australian.
(Participant 20, Interview 41)
Some participants also attributed the superficial nurse-patient relationship to their
failure to address patients in a “proper” way.
What impressed me most is that local colleagues can easily treat patients as their
own relatives. I was moved that they can address patients so warmly and intimately.
I feel I lack this ability. There is a certain distance between patients which I feel
hard to close. (Participant18, Interview 18)
Goffman’s notion of life as a dramatic performance provides a useful frame for
interpreting this situation. From patients’ reactions, the participants perceived a need
to be sensitive to the expressive dimension of their behaviour. The nurses learned to
be “on” to perform for patients. The performance functions to create and sustain a
“projected self” and a show of normality in order to be viewed as legitimate
(Goffman, 1959). While not comfortable in doing so, the participants started to call
patients love and sweetheart gradually in order to give the impression that they were
not much different from local nurses.
It should also be noted that although the endearing form of address appeared an
accepted ritualised practice in the clinical areas, it is not without dispute in Western
countries (Oakley, 2005; Willey, 2008). It is argued that this form of address reflects
the association of caring with “mothering” in which the patient is “childlike” and the
nurse the “parent” figure (Hewison, 1995). This patriarchal relation of institutional
care reinforces the diminished power of the patient (Oakley, 2005).
A further difference in communication related to the delegation of work to enrolled
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nurses and carers which was a source of stress for the participants.
She (a local enrolled nurse) doesn’t listen to you sometimes, which makes it hard to
finish work on time...Local nurses will definitely bring this issue out, but as a
Chinese, I dare not offend her. (Participant 12, Interview 12)
Sometimes they won’t listen to you if you are too soft…In addition, one carer
reports to you that another carer is not good. Meanwhile, the latter complains to
you that the former is lazy. I feel it is difficult to deal with this kind of situation.
Also if you are too tough with them, they will unite and complain to the manager
about you. (Participant16, Interview 16)
The difficulties in work delegation appeared to be a shared issue among the
participants. Due to foreigner status, the nurses found it hard to manage local
enrolled nurses and carers who would not listen and were uncooperative. The
situation was exacerbated where enrolled nurses and carers were senior to the
participants in both practice experience and age. Coming from a Chinese culture
where harmony in the workplace and a deep respect for the elders is valued, the
participants were discouraged from confronting these staff and from reporting
interpersonal issues with co-workers. Indeed, the relationships with enrolled nurses
and carers were consumed with negotiations over status and authority.
Chinese are taught to be humble and modest in their interactions because people
think that if one speaks out loudly for oneself, one does not have much inside. While
modesty is a primary virtue in Chinese relationships (Gao & Liu, 1998), in Australia,
one needs to promote oneself.
If you are too gentle and modest here, people will look down on you…You should
show your capabilities wherever you go, be courageous, show initiative and be
active. Here people will only have belief in you if you can talk a lot. People will
only appreciate you if you are knowledgeable. (Participant 1, Interview 1)
Presumably, a strong desire to impress people entices one to brag about one’s
accomplishments (Schueler, 1999). Modest people underestimate self worth to some
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extent to avoid provoking an envy response in others (Schueler, 1999). In a
collectivist culture such as China, it is necessary to be humble and modest to
maintain group harmony. There is also a negative association between the amount of
words one speaks and how trustworthy others consider one is, with those who speak
less viewed as more trustworthy (Lebra, 1987).
The interpretation of the concept of hard work further situated the China-educated
nurses differently.
They are clear on work and breaks. You should take a break when it is time to
break…They feel it is inappropriate for you to sacrifice your time…They won’t
consider this as hard work. Indeed, they feel you are being irresponsible.
(Participant 2, Interview 2)
In China, nurses are expected to sacrifice their break times for patients when
necessary. A strong work ethic is considered a source of great pride. To the
participants, working longer hours and assuming heavier workloads were
compensating strategies for their perceived inadequacies. Dedication and hard work
would reduce complaints from patients and colleagues. The nurses assumed that
local colleagues would share the same definitions of the situation (not taking a break
demonstrates dedication) and act accordingly. However, the nurses were
unappreciative of this practice.
Learning to act appropriately is a process of ongoing socialisation. It is about “taking
over specific standards, beliefs and moral concerns” (Fine, 2003, p. 76) and involves
more of what is not said than what is stated (Clausen, 1968). Socialisation thus
represents a ubiquitous feature in all interactions: the apprehension of another’s
perspective so that joint action can occur (Denzin, 1969). As newcomers, it is
necessary for the participants to display these implicit, often “taken for granted”
qualities to be accepted.
Perceptions on how to nurse also differed between the participants and local
colleagues.
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We have different ideas on what is the right way. But as a newcomer, locals
wouldn’t accept my view…The baby was agitated and crying. They gave the baby
no sedation but a pacifier. Actually the use of a pacifier could even inhibit
breathing…From a Chinese viewpoint, we thought the baby needed comfort…We
emphasised that therapeutic touch could comfort the baby. I tried to touch the baby
but they thought I was wrong in disturbing the baby. (Participant 26, Interview 40)
There is a tacit understanding about how nursing care should be carried out in a
given context. The participants who attempted to act based on pre-established
Chinese understandings failed. Using Blumer’s (1969) words, the structural and
cultural conditions of Australian nursing was an “obdurate” reality capable of
“talking back”. Problematic situations required the nurses to construct new meanings
dependent upon the response of others and to act differently.
The point here, as Xu et al. (2002) have argued, is that nursing education and
practice are never value free. Rather, they are deeply embedded, either explicitly or
implicitly, in the cultural values and norms of a given community. This may, in part,
explain why even some very experienced China-educated nurses had significant
problems at the outset. Nervous and tentative, the participants were eager to conform
to the Australian way and to live up to the attitudes and behaviours expected of them.
You live in Australia and take care of patients in Australia under the Australian
health care system. You cannot work at all if you still retain your Chinese way and
it won’t fit. (Participant 7, Interview 42)
The differences in work are demonstrated in the different emphases on nursing work
and how to deliver care. What China-educated nurses take lightly, local nurses
consider more seriously and that which China-educated nurses feel strongly about,
local colleagues consider of no consequence.
Some locals pay a lot of attention to those details, such as our work manners. Since
we do our work quickly, we may overlook some minor details and they consider us
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rude or impolite…Actually we are only concentrating on how to do our work,
looking after our patient. (Participant 26, Interview 26)
Coming from diverse social and cultural backgrounds, it is realistic to assume that
the participants would work differently, particularly during the initial period.
Difference is a means of describing and recognising, but the shared negative
evaluation of human differences become social markers and bring stigma to people
(Ainlay & Crosby, 1986). The undesired divergence from normal creates challenges
and dilemmas for the nurses and renders them deviants in Australia.
Labelling theory is useful here in understanding the negative meanings attributed to
human difference. According to this theory, deviant behaviour does not simply
violate norms, it is the behaviour that others successfully define or label as deviant
(Becker, 1973). That is to say, an act itself is not inherently deviant but rather it is
others’ negative reactions to the act that makes it and the person who performs it,
deviant. As Goffman (1963) put it, the “normal” and the “deviant” are not about
persons but perspectives.
Conceiving deviance as a “reaction process” leads to a perception that the boundary
between normal and deviant is disputable and ambiguous (Herman-Kinney, 2003).
Social inequality may directly or indirectly relate to labelling which takes the
meaning of dominant group as legitimate (Becker & Arnold, 1986). The view that
deviance is a social definition makes it necessary to understand the behaviour from
the subjective points of view of the deviants, by sharing their “definition of the
situation” and “constructions of reality” (Berger & Luckmann, 1967).
The workplace exposed the participants to a different approach to work. However,
defining the Australian way of nursing as the norm rendered the Chinese way
abnormal and unacceptable. The process of social labelling is also a process of what
Roth (1972) termed “negotiating for social worth”. Aware of the difference and the
negative consequences it implied, the participants accommodated themselves to the
social norms of the work setting. The understanding of how one should behave
arises, unfolds, and is passed on during interaction with others (Reynolds, 2003a).
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Over time, the nurses learned how to act appropriately in a range of social situations.
Apart from differences in nursing work, there were also perceived discrepancies in
collegial relationships. The following sub-category you are you and I am I captured
the superficial collegial relationships experienced by the China-educated nurses
while working in Australia.
5.3 You are you and I am I In migrating to Australia, the participants relinquished previous social ties in China.
In seeking to build new relationships in Australia, the nurses encountered many
barriers. To begin with, participation in social activities required one to embrace the
cultural norms. The disparity in values and interests made the nurses realise that we
cannot live a life like that. In addition, without a common experience, meaning is not
shared when communicating with local colleagues and this resulted in a sense of we
are among but not in. Furthermore, the ideology of individualism in Australia
implies a preoccupation with self and loose human connections. The comparison of
human relationships in Australia and China exacerbates a perception of it is
courteous but not close. Although a simple relationship has its advantages, the
participants perceived loneliness as the price paid. All these aspects shape a social
reality of you are you and I am I from the perspective of the China-educated nurses.
The following is a depiction of the sub-category you are you and I am I and its three
properties: we cannot live a life like that, we are among but not in, and it is
courteous but not close.
5.3.1 We cannot live a life like that Having no family or friends nearby, the participants experienced loneliness to
various degrees during the initial settling down period following immigration to
Australia. Longing for new relationships in the new community, the nurses were
disappointed.
Since you are in a new environment, you want to fit in very much. But people in
that environment resist you to some extent. It was obvious that no one talked to you
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when you took a break. You felt the place was very cold and everyone was serious.
(Participant 26, Interview 40)
Loneliness is related to both a lack of quantity of social interaction (social) and a
lack of quality in relationships (emotional) (Weiss, 1973). It is a response to a
discrepancy between desired and achieved levels of social contact (Blazer, 2002, p.
315). The need to talk during work breaks is really a need to relate, not in the sense
of telling or narrating, but in the sense of having relationships and connections with
other people.
Participation in informal social activities is critical to relationship building. Yet, the
nurses felt removed from local colleagues. Apart from a few colleagues interested in
China and Chinese culture, the participants felt that they had to initiate conversations
if there was to be any interaction. There was little involvement among colleagues
after work and thus few opportunities to get to know and understand each other.
Unlike colleagues who paid more attention to leisure and to enjoying life, the
participants were concerned more about work.
The concept of Australians differs from us. They pay more attention to life quality.
They can work for two days and then play for five days, things like that. Chinese
are different…We may also spend time travelling, but we still are concerned more
about work. (Participant 20, Interview 20)
Work and study occupied much time for the participants. They were also concerned
about the financial costs involved in social activities. Unlike Australians, who
appear to be able to spend at will, the nurses were accustomed to saving money.
We don’t like local people, they only think about today, not even care about
tomorrow. Chinese think about the future and plan for it. We need to save money
all the time to feel secure while they (local people) want to enjoy life all the time.
(Participant 1, Interview 43)
Chinese in general are pragmatic about life. The participants perceived a strong need
to restrain from over spending. In addition, one’s life is very much bounded by the
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family in China. As a result, the nurses perceived a higher level of family
commitment and concern than local colleagues.
There is no way (for us) to live a life like that. After all we need to consider the
family, but they (local colleagues) only need to consider themselves. (Participant 2,
Interview 2)
The different interests and forms of recreation also created disconnection between
the participants and local colleagues.
We have got different interests. Local people like to drink in a pub. This is their
way to relax and socialise with others. However, our life is not like that. We don’t
like to go there and sit, spending hours of chat over a cup of drink. (Participant 18,
Interview 36)
Social activities can mean different things to different people. Culture is an
“interpretive framework” through which the individual views the activities. While
most local colleagues considered drinking and partying culturally appropriate and
relaxing, the participants found these activities boring and meaningless. Also on
occasions of drinking and partying, local colleagues tended to be causal about
matters such as male-female relationships.
Colleagues of my age would like to look for short term relationships. However…I
am still quite Chinese in this respect…I cannot do the same thing as my colleagues
such as clubbing and spending the night with a boy. (Participant 22, Interview 44)
The social environment in which one was born and raised exerts a tremendous
influence on a perception of what is moral or immoral. According to Goffman,
Lemert and Branaman (1997), as social beings, individuals are concerned with
emulating the moral standards of the society. In the Chinese context, a casual
relationship is considered immoral and thus unacceptable.
Communication with local colleagues was also mentally difficult and the
participants experienced less personal control in conversation. Any conversational
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topic was usually unfamiliar and held no interest. Unable to make oneself
understood brought frustration to whoever was the speaker. Taking into account the
effort needed on both sides, it is understandable why some participants eventually
ceased trying to socialise with local colleagues.
The type of social activities one engages in influences one’s language acquisition
(Miller, 2000). However, during social interaction, we tend to see ourselves as we
think others see us and we also see others as we see ourselves (Hewitt, 2007). This
culturally embedded sense-making makes it difficult if not impossible for the
participants to find common ground, to see local colleague’s viewpoints, or even to
really hear one another (Chayko, 2002).
Indeed, acquisition of a non-native language by an immigrant is not just a practical
skill that one can acquire value-free (Gao & Liu, 1998). Learners have to adopt what
they see as alien values first before engaging with locals. The more one is ready to
embrace a culture, the more one will mingle with locals in social activities and as a
result the more one will be tuned to the language of that culture.
Only when you embrace their culture, can your language be improved…If you want
to fit in with locals, you need to embrace their culture first. Then this would help
you to step into their group and facilitate your interaction with locals. (Participant
7, Interview 42)
However, adjusting the meaning system takes great effort, for in doing so one must
break with a deeply internalised, seemingly natural perspective on how the world
works (Chayko, 2002). Most participants had the intention of settling down in
Australia when immigrating and were ready to embrace “the Australian way of life”.
However, they became conscious of differences rather than similarities as life in
Australia underlined the incongruities between personal and social values. The time
away from home, combined with exposure to the experiences of local colleagues,
allowed the participants to re-examine their own beliefs and practices. This
seemingly insurmountable difference gave rise to a moment of we cannot live a life
like that.
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Human beings create their own social world (Blumer, 1969) and different meaning
systems function as invisible walls in separating people into groups. The
separateness leads one to consider “the other” as immature, bizarre, crazy, and
difficult or impossible to live with (Manning, 1992). This in turn generates a dislike
of difference. These separate worlds of the participants and colleagues disrupted the
meaning making and constrained social interaction in many ways.
5.3.2 We are among but not in Social interaction does not guarantee that a true social connection will emerge when
people spend time together. Building close relationships with local colleagues is
difficult if not impossible for various reasons. Language is the medium through
which many relationship activities are conducted (Duck, 2007). Using English to
forge close ties at work was difficult for the participants.
How to communicate with your boss, how to effectively express your ideas, these
are problems for us. For example, we can only have work relations with doctors. It
is hard for us to reach the level of friendship. However, many local nurses are
good at small talk and they are very close with doctors. I think our language is still
inadequate for developing and sustaining good collegial relationships. (Participant
7, Interview 42)
Language also inhibits the formation of meaningful relationships with colleagues
outside work. Although the participants can function at work, there is little
opportunity to use English in interpersonal communication after work. Just repeating
the same sentence in routine communication does not reach far for one’s utterances
(Miller, 2000).
Local people may have lived here for 30 years and you have only 2 years. The
experience is like a 30 year-old talking to a two year-old...To me, the
communication is almost one way. The 30 year-old plays with the two-year old.
(Participant 12, Interview 31)
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In conversation with colleagues, there was little of shared interest. The effort
involved in being seen to be interested was tiring.
I know I should try my best to communicate more with others. But sometimes I am
too tired to talk with them. I always feel I don’t have much to talk about.
(Participant 2, Interview 2)
As Mead (1934) argues, during social interaction one attempts to fit one’s action
with others through the process of role taking. Role taking or assuming the
perspective of others was more problematic when interacting with local colleagues
who acted in unexpected ways. The nurses sought to present a self appropriate to the
situation even though inwardly alienated from this presented self. An authentic
expression of self was usually lost as it was necessary to pretend to understand at all
times.
Without a common experience, conversation with colleagues became awkward.
There was always risk of embarrassment due to the inadequacy of engaging with the
focus of conversation. This is reflected in the following quote:
When they talk about food… How can we know if we have never taste it before?
Like they have all kinds of salads here and we know nothing since we have never
seen them before. (Participant 6, Interview 28)
We see that social interaction is mediated by symbols and meanings, which are
socially constructed and subject to modification (Blumer, 1969). Shared experiences
enable someone to interpret a given symbol with similar meaning (Mead, 1934) and
thus facilitate joint action. Participants saw different meaning systems with
colleagues and could not create a shared understanding of reality. The symbols
colleagues used in talking are “just another thing” (Chayko, 2002) for the nurses and
they could not mentally “go there” and thus were at least temporarily excluded from
the conversation. The symbolic meaning systems which connect people can create
and maintain social distance and separate people into groups of “you” and “I”.
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Although cherishing the chance to get to know people, social activities can lose the
intended meaning for the participants.
I also attend some social activities among colleagues. But in this atmosphere, you
are not truly there to relax and… enjoy that atmosphere. You go for the sake of
going. It becomes a task to be done. (Participant 17, Interview 34)
Uneasiness and lack of reward in relating to colleagues discouraged further
interaction. The participants were uncomfortable because they were unsure of the
expectations of others and of how they should best respond. For example, they could
not do what Becker (2005, p. 119) refers to as framing “the appropriate verbal
context for sustaining the action or the ceremonial”. They did not “hear cues
familiar” to them nor could they “easily give those that make for smooth transitions
in conversation” (Becker, 2005, p. 119).
In the age of migration, many people are living and working in countries very
different from their own. In order to locate a sense of connectedness, they must
either overcome differences or relate with others who are similar in some aspects
(Hewitt, 2007). Migration overcomes the physical boundaries, but the invisible wall
of social-psychological distance remains. In failing to develop friendships with local
colleagues, the participants turned to their own people for a sense of connectedness.
The families in China were still connected somehow through technologies. Fellow
Chinese who are not part of the social mainstream provided the needed
companionship and comfort.
People might argue that the participants chose not to use English after work and thus
chose a self-imposed alienation from local colleagues. This view coincides well with
the stereotype of Chinese as withdrawn, quiet, and resistant to integration (Miller,
2000). Such a view places any language and social problems with the individual,
ignoring any deeper social structural cause. What is difficult to resolve is whether
the participants separated themselves from colleagues through choice or as a
response to an inability to do otherwise. What is known is that where confrontation
with difference became uncomfortable, they distanced themselves further from
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colleagues. Difficulties in facilitating social connections are further illustrated in a
perception that local colleagues are courteous but not close.
5.3.3 It is courteous but not close It was not long before there appeared an invisible gulf between the participants and
colleagues. It was hard to enter into colleagues’ groups and share feelings such as
joy and sadness. This sense of being left out is evident in the following excerpt:
Things they find interesting, you don’t always find appealing. And, things you feel
are funny, they do not always understand. This is psychologically stressful. You feel
you cannot share with local colleagues many happy moments and you cannot enter
into their group… It is not that they keep a distance from you intentionally, but it
was there when you first arrived. (Participant 23, Interview 23)
Although longing for connection and community, the participants were disengaged
in the workplace. Apart from casual conversation, there were no colleagues the
nurses could talk to seriously about life and no one to be called a friend. The
participants perceived the collegial relationships in Australia as superficial and
existing only at the level of the working relationship. This is reflected in the ritual
greeting in daily interactions. Indeed, relationships with local colleagues did not go
beyond the ritual greeting. The greeting itself was evidence of the relationship and
was the relationship itself.
The view of a superficial relationship is also embedded in the perception that it is
courteous but not close in Australia. Local colleagues were gentle and polite to the
nurses, but apart from this, there was no closeness. It seemed that they talked to the
nurses out of courtesy rather than genuine interest and this courtesy sustained the
disconnection experienced by the participants.
They (local colleagues) don’t really care about you in the heart, but they talk to
you out of courtesy…That is to say, the relationship is superficial. It is like
Englishmen talk about the weather when they meet each other. They usually ask
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you where you come from and why you have come to Australia ...After that, there is
nothing else to talk about. (Participant 12, Interview 12)
The perception that it is courteous but not close is also shaped by the ideology of
individualism that prevails in Australia. An individualistic society means a social
reality of preoccupation with self and loose personal relationships (Hay, 2000).
There is a sense from the nurses that even relationships among family members in
Australia are not as close as in China. In Australia, it appeared that each person
entered into his or her private life world, doing his or her own things, attending to
the self, and seemingly acting exclusively on the basis of self-interest. Not
accustomed to this structure and related sentiments, the nurses perceived there was a
lack of the human touch in Australia.
Chinese are very dedicated…When we give we give all…However much the
“foreigner” give, he/she is still him/herself. They want to be independent first,
everything else comes after that. (Participant 1, Interview 1)
The participants yearned for someone to talk to and to share experiences with;
someone who could be counted on and would always be there; and someone who
could resonate rather than passively attend. How to reconcile the separateness and
togetherness, to be both independent from and connected to each other, was a
struggle.
The very meaning of friendship differed. In the Australian society, a friend may be a
non-intimate acquaintance while in collectivist cultures such as China, friendship
implies a long term intimate relationship, with many obligations (Triandis,
Bontempo, Villareal, Asai, & Lucca, 1988). The participants wanted and needed
more from friendships than local colleagues could give. However, the sentiment of
psychological and emotional distance may also have been the creation of a nostalgic
comparison with China, as shown in the following quotes:
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Unlike in China, colleagues are usually familiar with each other, here the collegial
relationship is working relations and they have no relations after work.
(Participant 2, Interview 2)
Anyway, they (local colleagues) come when they are on duty and they leave when
they finish the shift. In China, we are colleagues even after the work. We go out
together, and then we become very good friends. (Participant 1, Interview 1)
In China, work, play, and friendship are more often blended and colleagues are
expected to engage socially with each other after work, sharing thoughts and
experiences and helping each other when necessary. The Chinese culture emphasises
the sense of the group and personal relatedness. In a close-knit community such as
China, there is a sense of intense and meaningful connections with others.
Another thing is a sense of belonging and attachment, the collective attachment;
here it is far from as good as in China. You do not feel like a home here. In China,
if we are colleagues, then they know everything about you, and you tell them
everything… Here people never say anything about themselves, and they never ask
you. (Participant 1, Interview 1)
In China, nurses do not change jobs very often and the community of colleagues
exists as an “extended family”. In contrast, the turnover rate for nurses in Australia is
much higher and people flow easily from one place to another. The nursing
workforce is one characterised by casualisation and mobility (Peerson, Aitken,
Manias, Parker, & Wong, 2002). This unstable pool of colleagues may to some
extent dilute relationships. All of the above leads some participants to conclude that
inwardly they are not as happy as they were in China.
Like my uncle and elder brother at home…They lead an easy and comfortable life
in China and they go out and have fun together every weekend…The social life
here is not as good as in China. And you don’t have friends…That is why
sometimes I feel I am not as happy as I was in China. (Participant 1, Interview 1)
Lonely and detached, it is “a world of others” to the participants. Longing for a
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sense of connectedness and to be one of them, the nurses were frustrated by a
“failure” to develop close friends in the new place. An inability to form friendships
with colleagues signals that one is still an outsider to the group.
Interestingly, some participants also considered the superficial relationships in
Australia an advantage. The complex human relationships experienced in China can
be a burden. One has to constantly watch his/her behaviour in dealing with people
and particularly superiors. In Australia, one is relatively free to do whatever one
wants. The lack of complicated human relationships is welcomed but the price is
loneliness.
A sense of you are you and I am I means that people are different. It implies a social
and emotional separateness and a lack of connectedness between each other.
Friendship is “we”; what we have created mutually (Josselson, 1996). The use of the
pronoun we is an indication of the communal connectedness between the
participants and other Chinese, people like them. In contrast, the participants felt
unconnected with local colleagues. They referred to them, specifically the Anglo-
Saxons, as “鬼佬” (Chinese colloquial, means foreigners): people not of their kind,
while they themselves were the ones living in a foreign land.
No shared experience leads to no shared meaning which in turn makes
communication problematic and community building difficult. Relationships with
colleagues are superficial and it is hard to build strong, meaningful connections.
There was an invisible distance between the participants and their local colleagues
which language itself could not bridge.
5.4 Summary After immigration, the participants not only faced the challenges of understanding
Australian nursing but also of delivering nursing in the Australian way. Based on
past experiences in China, nursing work in Australia was perceived to be different in
many aspects. For the nurses, past experience both enabled and constrained
interpretations of nursing work and practice in Australia.
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The participants also perceived collegial relationships in Australia as you are you
and I am I. The differences in interests and values posed barriers for interaction in
everyday life between the nurses and colleagues. Lack of common experience also
inhibited communication and relationship building. The collegial relationships were
superficial and colleagues are courteous but not close.
From the SI perspective, social interaction requires a shared system of symbols and
meanings among actors (Lamertz, Martens, & Heugens, 2003). A discrepancy in
meaning systems leads to the breakdown of sense making and a collapse of joint
action (Blumer, 1969). The meaning system connects human beings together but
once established, it becomes highly resistant to change (Clark, 2002). Along with the
experience of being different the participants gradually realised the presence of
symbolic boundaries between themselves and local colleagues.
It is indeed different, this is the Western way and you are you and I am I create the
need and context for reconciling on the part of China-educated nurses. The
participants regarded differences as learning opportunities and took responsibility for
the learning. All these factors may have contributed to their late struggling
experience while in Australia. The category of struggling and its sub-categories are
the focus of the next chapter.
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Chapter 6 Struggling 6.0 Introduction The category of struggling reflects the dilemma of the “middle position” of the
participants and how being situated as “the other” was experienced. There are a
number of key elements of this experience. First, in living between China and
Australia, the nurses were often caught between two worlds and faced the dilemma
of whether to be “Chinese” or to be “Australian”. Second, a sense of not knowing
underpinned the differences in nursing practices between China and Australia.
Indeed, the change in environment inevitably exacerbated a sense of the unfamiliar.
Third, being “the other” in Australia, the participants had to prove themselves to be
accepted and recognised. A desire to present a good self-image in public and to
ensure no loss of face meant that the participants felt compelled to equip themselves
totally. Finally, there was so much to learn to compensate for perceived inadequacies
that learning became a central part of life and as “the other” it was considered this is
your own business. To meet social expectations and not to present oneself as needy
or weak requires a high level of self-reliance. Thus the learning process was isolated
and difficult for the China-educated nurses. This chapter explicates the category of
struggling which consists of the following three sub-categories: caught between two
worlds, you have a lot to learn, and this is your own business (Figure 2).
Struggling
Caught between two worlds
You have a lot to learn
This is your own business
Living between two cultures
Not knowing
Coming to be recognised
To be Chinese or to be Australian
To save face or to ask
Becoming self-reliant
Figure 2. The category and sub-categories of struggling
6.1 Caught between two worlds According to Berger (2004), immigration is inevitably an experience of being caught
between two worlds. For the China-educated nurses, a clear tension emerged
between a “here” and a “there”, between traditional ideas and modern values,
between a desire to hold on to the old self and a need to conform to the new society.
This duality characteristically defines the existential condition of the immigrants as
“a state of in between-ness” (Lawson, 2000). That is to say, being an immigrant
means being in a “middle position” or in between two cultures and systems of
reference (Bagnoli, 2004). The main properties of the sub-category caught between
two worlds are living between two cultures and to be Chinese or to be Australian.
Each of these will be addressed in turn. What follows is an explication of the
consequences of being caught between two worlds: not belonging in either place or
Chinese still form communities with Chinese.
6.1.1 Living between two cultures As Cox (1987) has argued, no person at any point of time can or does start as an
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empty vessel. China-educated nurses therefore, bring with them considerable
“cultural baggage”. Since they have been raised in China, they cannot simply discard
the Chinese element. After all, it is deeply embedded in their minds and is part of
who they are. Yet for those relocated to Australia, the host society exerts some
degree of pressure to conform, whether subtly or explicitly. As one participant
indicated:
Sometimes I struggle over whether I should act Chinese or Australian. For example,
when my colleagues invite me to go clubbing with them, I am always hesitant. I
think I should go because it is a good chance for me to communicate with them in
private. However, as a Chinese, I don’t like clubbing and I don’t have the habit as
well. Even if I go, I know I won’t fit into that environment. (Participant 7, Interview
42)
According to SI, culture refers to the “consensus” of the group (Blumer, 1969).
Individuals who become part of a group agree to some extent to control their own
behaviours through adherence to a consensus. Living in Australia, the China-
educated nurses saw a clear need to fit in and become part of the community. On one
hand, adjustment is necessary because it indicates respect for the local culture (Lee,
1994). It would be neither reasonable nor practical to expect any significant change
of the host culture to accommodate immigrants’ needs within a short period of time
(Lee, 1994). Thus, one needs to modify one’s attitudes, belief system, and life
following immigrating.
We are the ones who came here to their country, therefore we have to change
ourselves to adjust to them, rather than expect them to accommodate us.
(Participant 7, Interview 7)
On the other hand, conforming to the host society is perceived as beneficial for
immigrants even if that means relinquishing some of their own cultural background
(Lee, 1994). Boswell and Ciobanu (2008) argued that if one stays close to one’s co-
ethnics, one does not move far. It is also futile to spend one’s life resisting the
inevitable.
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Because you live in the real society here, not in the dream, your life has to change
in some way after immigration. How you work, how you entertain, how you make
friends, all of these have to be changed in order to carry on with your life.
(Participant 1, Interview 43)
However, to fit is not an easy undertaking. A commitment to a culture one has
known for most of one’s life may produce resistance to new ways of doing things.
Without a shared background, relating to the Australian culture appeared unnatural
to the participants. Even where there is a willingness to change, there is no desire to
be alike just to be accepted. As one participant stated:
If I had grown up here, if my Chinese cultural background was not that strong, I
could fit in more easily…When I first arrived here, I was full of interest to
communicate with locals. Now after a period of time, I am tired of forcing myself to
do so. (Participant 2, Interview 2)
Another participant put it this way:
Unlike you mix the juice together it is not easy to fit in to a new community. Even
for those who have been here for many years, they still feel the Chinese community
suits them better. It is like a fish, it is deemed to live in water. It does not like to live
in sand. (Participant 6, Interview 28)
Participants who perceived a need to conform and could not do so because of
inadequate cultural skills were subject to frustration. This frustration, over time, can
lead to criticism of the need to conform and therefore reduce that desire (Lee, 1994).
Some people may feel that we Chinese cannot fit in with the society here, but why
should we? What they like is only to have a drink. We do not enjoy that anyway.
What they talk about is also uninteresting to us. Even if they invite us to a party, it
is not fun at all. (Participant 16, Interview 16)
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As a result, the China-educated nurses may perceive fitting in an issue of lesser
importance to social and economic mobility which is the major objective of
immigration. An absence of assimilation does not in any significant way impede
achieving such a goal. As Gans (2007) has pointed out, assimilation and mobility are
two independent processes. This means that immigrants can assimilate without being
socially or economically mobile and vice versa.
In addition, as Kim (2001) proposes, the exposure to Western culture brings to
immigrants an understanding not only of the people and their culture in the new
environment, but of themselves and their home culture. As part of the immigration
experience, the China-educated nurses came to a greater appreciation of Chinese
culture.
After I went abroad, I realised there are many good things about the Chinese
tradition. The longer I am away from China, the more I am attracted to the beauty
of the traditional Chinese culture. Before I possessed it, but I never appreciated its
value. Now I cherish it more. (Participant 6, Interview 28)
Thus there appears in this study a tension between a need to assimilate14 and a wish
to preserve tradition. Indeed, Lee (1994) insisted that immigrants cannot realistically
choose between keeping their past self intact and becoming the same as the majority.
Living in a new society, some degree of conforming is necessary and unavoidable
(Kim, 2001). This can be explained in terms of the concepts of negotiating
boundaries and switching off.
Negotiating boundaries, as conceptualised in relation to the data, means making a
conscious decision about how far one will fit in or assimilate. It is said that there are
two broad spheres of culture: instrumental culture and expressive culture (Suarez-
Orozco, 2000). Instrumental culture involves behavioural level learning while
expressive culture involves a deeper level of transformation of behaviour linked with
14 The use of the term assimilation is more a pragmatic word choice. It is possible that some element of integration is also occurring. The use of term here is quite loose but is used to reflect the wording used by the participants about pressure to fit in, the reality that any change was on part of the nurses, and also to contrast the experience with the political rhetoric of integration.
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rview 31)
changes in value, meaning, and sense of inner self (Suarez-Orozco, 2000). Because
it is hard to assimilate completely (Kim, 2001), the China-educated nurses adopted
the rules of fit in at the behavioural level only. One participant made this point as
follows:
When you interact with Western people, you need to obey their etiquette. That is a
courtesy issue. Like the Chinese saying, “入乡随俗”15. But “follow” is more
about your behaviour, not your internal values. I don’t think we can reach the
value level of fitting in. (Participant 12, Inte
While living in Australia, the China-educated nurses sought to practice in
accordance with the local culture in order to build harmonious relationships. This
instrumental level of conforming means changing external behaviour to
accommodate the environment so that one does not appear too different from the
local people. However, deeply held values remain unchanged or barely changed.
This is what Marcelo (2000) referred to as “acting white”.
Learning another language and culture is not considered threatening, but additive
and instrumental. Instrumental skills are important because these can be a vehicle for
upward mobility. Through instrumental assimilation, the participants learned to
project externally the values of the dominant culture such as assertiveness,
independence, and individualism. Yet, they did not abandon the conformity,
connectedness, and interpersonal values of the collectivistic systems.
Fitting in to me is that I know the practice of being a local Australian, not that I get
rid of my Chinese element. (Participant 16, Interview 33)
Although the participants encouraged their children to cultivate the instrumental
aspects of culture in Australia that would make them more accepted and successful,
they remained ambivalent about their children’s exposure to some of the expressive
cultural elements.
15入乡随俗 is a Chinese idiom (cheng yu), which literally means “enter village follow customs”, but is usually translated as “when in Rome, do as the Romans do”.
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There is no need to fit in completely. The Western culture is not all good. If I have
a child in future, I hope he/she possesses more Chinese elements and less Western
elements in him/her. (Participant 22, Interview 22)
In broad terms, negotiating boundaries also means that participants adopted some
values and practices but not others and did so to differing degrees. It is impossible to
embrace all values and behaviours associated with both China and Australia because
of the internal tension. Rather than abandoning one to embrace the other, they
pursued a delicate balance between the two, locating themselves somewhere in the
middle.
I feel I am in the middle of Chinese and Australian cultures. Something about me
is never going to change. (Participant 6, Interview 28)
The assimilation is an ongoing process and it occurs both consciously and
subconsciously. At a conscious level, the participants evaluated the two cultures,
holding on to some “Chinese ways” (those elements that they like or consider good)
while taking on some “Australian ways” (in rejecting those they dislike or consider
bad). Subconsciously, the participants are influenced through their daily interactions
with local people and only come to realise the effect, when on visiting home, family
or friends point to changes. Oscillating between being more or less “Chinese” and
“Australian”, the participants managed two cultural realities with different levels of
comfort and efficacy.
Switching off is a further strategy the participants used to manage assimilation. This
meant behaving differently within different contexts. In the public sphere, the
Western culture shapes behaviour, while in the private sphere the Chinese tradition
dominates. It is the case, one participant said, that:
“入乡随俗” (When in Rome, do as the Romans do) is necessary as it is a kind of
respect for local people. However when we are back home and we close the door,
we should keep our own tradition. (Participant 12, Interview 31)
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Home represents a retreat from the workplace, a space of comfort with others like
themselves. Thus the participants chose to limit their association with the host
culture to their public life and had no strong desire to do so in private. As one
participant said:
I don’t have local friends and I don’t want to either. The involvement with locals at
work is unavoidable. As to life, I don’t want it to be so. (Participant 22, Interview
22)
Bun (2004) makes the point that the strategy of switching off is reflected in the
image of one face, many masks, or being “Chinese” now and not being “Chinese”
later depending on the nature of the situation. One reason for alternating is that the
workplace gave the participants little room for being “Chinese”. They behaved in the
Western way in order to be accepted and successful. But when it comes to home,
there is choice and after all it is totally their own business. Thus the China-educated
nurses lived “the Chinese way”16 but did not work “the Chinese way”.
In a broader sense, switching off is also adopted when the participants travel across
China and Australia. There is a need to conform to the Chinese culture and act
accordingly during home visits. On return to Australia, it is necessary to revert back
to being less Chinese.
Time can change a person. Each time when it is close to going back (to Australia),
I nearly change myself to a complete Chinese; however, after a few days’ stay in
Australia, I become Westernised again--like a double faced person. (Participant 9,
Interview 32)
Individuals have to distinguish when Chinese values and behaviours are to be
expressed and when they are to be concealed.
16 The quotation marks indicate our understanding that “the Chinese way” is neither homogenous nor static.
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So you need to act according to where you are. When interacting with Westerners,
you need to talk in the Western way. When you are among Chinese, you need to
return to your previous self. (Participant 1, Interview 43)
The common practice of adopting an English name for those whose Chinese names
are considered “difficult” is one indication of “obeying” the rules. According to Li
(1997), the use of an English name not only eases the difficulty Westerners have in
pronunciation and recall, it also has a symbolic meaning of being assimilated into a
Western society. While such a change may appear superficial, those going through
the process experience a transformation of identity, including some loss of their
previous sense of self. At home, most prefer to keep their Chinese names.
The participants were not so much interested in seeking either to become or to
mimic locals but simply to function successfully in Australia. As migrants, China-
educated nurses remain tied to the Chinese culture. The frequent moving back and
forth between China and Australia contributes to a sensation of, what Bagnoli (2004)
refers to as, being caught on the edge of a wave: neither in the sea nor on the beach.
Yet, there is no question of choice about being “Chinese” or “Australian” because
change is occurring anyway. As Kim (2001) has argued, no immigrants can
completely escape assimilation as long as they remain in and are functionally
dependent on the mainstream culture. In a similar vein, no matter how successful
immigrants may be in adjusting to a new culture, they can never reach full
assimilation (Kim, 2001). As a result, both cultures can exist and are expressed to
varying degrees across situations and over one’s lifetime. Although this may give
rise to a sense of “fitting in” in more than one place, equally possible is a feeling of
not belonging fully in either place (Falicov, 2005).
As to culture, I feel I am kind of marginalised. Having detached from Chinese
culture, I am not quite attached to Australian culture as well. (Participant 15,
Interview 30)
Not knowing where to belong can be a source of struggle and unhappiness. The
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double life of the immigrant underlies the inevitability of coping with duality
(Berger, 2004). Being both inside and outside a culture, the immigrant is involved
and detached at the same time (Bagnoli, 2007). This notion of living “nowhere and
everywhere”, “neither here nor there” is a key consequence of living between two
cultures.
I feel I am the middle of sandwich. Here, Australian people feel you are Chinese
since you are different. However back in China, you may also appear different to
Chinese. (Participant 20, Interview 41)
While living within “two cultures”17 is a painful experience, something valuable
may also be achieved. On one hand, the experience of going back and forth between
two countries can result in development of an outsider’s perspective on both cultures
(Berger, 2004). As Bagnoli (2007) points out, this enables participants to view both
societies with a degree of detachment. Seeing the advantages of both cultures also
opens wide the possibility of reconstructing the self (Bagnoli, 2007). That is to say,
one has two cultural resources on which to build and from which to learn. On the
other hand, moving between cultures makes participants aware of their own cultural
values and prejudices which is essential in increasing awareness and cultural
sensitivity towards others (Chenowethm, Jeon, Goff, & Burke, 2006). There is also
less adherence to the idea that there is a right and wrong in behaviours and
preferences. The participants pointed out that their lives had been enriched as a
result of exposure to other ways of life and to new and different people and
experiences.
You came across many people and events here, and you learned from the good
things, which is not bad…Also you came to a different world…You found
something quite interesting here and this broadened your eyesight. (Participant 1,
Interview 43)
Apart from caught between two cultures, the middle position of the participants also
17 The reference to “two cultures” does not suggest an unchanging situation. The participants perceived there to be two cultures even though it is clear that cultures are moving and mixing all the time.
137
gave rise to the dilemma of whether to be Chinese or to be Australian.
6.1.2 To be Chinese or to be Australian Identity is closely linked to culture (Coté, 1996) and thus a change of cultural
environment may see a restructuring of self-concept. While the China-educated
nurses wanted to become part of the Australian community, they also needed to
sustain close ties with other Chinese. That is to say, they wanted at once to be the
same and different. One participant put this dilemma in the following terms.
On one hand, I want to fit into the society here; on the other hand, I don’t want to
completely lose my true self. I frequently question myself why I try so hard to fit
into their group, eat the same food, do the same thing, and think in the same way
each day, and try to change myself totally to pretend to be a Westerner. Actually I
am not. (Participant 3, Interview 3)
However, the participants found it hard to become Australians.
I have seen some nurses who have been here for many years. Language is no
longer a problem for them. But they still cannot bridge the gap. However hard they
try to fit in, they are still different from local people. (Participant 11, Interview 11)
This poses the question of why the difficulty in transforming one’s identity. We
draw from SI the understanding of identity as socially constructed (Hewitt, 2007). It
refers to the way in which an individual defines, locates, and differentiates the self
from others (Hewitt, 2007). Identity is multiple and it includes both individual and
collective senses of meaning (MacInnes, 2006). Here, individual identity refers to a
core sense of self (who I am) while collective identity refers to a sense of belonging
to a particular group (where I belong) (MacInnes, 2006).
The notion of collective identity therefore involves negation or difference: it can
only function to include and enclose because of its capacity to exclude and leave out
(Hall, 1996, p. 5). Thus a boundary has a dual role. First, it works to establish
insiders (members): those who belong to that group (Smith, 1991). The second
138
function of the boundary is to establish outsiders (non-members): those who do not
belong (Smith, 1991). Yet, those who are perceived as belonging elsewhere may also
be excluded from belonging to other groups they wish to identify with.
Since people simultaneously occupy various positions in sets of structural relations
to others, this means that they possess multiple collective identities. A major form of
collective identity is called cultural identity, which represents an attachment to
places, events, symbols, histories, and traditions (Smith, 1991). Cultural identity is
often asserted through a process of exclusion where feelings of belonging depend on
being able to say who does not belong (Craib, 1998). The “Australian identity”
excluded the participants in many ways from identifying with “Australian culture”.
It is not that Australian individuals act to exclude, but rather it is the existence of an
Australian identity that sets up boundaries and marginalised the nurses. This
explains why the participants felt not so much that they were actively marginalised
but that they simply could not be Australian.
After all we have grown up in China and we received our education from China
and we have been influenced by Chinese culture. We don’t feel we can be
Australian. (Participant 17, Interview 34)
Identity claims also depend on others (Hubert, 2001). As Hermans (2001) argues,
identity evolves in response to an ongoing dialogical relationship with others. In
other words, people know who “they” are in relation to the other (Mead, 1934). The
significance of this concept is reflected in Cooley’s (1983) metaphor of the looking-
glass self where we often see our reflections in the eyes of others and even imagine
what they think of us. If Australians think of China-educated nurses as “foreigners”
(because of physical appearances and/or accents) and people who, despite living in
Australia do not belong to Australia, then the nurses will internalise and reflect upon
the way others view them (that is foreigners as outsiders).
I am still considering whether I should change my passport or not. Even if I do
make the change, local people will not think of me as an Australian because of my
are insufficient. Indeed, more conversation and discussion needs to take place to
promote mutual understanding and to make support services more effective. One
issue to be addressed is how to create a non-threatening work environment. Another
concern is the negative connotation of support. A further issue is how to ameliorate
the social cultural differences between immigrant nurses and local colleagues. Given
the circumstances of immigrant nurses (being situated as the other), it is inadequate
to merely offer some education in an effort to achieve this goal.
9.4.2 Implications and recommendations for future research Since the experience is about China-educated nurses in Australia, the sample in this
study was limited to those nurses who were currently registered and practicing. It did
not include China-educated nurses who had left the nursing profession or who did
not succeed in gaining registration. It would therefore be interesting to explore these
two cohorts of China-educated nurses to determine whether there are significant
differences in experience. In addition, although the participants referred to the
process of seeking nursing registration, this was not the focus of current study. In
future, a study with a focus on the experience of China-educated nurses gaining
registration in Australia would be of value.
The findings of this study also suggested that the husbands of the China-educated
nurses experienced significantly diminished social status and employment prospects
242
following immigration. It is assumed that the emotional experience of the husbands
exerted a considerable influence on these nurses. It is suggested that future studies to
be conducted with a focus on the husbands in relation to their experience of
settlement and the changing dynamic of families following immigration.
This study explored the experience of China-educated nurses from an emic
perspective. Further studies might examine the experiences and expectations of local
Australian nurses who work with these nurses. It would also be of interest to explore
the issue of China-educated nurses from the perspective of Australian patients who
are cared for by these nurses.
Longitudinal studies to follow up a cohort of China-educated nurses would be
informative in revealing how the experience changes over time and would better
determine how the process of reconciling unfolds. In addition, the concepts of
reconciling and ambivalence need to be explored further in immigration studies.
Finally, a more in-depth analytical and theoretical focus is desirable in this research
area.
9.4.3 Implications and recommendations for policy consideration The findings of this research also have implications for policy consideration in
Australia. First, participants in the study referred to instances of bullying and
discrimination in the workplace but did not know where to locate assistance and
were concerned over visa implications and retaliation from employees. It is therefore
necessary to review current policy to ensure the rights of immigrant nurses are
protected.
In addition, the findings of the study indicated that China-educated nurses are made
to feel they have to “fit in” in the workplace to be accepted. Thus both this study and
the literature suggest it is necessary to promote an inclusive culture which values
rather than eliminates diversity (Brunero et al., 2008; Wickett & McCutcheon, 2002).
However, as the study findings shows, for difference to be valued some social-
structure change, rather than merely a change of words on paper, is required.
243
In conclusion, the aims of this research have been addressed. First, in-depth
interviews were conducted to explore the experience of China-educated nurses
working in Australia. Second, a modified constructivist GT approach informed by SI
was used to analyse the experience. Theoretical understandings were generated from
the analysis about the study phenomenon. Finally, recommendations on how to
enhance support for these nurses were posed based on the research findings.
244
245
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Appendices Appendix A: Publication in the Queensland Nurse My name is Yunxian Zhou and I am a Chinese PhD student currently studying at the
School of Nursing, Queensland University of Technology. My research is focused on
Chinese nurses’ experiences of working in the Australian health care system. The
aim of this research is to analyse the experiences of Chinese nurses working in
Australia. A key objective is to determine whether existing support structures for
Chinese nurses are adequate.
This research is a qualitative study and will involve face to face interviews and focus
groups with approximately 25 participants. The interviews will of about 45-minute
duration each and will take place in locations chosen by participants. The focus
groups will be 1 hour in length and will take place in Room 601 N Block Kelvin
Grove QUT or alternatively using teleconferencing facilities. I will interview in
Chinese.
If you are a nurse born and educated in China or Taiwan and are currently registered
and working as a Registered Nurse in the Australian health care system, I would be
grateful if you would contact me through the following:
The experience of China-educated nurses working in Australia:
A symbolic interactionist perspective
Statement of consent By signing below, you are indicating that you:
• have read and understood the information document regarding this project
• have had any questions answered to your satisfaction
• understand that if you have any additional questions you can contact the research team
• understand that you are free to withdraw at any time, without comment or penalty
• understand that you can contact the Research Ethics Officer on 3138 2340 or [email protected] if you have concerns about the ethical conduct of the project
• agree to participate in the project
• understand that the project will include audio recording
Marriage status: Single Married Divorced Others , Please describe
Live with family: Yes No
Work experience in China: years
Place of employment in China:
Job title and position in China:
Work experience in Australia: years
Current work place:
Type of employment: Public hospital Private hospital Nursing home
Community Agency Others
Current work department:
Current nurse level:
Current employment type: Full-time Part-time Casual
Work experience in countries other than China and Australia:
289
Appendix F: Interview Checklist Arrive 15 minutes before appointed time Before the interview: Date: Time: Location:
Things to prepare: 1. Participant contact details (phone or mobile number) 2. Transportation details (bus information and timesheet) 3. Map 4. Mobile charged, with credit 5. Folder with information sheet, consent form, and demographic sheet 6. Interview questions 7. 2 digital recorders charged 8. 2 pens 9. 1 notebook
On commencement of the interview: 1. Greeting, self introduction, and casual talk 2. Find a quiet and private place for interview 3. Turn off mobile 4. Explain the aim of the study 5. Information sheet, consent form, and demographic sheet 6. Explain rules of the interview 7. Set up recorder and check its function
At conclusion of the interview: 1. Anything to add? 2. Potential for future contact? 3. Thanks
Appendix G: Interview Questions for the Seventh Interview
Note to participants:
I want to know about your experiences and feelings of working in Australia as a
Chinese nurse. I want to hear the story in your own words. After you have completed
your storytelling, then if I have further questions or if something is unclear, I will
ask you. But for now just talk freely. Begin wherever you would like to tell me.
Interview questions:
1. Could you explain how you came to Australia to work as a registered nurse?
2. What were your thoughts about working in Australia before you came?
3. Tell me your early experience (concerns, thoughts, feelings, and perceptions) of
working as (being) a registered nurse in Australia, when you first came here?
4. How has that experience (concerns, thoughts, feelings, and perceptions) changed
over time? What happens next, later on?
5. What support services are available for immigrant nurses in your hospital? Do you
find them helpful?
6. What is your suggestion to further improve the support services for immigrant
nurses?
7. What are your recommendations for those future Chinese nurses who may
consider working in Australia?
8. Please tell me if there are other issues which you consider important for me to
understand the experience of Chinese nurses working in Australia.
291
Appendix H: Examples of Reflexive Journal November 27th 2007 It is so hard to persuade myself that I am not looking at truth. From my quantitative background, I felt a bit uneasy when I realised that I was not searching for truth in my research but more an in-depth understanding of something. I was concerned whether my analysis would twist the experience in some ways and resulted in a distortion of reality. I mean when I did the interview, the participants tended to tell me what was significant in their mind. They would not tell me the normal part usually, but more about the problematic area. When I did the analysis, I tended to pick up what was significant in the data through my eyes and gave them meaning through my own interpretation. I mean my analysis is based on the knowledge I have of course. That is the only way it is going to work. However, it is quite possible that some parts of the experience get exaggerated and some overlooked. It is no more a neutral reality really. It is the reality filtered through my perspective. It is something real but not truth. It tells what is going on to a large extent, but it is simply not the same with the reality as it is just one perspective from one person’s point of view. March 28th 2008 I have always thought that it is important to find out what Chinese nurses’ support needs are in order to better support them in the Australian health care system. After some interviews, I found I was wrong. Many of them claimed no need for support as this may indicate them as inferior. Also, they were unwilling to reveal unknowns as they may be viewed as unqualified. Now I felt I needed to look more in-depth at this kind of issues instead of focusing only on what services they think might be good for their support. June 30th 2009 The theory emerges from the data. Is it from data, or more? To me, I feel it has to go beyond data at some stage to be abstract. So why we emphasise it emerges from data instead of somewhere else which might be as important as well? Is it theory? Not sure. Maybe it depends on how one defines a theory. Why we have to call it theory? To me, it is abstract understanding only. A neat theory, while neat, is usually too simplistic to reflect the complex reality. Is it emerged? Absolutely not in my case. To be fair, it is constructed by the researcher. Maybe Glaser would worry if it is simply constructed, it will be too subjective to be of any scientific value.
292
Appendix I: Examples of Initial Coding transcript Initial code
Yes! I can experience more. When I was
at home, since I was the only child in the
family, I never did any house chores. The
hospital which I worked was also close to
my home, I never think too much. I feel I
need to learn lots of things when I am
here, away from the family, lots of stress
to face. I felt it is indeed different. Before,
I never did any house chores at home. My
mother even handed chopsticks to me
before I ate, but I still got angry
sometimes without a good reason. Now I
live away from the family, I need to take
care of myself and there is no other way.
Indicating reasons for coming
Being the only child
Being well looked after
Never thinking too much
Indicating the learning required
Being away from family
Facing stress/It is indeed different
Being well looked after
Being spoiled at home
Taking care of self
There is no other way
Since the morning, you need to take care
of patients when they have breakfast; this
is absolutely not the case in China. Then
take a shower for the patient, all these
things. Patients here are totally dependent,
you have to take care of everything,
including bathing and going to the toilet,
so many things, this is what I haven’t
thought about.
Explaining what nurses do
Being different from China
Patients being dependent
Taking care of everything
Not having thought about
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Appendix J: Examples of Focused Coding transcript focused code You have to consider the situation carefully. Ask those who can help you and keep away from those who are suspicious of or questioning you. Sometimes work is like walking on ice and you have to be extremely careful. That is true. You do have many unknowns. For example, you knew the patient got a wound, but you didn’t know the name of dressing used. Then when you read the notes, you couldn’t tell as well. As most doctors’ handwriting is not easy to recognise. If you ask other RNs too often, they would think why you always ask them since you are an RN yourself. There are also ENs there, but how can you turn to them--people who work under your supervision, for help?
Weighting up the situation Having many unknowns Explaining difficulties in seeking help
Yes, I use the Chinese name and they cannot call me by that. They feel awful as well, you know. They asked me all the time: we are so sorry to ask your name again, how should I call you? Can I call you by another name? For example, XY, or X or Y, anyway, there are all kinds really. At last I said, never mind, call me whatever you feel the easiest. I said I can have an English name, but finally my passport, my pay list or any of my documents, I still need to use my genuine name. That is to say, the name on my RN license is my official name, so I cannot use an English name to replace that.
Failing to remember my name Requesting an alternative name Questioning the adoption of an English name
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Appendix K: Examples of Memo March 20th 2008-Trust in emergence? Trust in emergence? How does it actually happen? Glaser’s criterion of emergence is too elusive and his words are misleading in some way. We need at least some demonstrations of that mysterious process. I mean he is quite voluminous in what is forcing. But what on earth is emergence? If people do not have a correct understand of this, they can easily go wrong. Probably one person’s emergence is forcing in another people’s view point. I think the concept of emergence is too soft to be useful in practice. March 21st 2008-Going abroad is like a high wall One participant mentioned to me that going abroad is like a high wall. Those people outside the wall are dreamed of going inside one day. But once they have an opportunity to be there, they start to question themselves whether it is a right choice for them to be there. They feel hesitated, confused in some way. Divided by the wall are two quite different realities and they never thought of what life would like inside the wall. Maybe it is too hard for them to have a clear idea before they go inside, the willingness to go inside make them even not bother to think of what is like being there, or there is too less information available when they are outside the wall. The high wall makes it very hard for people to observe the other side and have a clear idea early on. Once they are inside the wall, they start to face the different realities and struggling to deal with the difference. They may feel painful during the process, but they may also grow out of it. Life needs to carry on anyway so reconciling is happening day after day. May 22nd 2008-Trust in emergence? Trust in emergence? My experience is that it is not something appears automatically. It takes lots of efforts (reading, thinking, and trying) to get the core category and even after I get the tentative core, I am not so sure whether it is absolutely the case. I hesitated; I was reluctant to decide on that core; I tried to be as much open as possible to allow something else to emerge if it did prove to be significant later on. So, it is not simply emerge. Also, the articulation of the core category is a challenge as well. The idea may emerge, but its name never. I have to find the right words to best capture its imageric meaning. This is something I have to try hard, not come to me easily. And I may need to name and rename the core category if it appears not so fit. This fitting of words is like a game really and I need to learn how to play it. If I fail to name the category appropriately, what is the difference between forcing then? All of this is hard work, which is more than something emerging out of blue.