The Lived Experience of Non English Speaking Background The Lived Experience of Non English Speaking Background The Lived Experience of Non English Speaking Background The Lived Experience of Non English Speaking Background Overseas Qualified Nurses Working in the Western Australian Overseas Qualified Nurses Working in the Western Australian Overseas Qualified Nurses Working in the Western Australian Overseas Qualified Nurses Working in the Western Australian Metropolitan Metropolitan Metropolitan Metropolitan Hospital Workforce: Hospital Workforce: Hospital Workforce: Hospital Workforce: A Transcendental Phenomenological A Transcendental Phenomenological A Transcendental Phenomenological A Transcendental Phenomenological Study Study Study Study Christine Denise Andree Smith This thesis is presented for the Masters of Health Professional Education at the University of Western Australia Education Centre, Faculty of Medicine, Dentistry and Health Sciences May 2010
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The Lived Experience of Non English Speaking Background The Lived Experience of Non English Speaking Background The Lived Experience of Non English Speaking Background The Lived Experience of Non English Speaking Background
Overseas Qualified Nurses Working in the Western Australian Overseas Qualified Nurses Working in the Western Australian Overseas Qualified Nurses Working in the Western Australian Overseas Qualified Nurses Working in the Western Australian
A Transcendental Phenomenological A Transcendental Phenomenological A Transcendental Phenomenological A Transcendental Phenomenological StudyStudyStudyStudy
Christine Denise Andree Smith
This thesis is presented for the Masters of Health Professional Education at the
University of Western Australia
Education Centre, Faculty of Medicine, Dentistry and Health Sciences
May 2010
ii
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ABSTRACT
The purpose of this research study was to explore the lived experiences of 13
female Non English Speaking Background (NESB) Overseas Qualified Nurses
(OQNs) as they integrate into the Western Australian (WA) metropolitan
hospital workplace. The current shortage of nurses worldwide has taken its toll
on the Australian health care system. In fact nurses are at present at the top of
the ten occupations in most demand. As a result there is an increased and
ongoing migration of OQNs, some of them coming from non English speaking
countries. Studies of migrant nurses working abroad have been conducted in
countries such as the United Kingdom, Canada and the United States of
America each of which have a long history in employing OQNs. Similar studies
have also been carried out in the eastern states of Australia. However while
NESB migrant nurses are employed in the WA health care setting and are still
encouraged to come and work here, there is very little research on their
employment experiences in WA. This study was a first step in addressing this
gap in knowledge.
A qualitative design based on Husserlian transcendental phenomenology was
used to explore the lived experience of working in the WA metropolitan hospital
system of 13 female NESB OQNs from five different WA metropolitan hospitals.
Four main themes emerged from the data analysis; “the initial feelings of
professional loss”, “feelings of otherness”, “rediscovering nursing” and “it all
works out in the end”. The findings from this research highlighted the personal
and professional journey of the participants as they integrated into the WA
workforce. A feature of the outcomes of this study was the participants’
resilience and agency in terms of their willingness and determination not only to
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adapt and to learn from the new country and work practice, but also to maintain
their integrity as unique professional individuals practising nursing.
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ACKNOWLEDGEMENTS
Now that I have completed the thesis I admit that while the journey has been
long and tumultuous, I have thoroughly enjoyed it and learnt immensely.
However the successful completion of this research would not have been
possible without the interest and support of the following individuals to whom I
wish to express my appreciation.
I am very grateful and would like to thank the 15 NESB OQNs who volunteered
to participate in this study. I feel very privileged that they offered to share their
experiences with me so that this project could take place. This thesis is the
result of their valuable contribution.
Special thanks go also to my two supervisors. Dr Annette Mercer’s patience
and encouragement assisted me to persevere on what I recall being a difficult
journey. Dr Colleen Fisher who came on board in the middle of last year
provided the guidance to undertake Husserl’s transcendental phenomenology to
this project. Her high competence in qualitative research and genuine
supportive approach gave me the confidence to carry out this project.
Finally I would like to express my above all appreciation of the support and
understanding provided to me by my husband Kim and my two children Jeremie
and Melanie.
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DECLARATION
In accordance with the regulations for presenting theses and other works for
higher degrees, I hereby declare that this thesis is entirely my own work and
that it has not been submitted as an exercise for a degree in any other
university.
Christine Denise Andree Smith
Date: / /
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ABBREVIATIONS
ABC Australian Bureau of Statistics
ANMC Australian Nursing and Midwifery Council
APNMF Australian Peak Nursing and Midwifery Forum
CGFNS Commission on Graduates of Foreign Nursing Schools
CN Clinical Nurse
DIAC Department of Immigration and Citizenship
EN Enrolled Nurse
ESB English Speaking Background
HPH Hollywood Private Hospital
IELTS International English Language Testing System
INC International Nursing Council
IV Intravenous
MDGs Millennium Development Goals
MODL Migration Occupation in Demand List
NESB Non English Speaking Background
NHS National Health Services
NMBWA Nurses and Midwifery Board of Western Australia
NMRAs Nursing and Midwifery Regulatory Authorities
OECD Organisation for Economic Corporation and Development
OET Occupational English Test
OQN Overseas Qualified Nurse
PCA Patient Care Assistant
QNU Queensland Nurse Unions
REOH Researching Equal Opportunities for Overseas-trained
nurses and other Healthcare professionals
RN Registered Nurse
SCGH Sir Charles Gardner Hospital
UK United Kingdom
USA United States of America
WA Western Australia
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TABLE OF CONTENTS
Abstract.............................................................................................................. iii
Acknowledgements............................................................................................. v
Declaration......................................................................................................... vi
Abbreviations .................................................................................................... vii
Table of Contents .............................................................................................viii
1 Chapter One – Introduction .........................................................................1
have better clinical experience that some of the nurses who work with me [in
Perth]. At home I can take blood... do cannulation... I can do stitch, suture ...”.
In Helen’s home country the nurses’ tasks: ”... is quite different [they] focus
more on their skills ... they are really excellent with skills... they do quite a lot of
things... [In WA] most of nurses can’t do cannulation... they can’t put urinary
catheter…”. Lucy was adamant:
“… our nursing is more advanced that Australian nursing …we
are more independent we do things ourselves …our scope of
practice is 50 pages …When you do your second year you
need to know how to cannulate … no one’s going to come to
your rescue……Here… Australian nurses, they know much of
106
the theory; they are good in theory but … when they come to
clinical nursing area they don’t know nothing…”,
However, the realisation that in WA they were not allowed to implement all their
clinical skills left them feeling frustrated; Julie felt:”…totally underutilised… I
can’t tell you in how many positions I’ve put up an IV line in my life before…it is
like giving a bedpan that’s a normal part of my life…”.
They also felt that communication and holistic patient care was fundamental to
the practice of nursing in WA, something with which they were not familiar.
Helen’s statement described how she perceived nursing care in WA and this left
her feeling overwhelmed:
“…the work is not much ... the nursing skills... they emphasize
our communication skills, how you are going to help patients to
overcome their concerns and help them in transitional like from
hospital to the community...”
”... you have to do everything... you need to keep all this
medication and go to doctors round and listen to the phone all
these things... organise everybody’s treatment has to be done
properly and in time and then you have all the showering,
bathing all these other things to do and then communicate with
patients about their social problems, organising their physio,
the social worker, or occupation(al) therapists regarding their
discharge. I find it is physically and mentally challenging...”.
107
6.2.3 The ‘other’ health services
The availability of extended and specialised health services available to assist
with their patients’ health needs was also unfamiliar to the participants as they
did not exist in their home country.
Alice was surprised: “… sometime you would refer a patient to …Silver Chain
or …the baby one the Ngala … I was not aware of all these…”. In Fleur’s home
country: ”... there isn’t any social worker, so if patient have any social problem
well too bad,... you never bother [to] ask a patient... there’s no ... resources that
you can use to help your ...patients …”. Similarly in Helen’s home country:
”... society doesn’t have the resources to help people so it’s not
part of the care... Family looks after them... you don’t have these
responsibilities to go to talk to them You don’t have time, you
don’t pay attention to their psych(o)- social issues, here it’s a
large part of your duty... the system is so different ... so you just
have to know the health system working all these kind of
things...”.
6.2.4 Relationship and discussion of findings to ex isting literature
Some of the participant responses in this study are congruent with the existing
body of research. In fact, current international literature acknowledges the
culture of a country influences how nursing is practiced within the existing
health care system. This concept of diversity within the world of nursing is a
reality that affects nurses as they go and work abroad. 5, 9, 11, 118, 132
108
In New South Wales, Australia, Omeri and Atkins’5 qualitative study of five
migrant nurses elaborated on how culture highly influences nursing practice.
They argued that in some countries nurses do not attend to basic nursing care
such as bathing and feeding patients, as it is attended to by their family. In other
countries nursing is tackled holistically. Therefore all patients’ needs are
performed by the nurse. Nursing care can vary from a bedside approach to a
more scientific, task oriented approach. Furthermore Josipovic’s118 research
which reinforces the concept of diversity in nursing argues that nursing practice
is influenced by the social status placed on the profession. She explained that If
migrant nurses come from a country where the nursing profession is ranked
lowly they will tend to be more submissive in their practice than nurses who
came from countries where nurses are almost equivalent to a doctor. With this
in mind, Omeri and Atkins5 stated that their participants who were from varied
countries of origin had difficulties in adjusting to Australian nursing practice.
In the USA, Yi’s9 study of twelve Korean nurses describes how participants did
not anticipate differences in nursing practice. They were shocked to have to
attend to patient’s bedside nursing care and baffled by the little emphasis their
new role had on the management of their patients’ medical care. Another
important difference the Korean nurses discovered was that they lacked the
communication problem-solving skills displayed by their American co-workers.
Unfamiliarity was noted in Bola et al’s107 study describing the wide range of
confusion faced by foreign educated nurses. This included unfamiliarity with
documentation, medication, equipment and technology, patient education and
psychological support. Patient’s health problems, which can vary from country
109
to country, were also elements that migrant nurses felt could, at times,
undermine their nursing practice.
In relation to the holistic nursing care approach, the current literature highlights
the shock experienced by migrant nurses when they came to the realisation that
their practice was to include the feeding, showering and the overall hygiene
care of their patients, something that most of them did not have to do in their
home country. As a result they felt a sense of belittlement in their professional
status. 9, 107, 108, 112, 118, 128 In addition the complexity in individualised and holistic
patient care was also described as challenging for migrant nurses who
previously worked in a task oriented fashion together with their nursing
colleagues. They missed the team approach and the camaraderie and support
associated with it. 2, 7, 108, 112, 122, 128
In the UK, Gerrish and Griffith’s evaluation research project of seventeen
female OSQNs report how they also commented on holistic care. This
understanding of it was that they had to manage their time, prioritise their
delivery of care and liaise with the diverse health team, something that they
found challenging especially for the participants who were used to task oriented,
team approach nursing practice.2 In Taylor’s7 report of eleven nurses working in
the UK NHS, holistic care was also mentioned as a challenge for most
participants. The complexity in organising their patients’ discharge planning was
a major concern to them. In Matati and Taylor’s112 paper and in the “We need
respect”122 report, the amount of paper work which made up part of the nursing
daily routine was unfamiliar to the participants, who found the process
overwhelming and left little time for patient care.
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In Melbourne, Australia, Josipovic’s118 paper based on a descriptive
ethnographic study of NESB OQNs commented on their surprise in discovering
that Australian nurses were engaged in patients’ hygiene needs and how much
paper work and signing they had to do. Teschendorff’s108 account of Filipino
nurses showed similar results. It describes how overwhelmed the participants
were at having to shower patients and attend to their intimate care. It was
something they did not have to do in the Philippines. Consequently they felt that
the social status of the Australian nurse was low.
Furthermore Jackson’s11 research study describes how the participants’
account of varied nursing practices was framed within the national wealth and
health politics. For example in some countries it was not part of the nursing
practice to take patients’ blood pressure because of the shortage of equipment
such as stethoscopes which were only used by doctors. In Australian hospitals
the extensive use and reliance on technology and sophisticated pieces of
equipment did not always fit with the prior practice of migrant nurses. This
applied especially the nurses who migrated from poorer and less industrialised
countries where public health tasks, such as checking the communal source of
water, dominated their daily work activities. For these particular migrant nurses
the lack of technical proficiency left them feeling estranged from the Australian
nursing workplace. On the other hand, migrant nurses whose past nursing
practice included a high reliance on technology felt more at ease to utilise and
learn about the equipment available in Australia. However these technically
skilled nurses felt that it was a waste of their knowledge and a decline in their
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professional nursing status to have to attend to patient’s hygiene and feeding
needs.
The other concerns experienced by the WA participants in this research project,
which reflects the current literature, is the inability of migrant nurses to perform
the clinical skills they learnt and practised in their home country. While the
literature suggests and comments that migrant nurses’ prior knowledge and
skills are assets that should be valued and utilised by the host country, it
nonetheless appears that this concept has not been followed.118, 119, 136, 137 In
fact research data commonly highlights that most migrant nurses report their
wide range of clinical skills and extensive clinical knowledge are not recognised.
As a consequence, participants in these research studies explained how their
inability to utilise their prior knowledge left them feeling undervalued and
disempowered as professional nurses.5, 11, 109, 117, 122
In the Omeri and Aktins’5 study, feelings of being undervalued because their
past professional knowledge and skills had not been recognised was stated.
Some nurses who came from countries where doctors were scarce and who
had extensive clinical skills, felt very offended that in Australia their professional
expertise was totally ignored and therefore could not be used. Similarly
Jackson 3, 11 reports migrant nurses experiencing professional disempowerment
when attending to patient care. They complained of their inability to perform and
to share with their WA colleagues their clinical skills and prior knowledge.
Respondents in Withers and Snowball’s117 study of Filipino nurses working in
the UK reported that their supervisors were oblivious to their skills,
competences and extensive past nursing experiences. They were annoyed to
112
not be allowed to insert intravenous (IV) cannula and to take blood, which was
commonly part of their former nursing duties. As a consequence, they
expressed great concern at losing these very valuable clinical skills. Similarly
Matiti and Taylor’s112 investigation pointed out that all participants were
surprised at not being allowed to practise the range of nursing skills they
acquired during their nursing training in their home country. They thought that
these skills were universally taught and therefore part of nursing education and
practice.
In the REOH study,114 results confirmed the extensive deskilling and devaluing
process migrant nurses entering the UK health system go through. Their
nursing aptitudes and competences gained overseas were appreciated by
neither their employer nor their colleagues. They were perceived not as skilled
nurses, but as learners to be trained to fit the British nursing system. Therefore
the report highlighted that placing migrant nurses as learners resulted in major
skills wastage. Similarly in the “We need respect” report122 participants
expressed their dissatisfaction at not being able to apply their prior nursing skills
so that they could fit within the British nursing standards. As a participant
mentioned, putting an IV infusion could save a patient’s life but they are not
permitted to do it until they completed the specific courses. In shaping migrant
nurses into British nurses, migrant nurses felt it was a professional step down
and an unfair lack of appreciation of their nursing proficiency.
In a descriptive survey sent to one hundred and fifty migrant nurses in a Sydney
hospital127 participants complained of having to be reassessed for professional
competencies such as IV cannulation and venupunction. They claimed that
113
these skills were essential components of their nursing training and daily
nursing duties in their home country and that they were fully competent in them.
6.3 Working with patients
The nurses’ approach to patient care and the patients themselves were both
very different for the participants. Their initial surprise of being allocated a low
patient load was followed by the realisation that the purpose of it was to
facilitate and implement patient centred care.
6.3.1 A patient centred approach
Initially participants did appreciate having fewer patients to look after. Alice
described:
“…Here you take patients, lets say you’re only one to four
sometimes one to five but you’ll look after them as a person
rather than a task so you look after everything together so this
is very different… in [her home country] you are dealing with
the whole ward … five of you … with 48 patients…we only do
the medication and the documentation…”.
Barbara felt: “… that you are doing nursing to the patients...”. in her home
country: ”…there is too many patients, too much to do... ”. With nursing in WA
being about patients and not instrumental tasks, they could now devote more
quality time to each patient. Eileen was astounded: “…I only look after 4
patients instead of looking after 40 patients ... in fact I love it at the first sight...”.
In her home country nursing was: ”…like a factory …you don’t have time to see
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the [patient’s] face ... you don’t talk... you just do the task ...”. Fleur felt that the
patients were treated more: ”...like a friend... [you] make your patient feel
comfortable ...they are willing to trust you... they do it automatically.... we have
primary nursing... so you get more chance to talk to your patient....”. In her
home country: ”… we treat patients … as patients… it’s not closer than that…
you just focused on medical things… I’m the nurse… so they are forced to trust
you…”. Barbara was surprised that patients were treated as customers and that
nurses respected their wishes and tried to make them happy. Eileen felt the
impact of patient centred care is that:”…the patient is your patient... I have more
time to have contact with my patients and assess [them]...”.
They were amazed that nursing agency staff were employed to cover nursing
shortages. Melissa could not believe that: “…for this many persons [patients]
there should be this many nurses...here [patients] get enough time from … the
nurses”. In her home country: “…they don’t have agency system… and nurses
workload was very high... it’s like more than 40 persons and 2 nurses…”.
6.3.2 The WA patients have a say
The participants felt that the patient centred approach to nursing care
empowered patients to communicate. They found that patients liked to talk and
discuss their care, something that was also new to them. Julie described how
they were quite eager to give information and talk about themselves. Similarly
Helen found them very assertive in the way they talk, ask questions and request
for things to be done for them.
115
It was also new to them that patients wanted to be informed about their health
condition and that it was in their right to refuse treatment. Fleur noted:”… here if
the patient ...says no I don’t want that treatment you can’t carry on that
treatment... ”. Fleur came from a background where patients were not given
options:”... a doctor make the decision for the patient…”.
They felt that their patients were mostly friendly and fun. Kerry described her
patients as very funny, and liking to make jokes. Lucy explained how she
enjoyed looking after her patients as they were appreciative of her work and
liking to have a good laugh. She felt valued when a patient who she looked
after in hospital recognised her in the city and greeted her. However patients
could also be direct and abrupt. Barbara and Georgie were staggered at how
freely their patients expressed their feelings:
“…Here you can see what they want ...and when they say no
it means no…they show their anger without any hesitance
(sic), anger or many different emotions... they don’t hide.
Sometimes I thought “oh oua, why you are angry? “Are you
angry with me?” But no they are just showing their
emotions…”. (Barbara)
”…people here …..don’t beat around the bush - they tell you
what’s in their mind... they are very straight forward people …
they curse a lot and they swear a lot...” “... This morning I
heard a lot of swearing that’s the way it is here… [when]…they
are experiencing pain ... they will say the S word of the F
word... which I am not used to…”. (Georgie)
116
Lucy had been particularly offended by one of her patients who said to her that
she did not want a black nurse to look after her. However she was even more
offended by the response of her colleagues who said: ”…‘that person is a
patient… they don’t mean it’ … if someone do something wrong to you ‘no she
didn’t mean it… I don’t think it was her intention’…“ .
6.3.3 Relationship and discussion of findings to ex isting literature
The current literature reflects the experiences of the participants in this study
where the holistic nursing approach which encompasses the empowering of
patients in the delivering of healthcare, is reported as different for many
international nurses to what they were accustomed in their home country.
The concept of informed consent, where patients are given an explanation and
educated on their current health status so that they can actively make choices
in relation to their treatment and procedures, is broadly reported in the literature.
However such practice is stated as unfamiliar with the previous nursing practice
of many international nurses.5, 7, 118, 132, 138 In research conducted in Ontario132
participants were challenged by some aspects of the Canadian nursing practice
as it differed from their own. They pointed out that their Canadian colleagues
were assertive and pro-active in clinical decision making and more accountable
to their patients. For most of the participants the concept of informed consent,
where patients have to be fully informed and had to consent to treatment and
procedures, was new to their practice. They also reported that patients and their
families had more knowledge and control about the care and treatment that was
delivered to them and they generally had more rights than the patients in their
country. They also felt that they were valued and respected by health
117
professionals. Similarly in the UK, a participant in Taylor’s7 research stated how
surprised she was that patients and their family were involved in the decision to
resuscitate or not resuscitate, which in her country was the doctors’ sole
decision.
Josipovic’s118 report highlights that migrant nurses felt their Australian
colleagues were more legally and ethically aware of their duties toward their
patients and therefore of the legal implications of their actions. The participants
reported that in Australia patients were more medically aware and had more
rights than the patients they attended in their home countries. Therefore the
concept and respect to inform patients was new to them.
However while participants in this WA research commented on the extensive
amount of paper work nurses had to do, the literature showed similar findings
but further elaborated on this aspect. In fact the results of international studies
commented how migrant nurses viewed the extensive nursing documentation to
be directly related to the professional responsibility and accountability nurses
have towards their patients as well as their patients’ right to be informed.
Nurses’ fear of the possible legal litigation placed upon them by their patients
and/or their family was stated as constraining their practice, as well as the
driving force to keeping diligent records on their patients’ progress. 114, 115, 118,
122, 132 Furthermore in Allan’s 115 analysis of two qualitative studies investigating
overseas nurses working in the UK (one study looking at the lived experiences
of migrant nurses and the second study looking at equal opportunities and
career progression for migrant nurses) revealed that participants in these
studies believed that the emphasis on patient’s rights contributed to UK nurses’
118
fear of lawsuits and that a shift had occurred from nurses giving care to nurses
documenting care. These findings mirrored the RCN122 report where migrant
nurses in the British health system complained that their scope of practice was
restricted by the British nursing legal framework and that the rights of patients
constrained nurses from performing their duties, as they feared litigation.
In the USA Yi’s study revealed that patients were perceived by Filipino nurses
as demanding and self centred, which they believed was a reflection of the high
value Americans placed on individualism. This was not the emphasis in their
home country .9 Furthermore patients have also been stated in literature as
vocal in relation to their like and dislike of nurses attending to their care, leaving
many ethnic minority and/or ‘dark skin’ nurses feeling at times hurt and
discriminated against.1, 107, 114, 131, 132 These findings could be related to either
the empowerment of patients in their choice of care and therefore of health care
professionals or to their racism / ethnocentrism viewpoints or to both.
6.4 Working with doctors
The participants appreciated the team approach in working with doctors. They
found that their interactions with doctors made them feel part of the team and
found the doctors polite and approachable.
6.4.1 The team approach
Because of the lack of medical doctors on the wards they had to regularly
contact them to seek the medical advice they needed for their patients. Alice felt
that she had to use her own professional judgement to decide whether she
119
needed to contact the resident to review her patient, while in her home country,
residents were on the ward 24 hours everyday. Similarly Helen stated that here
she had to contact the doctors. This made her feel more like she was working
within a team because in her home country nurses did not have a voice and
they were subordinate to doctors; their main task was to help them.
Georgie recognised that: “... Here you use your critical thinking more... you can
even argue with the doctor ...”. But in her home country nurses only do what the
doctors said. She felt like they were more like little a robot. Melissa, who
worked in the operating theatre, valued the surgeons’ professional interactions
with the nurses as they spoke nicely and introduced themselves. She felt that it
was like working in a family. Nurses could express their satisfaction or
dissatisfaction which was unlike in her home country where all that mattered
was the surgeons’ satisfaction. Likewise, Lucy found doctors nice, and happy to
listen to and respond to her queries. However, they were shocked that in WA
doctors were called by their first name as they were accustomed to a more
formal way of addressing them. In her home country Barbara would have never
have called consultants by their first name; she could not even talk back to them
as the rules were very strict.
6.4.2 The doctor / nurse hierarchy
That being said, despite what seems to be a more casual professional
interaction between nurses and doctors, some participants still felt that doctors
dominated the health structure.
120
Fleur felt that the WA doctors did have authority over the nurses while in her
home country there was not much difference. Patients would sometimes call
nurses doctors. Julie found that:
”… it’s a lot of doctors and nurses here; doctors superior
nurses inferior… basically the relationship between doctors
and nurses are way different …We were highly seen by our
co-doctors…here you are just seen as the one to clean the
bed pans … so don’t expect too much of nurses cause they
might not know..”.
Lucy stated: “…You don’t make any decision … without doctor’s consent… You
ring the doctor for guidance and to have patients reviewed...”. In her home
country Lucy contacted the doctor after having initiated a plan of action. That
way she felt that the patient obtained their treatment quicker. Participants’
viewpoints on working with WA doctors thus varied depending on their past
practice of nursing in their home country.
6.4.3 Relationship and discussion of findings to ex isting literature
The current literature while limited in exploring the relationship between nurses
and medical doctors describes some similarity in findings which correlate with
this research.
In Teschendorff’s128 study of twenty Filipino nurses in Victoria, the Australian
informal way in addressing everybody by their first name including doctors has
been stated by the Filipino migrant nurses as different to the more rigid and
hierarchical system they were used to.128 In Allan’s paper ‘The rhetoric of
121
caring’115 international nurses in the UK complained that their inability to
perform the nursing skills and knowledge narrow their scope of practice. They
strongly believed that the high number of doctors available in the health system
was responsible for diminishing the scope of nursing practice. They felt
disfranchised as they had to follow doctors’ orders. As a result they believed
that their local colleagues and themselves were disempowered in attending to
their patients. This was reflected in the RCN results122 where international
nurses stated that in the UK, doctor’s professional power over nurses restricted
their nursing scope of practice. They expressed frustration at having to wait for
doctors orders, especially in situations where they knew and were capable of
initiating the care that would benefit their patient. They felt that being restricted
was detrimental to patient care.
It is nonetheless interesting to note that, as mentioned in this WA study,
depending on the migrant nurse background country, their appreciation of the
doctor nurse relationship differed. Taylor’s7 research study reports that Filipino
nurses who used to follow doctor’s orders in their home country, expressed a
view on their professional status that differed from nurses who migrated from
Finland and African countries. The Finish and African nurses who were
accustomed to work more independently felt that doctors undermined their
profession.
Furthermore in a research study conducted in Ontario Canada, participants
reported having a more egalitarian relationship with doctors. This finding does
not reflect the experience of the WA participants in this project and might
suggest that physicians’ status in Australia and Canada is different.132
122
6.5 Let’s talk about professionalism
The participants expressed their liking of the good WA working conditions
which, for most of them, was better that in their home country.
6.5.1 Feeling valued?
The nurses felt valued: they were satisfied with their working hours and the
financial compensation for overtime work. They also felt respected and trusted
as a professional body. Barbara liked having seven weeks holidays plus 10
days sick leave a year. She felt the WA system respected her personal life. In
her home country she worked harder and only received 20 days annual leave
including sick leave. Furthermore, she never received payment for overtime
work. Similarly in Eileen’s home country:
”... it is a monthly wage doesn’t matter you worked week day or
weekend everybody earn exactly the same amount but here ...
you get penalties [penalty rates] you sacrifice you social life: you
get compensation, fair is fair…”
The participants felt that the nursing profession was valued by Australian
society. Julie who came from a country where nursing was one of the lowest
paid professions was overwhelmed that in WA nurses were allowed to be a
‘Commissioner of Oath’. She felt Australian society truly trusted and respected
nurses. She also received some positive comments about nurses when she
spoke to her neighbours and some of the mothers at her children’s school.
123
However in relation to working with patients and health professional colleagues
their sense of appreciation differed. Fleur explained: “... people don’t look down
on nurses ... here I don’t think that they look up on you as well it’s like a
moderate... “. Cathy believed that the social label for nurses was quite low in
Australia and she felt less respect from her patients: “…here we look after the
patient holistic care... we look at everything, eating, drinking, showering,
hygiene... and mainly because of these you don’t [get] much respect”.
The participants expressed that, as a professional body, nursing in WA lacked
unity and political power. Ines’ statement below encapsulated that, while nurses
might be valued by society as a profession with decent working conditions and
wages, it was believed to be weak as a professional body and the participants
did not feel highly valued at work. In Ines’ home country:
”… a nurse it’s regarded much more as a profession and
you’re much more a professional group of people actually
trying to sort of develop the profession…they’re much stronger
in their unity and their union…In Australia … it’s not so much a
profession…. Nurses aren’t united in their speech… that’s
probably changing a little bit… you are sort of standing on the
same spot …[but in WA] … nurses in the profession… it’s
highly valued but there’s not actually a value put on it…
professionalism is sort of less here compared to [home
country]”.
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6.5.2 Etiquette and professionalism
The participants were surprised at some of their WA colleagues’ poor etiquette
and lack of professionalism. Alice was accustomed to working in a nursing
setting where the dress code was relatively rigid. In Perth however, she saw
nurses as being relaxed in their approach to work and in their dress code where
some have long hair hanging, jewellery and/or very bright nail polish. Cathy
found her colleagues less motivated:
“… at home we take more serious our responsibilities….here…
the environment the culture people are less motivated they are
… more relaxed… it more relaxed they don’t take things more
seriously… cannulation [for example]... if the doctor is there
they just ask the doctor ...they are supposed to learn but they
think that if there is a way they can get out why not…”.
In her home country nursing was much more competitive:
” …if you don’t do it [cannulation] if you try to get out of it you
will be the one left behind…”.
Most of the participants called their patients by their surname and therefore they
felt very uncomfortable with the closeness displayed by WA nurses towards
their patients. Debbie was shocked: “People [colleagues], they are calling
patients darling, love, whatever, it’s very difficult for me... “.
Participants also felt that the way nurses interacted amongst themselves did not
always meet their expectations of professional standards. Julie was surprised:
“… nurses they don’t respect themselves that much here… how they present …
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the coarse language that they use…”. She finds a lot of nurses very
unprofessional with:
“… the way that they communicate amongst each other,
talking over patients to themselves… ignoring the patient in
the meantime, swearing in front of patients… it’s totally
unprofessional… I don’t do things like that … ‘cause I see
myself as a professional...Here… there’s a lot of back
stabbing… there’s a huge turn around of staff … there is a lot
of turn around…”.
The participants observed that conflicts between nurses occurring within the
workplace were not uncommon. Kerry explained: “… [nurses] will say if they
feel unhappy…as I know there’s one nurse just going to the manager and the
clinical nurse specialist and tell them I feel unhappy with the who… or she’s
being not good to me I feel upset or something …”. Even nurse managers did
not always present themselves as highly professional. Kerry’s coordinator
spoke harshly to her in front of patients: ”…she uses… very strong words, big
voice… she tell me in front of the patient… and the other patients all listen…”.
The professional standards in relation to senior position and promotion were
experienced as unprofessional. When Lucy asked for assistance from a young
clinical nurse (CN) she was taken aback by her lack of knowledge:
”… oh I don’t know I’ll check, I don’t know I will ask and you
start to wonder the things she knows but she’s a CN… they’ve
got no experience to help so what is the use of giving that
position whereas you can’t utilize them properly…” In her
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home country:”… you get a position according to your years of
experience here … if you are in good mood with the CNS you
can end up getting a CN position… I believed in Australia they
were doing it according to their experience … if you got four
years experience of practice you qualify for certain position like
they do in HC and England, I think that’s … much better.”
6.5.3 Relationship and discussion of findings to ex isting literature
The current literature reports some similarities with some of the findings of the
WA participants’ experiences. The economic aspect of working abroad has
been mentioned in the literature as a driving force for many migrant nurses
whose economic and social status was quite low in their home country. 114, 118,
119, 122, 136, 139 Larsen136 uses his phenomenological analysis of two overseas
qualified African nurses to illustrate how the difficult economic and political
situation in their home country was the driving force to migrate to the UK. His
report was taken from the more extensive study of overseas-trained healthcare
workers’ experiences in the UK122 where for most migrant nurses’ economic
recession in their home country was the impetus in moving to the UK. Similar
findings were reported in Aboderin’s139 qualitative research on Nigerian nurses
where the deteriorating work situation in their home country provided the
incentive to migrate. Therefore the expectations to find better working
conditions and financial reward in the host country have been reported. Withers
and Snowball’s117 qualitative research of 120 Filipino nurses working in the UK
described how the respondents enjoyed having free email access at work and
also how they valued receiving annual leave and penalty rates for working
weekends and night duty. They said that their overall earning capacity was
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greater than in the Philippines. The study undertaken by the Commission on
Graduates of Foreign Nursing Schools (CGFNS)133 revealed that applicants
found the nurses in the USA and Canada had higher social status than in their
home country.
However it is important to note that while most nurses search for better
economic gain, and for professional and social recognition might be the driving
force to migrate to first world English speaking countries, it does not necessarily
mean that they are valued by the host society. In fact O’Brien’s116 case study
work on three hospital trusts in the UK reported that migrant nurses felt the
provision of basic nursing care was contributing to lowering the social status of
nurses. Drawing on the British study; ‘Researching Equal Opportunities for
International Recruited Nurses’ Allan, Tschudin and Horton135 argued the lack
of recognition of nursing as a profession by government and policy makers had
a negative effect on all nurses. However the emphasis of the paper was
primarily on the lack of respect, empathy and equity experienced by overseas
nurses working in the UK. The lack of political power and unity within the
nursing profession could be detrimental to not only migrant nurses but to the
body of nursing all together.
In Teschendorff’s128 research the participants found the Australian nurses to be:
“… assertive and aggressive; regardless if they are right or wrong, they have to
speak out…”.128(p38) This statement resonates with the experiences of WA
migrant nurses in this study. Furthermore participants also expressed that in
their home country the nursing profession has social status, and they were
proud to be nurses. However they found it was not the case in Australia: “… the
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nurses here… are not thinking of it as a profession. It’s just a means of
livelihood…”.108(p154) While there is not enough data to back up Teschendorff’s
findings on Australian nurses, it is nonetheless interesting to discover that it
was also mentioned by the participants in this WA research.
6.6 Phenomenological explanation of the participant s’ experiences
The participants involved in this research were all qualified and experienced
registered nurses in their own country. They had nursing skills and a sense of
professionalism that reflected their past working experiences. When they
entered the WA hospital workforce they recognised that while their past
knowledge and experiences were highly valuable, in order to function as
registered nurses they also realised that they had to adjust their nursing
practice to fit within the WA nursing environment. The NESB OQNs felt that,
while the practice of nursing in WA was not exactly the same as what they were
used to, they could however understand what was happening. They felt
reassured by their ability to identify that the core components and ultimate goal
of nursing was consistent with their own knowledge and experience.
They felt surprised that their WA colleagues did not have the range of clinical
skills they had, because for them this was an intrinsic part of their nursing
career. They were, furthermore, disappointed that they were not allowed to
utilise some of these skills and, as a consequence, felt that their scope of
practice had lessened. However, they soon discovered that the practice of
nursing in WA did not focus on tasks but was holistic and centred on the patient.
As a result they felt overwhelmed by the medico psycho social aspect of nursing
care which included holistic care, required extensive communication skills and
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paperwork and the varied health services available to their patients that they
had to know about.
They enjoyed the low patient to nurse ratio and the time they had to care for
their patients. As a result of this patient-centred care they felt that their patients
had a say. They were talkative, asked questions about their health and
treatment and expressed their feelings relatively freely as well as their likes and
dislikes. They felt that their patients had power and had to be treated like
‘customers’ with unique rights.
In working with doctors they welcomed their professional interaction and the
less formal way to address them by their first names. They found the doctors to
be polite and respectful. Nevertheless they realised that doctors had power and
authority over nurses and that they were very much controlling what nurses
could and could not do.
Finally the participants were satisfied with their working hours and financial gain
and felt trusted as a professional body. However, they experienced a sense of
professional loss as they did not feel as valued by their patients and society in
general. They believed that a WA RN did not have professional power. They felt
that their colleagues lacked professional motivation, that they demonstrated
poor professional etiquette and lacked unity as a professional body.
In the next chapter the fourth and last theme of the research titled “It all works
out in the end” is presented.
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7 CHAPTER SEVEN – IT ALL WORKS OUT AT THE END
7.1 Introduction
As discussed in Chapter Four, the participants experienced a deep sense of
professional loss when they first entered the WA hospital environment. They
were overwhelmed by the unfamiliarity of the clinical setting that was so
different from their home country. The ward surroundings, the work dynamic,
some of the equipment and medication, and various tasks they had to do, left
them feeling very confused. They also experienced multi-layers of
communication difficulties and failures that jeopardised their abilities to perform
their nursing duties at the level of competency at which they were accustomed.
Furthermore they felt that some of their WA colleagues and even some of their
patients did not trust that they were safe clinicians. As a result of all these
combinations of difficulties, the participants themselves started to develop self
doubt on their abilities to perform their nursing duties in a safe and professional
manner.
Following their initial sense of professional loss the participants experienced
persistent difficulties and work challenges related to their English language
skills and their cultural differences which, as discussed in Chapter Five, resulted
in feelings of otherness. Furthermore as described in Chapter Six differences in
the way they practised nursing in their home country and the way it is
implemented in WA was a recurrent feature of their difficulties in working
comfortably and effectively.
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Therefore after the initial shock in trying to function as registered nurses in a
new working environment, the participants soon realised that they had to learn
to adjust their communication skills and their nursing practice to fit within the
WA nursing context. It was, they recalled, a difficult journey. However, with time,
perseverance and a lot of effort they overcame some of these difficulties. In fact
they found support in their professional journey and as a consequence they
started to integrate and to feel more at ease working in the WA hospital system.
While support was available the participants’ self determination was a major
contributor to their success in adjusting to nursing in WA. In looking back at
their professional journey in Perth, the participants expressed that they still felt
‘different’ from their WA nursing colleagues, but they also recognized that they
have changed and, therefore, expressed how much more comfortable they
were in working as registered nurses in WA.
This chapter explores the lived experiences of the NESB OQNs as they
progressed into their WA registered nurse role. It describes how they did feel
supported, but also how they relied on themselves to find the strength to
persevere. Finally it explains how the participants progressed and became
acculturated to fit into a WA RN.
7.2 I am not left alone
In their quest to integrate into the WA hospital workplace the participants felt that
they were not left alone. They were appreciative of the overall multiple layers of
help and camaraderie present to assist and support their needs.
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7.2.1 There is support
All the participants described in great length how the WA nurses were very
approachable, helpful, and very reliable in providing the professional assistance
they required to carry out their professional duties. They felt the support was
available at all times.
Alice explained how: “… they guide you … even they don’t have time to do it…
they might find someone else to help you … they would sort of direct you to the
right resource…”. Similarly Barbara stated that: ”[they are] always ready to help
me out …they always say ‘come to me if you need some help’, so I never felt...
neglected…”. Julie found the people very eager to help: ”… if you asked
questions they were very keen to answer, if they didn’t know the answer they
would go find it…”. Debbie valued how, when she asked the nursing staff for
some clarifications they would always answer her questions in a professional
manner. Helen commented: ”… they make an approach to me to say ‘do you
need this book or do you know what to do’... and when you ask them for help
they are quite helpful...”.
The participants also felt that their nurse manager was looking after them.
Helen knew that her manager gave her relatively easy patients when she
started working on the ward. Melissa was very grateful that: “… every week the
nurse in charge ask me how I’m feeling things … she try to help me …the time
I said that I’m lost … she try to give me the regular [theatre] list…”.
When the participants experienced difficulties at work they went to their
manager who listened to them and took their concerns into consideration. They
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felt that they were genuinely concerned with their welfare and tried to help
resolve the issues at stake. After Georgie explained to her manager some of
the difficulties she encountered with her preceptor, she found afterwards that
the nurse had been relocated to another department and felt that they must
have talked to her and found out about what happened. Cathy, who was
struggling to integrate in the WA team, felt supported by her manager who
would ask her into her office to discuss any problems she had. In addition they
also found that their managers were an excellent source of information. Julie
found her direct line manager unbelievably ‘human’ and understanding and she
could go to her and asked her about anything.
However, at times some Australian nurses were not sympathetic in helping the
participants. Most of the participants found their colleagues supportive however
as Lucy mentioned: “the majority were…”. She felt however that unity in
support was not universal. The participants revealed that a small minority of
their colleagues were not keen on providing guidance. They nevertheless learnt
quickly who they could and could not approach for assistance. For example
Helen explained that while most of the senior nurses were obliging she
nonetheless had to be careful who she asked. She would always make sure
she asked a nurse who she knew was approachable. Similarly Cathy said that
she was quick at identifying the nurses who would be agreeable to help her.
The participants were highly appreciative of the hospital’s overall organisation
and the structures in place which they believed were conducive to their learning
and adjustment. Georgie was peered with a RN who was very helpful so she
was able to ask lots of questions that were answered immediately. As Julie
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described: “There is a lot of clinical staff on the floor … a lot the clinical
guidance …What I enjoyed was there’s a lot of systems in place… there was a
lot of education on hospital things …training and all sorts of stuff…”. Melissa
liked the established competency criteria forms because she could work
through them with the staff development nurse and learn through practising the
skills until she became perfect. She also valued the in-service education and
direct education sessions because she could learn a lot.
7.2.2 Feeling of belonging
In integrating into their new workplace the participants felt they needed to
belong. They liked the social and human interactions with others and described
how comforting it was for them to socialise with friends from their home country
and to develop new friendships. They expressed their strong need to feel part of
the team. They felt accepted by their co-workers but nonetheless they also
articulated their conscious effort in trying to fit in with the team.
The participants acknowledged their need to develop some friendships. Many
had friends from their home country and some valued the advice they provided.
Alice stated that when: “… living here … [it] is important that you have to have
friends… you are happy or sad you share with them… I had a good bunch of
[home country] friends and at the meantime I build up friendship here…”. Kerry
obtained some useful advice:
”... my manager ... she introduced some [home country]
colleagues to me…they …say ‘well Kerry don’t worry about it,
the first three months you will find very hard’ [so] that’s what I
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expect…’the only problem is the language barrier’…I realise my
English is going like improve a lot at the first three months ….’.
The participants expressed their overall satisfaction with the social dynamic at
work. The WA nurses were experienced as friendly and the participants felt
included in the nursing team. Julie commented: “…I found people extremely
friendly…the managers and everybody was extremely nice ...There’s a lot of
people that always ask me how you going and how you doing and how you
settling …”. Kerry was satisfied:
”... I didn’t feel isolated… They talk to you they make you feel
like you’re one of them… they were talking to me, … they did
not say anything special as such but I think talking to me was
the most important thing…”.
Melissa felt happy that during the tea breaks everybody in the team went
together, she thought that it was good that they always included her in the
group. Alice felt that: “… I’ve got sort of merge into the team very well… I am
part of the big family… the ward is part of my family...”. Likewise Ines reported:
“… I am happy where I am now [working]… [I’m]…more comfortable … all the
time…overall I love it here and I love the people…”.
However this feeling of belonging was something that the participants played an
active role in securing. They wanted to be part of the team and consciously
worked towards it. Barbara always wanted to have her tea breaks with her
colleagues because she did not want to be isolated or be a stranger to them.
She wanted to be part of the team. Socialising with their colleagues outside the
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workplace, however, was not necessarily something the participants liked doing.
Some felt that their dislike of alcohol contributed to their unwillingness to see
their colleagues outside the workplace. Julie felt that drinking:
”… is a cultural thing… ‘cause we’re not used to drinking …
indulgently… here the most things that they can talk about is how
knackered… how drunk they got… I just don’t find that
interesting… but… I don’t have to be social with them outside …”.
Fleur also expressed her dislike of going to the ‘pub’. She said that she was too
conservative to go to such places. However she felt that it was not a problem if
she did not socialise outside work as she was still part of the team. Similarly
Lucy had some difficulties:
”… with the staff sometimes it’s not easy to socialize with the
Australian people… … I don’t drink, I don’t smoke so it end up like
I don’t have anything in common with them, when they go out I
can’t go out cause I can’t stand noise…so I think that end up
making me distance myself because I won’t manage to go to the
pub...”.
However Lucy just like Fleur did not feel that her dislike of socialising outside
work jeopardised her sense of belonging to the team. She described how every
Friday after the ward round the team would have a communal lunch where
everyone brought a plate of food to share. There she would join the group and
eat, talk and laugh with her colleagues enjoying being part of the team.
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7.2.3 Relationship and discussion of findings to ex isting literature
The existing literature illustrates the loneliness experienced by overseas nurses
in the workplace. It also highlights the lack of support offered to them which is
unfortunately too often correlated with the ethnocentrism and racism displayed
by some of their colleagues and managers. The limited support available to
migrant nurses is described as detrimental to their integration into the
workplace.5, 107, 110, 122, 127, 134, 135, 139
Omeri and Atkins’5 report recalls the lonely path the participants working in New
South Wales went through following their migration. They missed their family
and friends which was intensified by the lack of support networks available in
their new working and living environment. Similarly, Brunero et al127 report on
homesickness experienced by migrant nurses where the support of family and
friends was lacking in their everyday living. In her research Jackson109 also
found that the participants felt lonely in the workplace and, as one migrant nurse
recalled:”… I was totally alone… [and] when you did approach, if the person
was too busy… it was like… a slap in the face...”.109(p123) Furthermore the need
to belong and to develop collegial relationships at work was stated as
paramount as participants felt that, despite their network support outside the
work environment, it did not ease their feeling of solitude within the working
place. Walters’8 also describes how participants having left their family in their
home country felt lonely and, in order to compensate for this loss, felt compelled
to develop a sense of belonging within the workplace. Matiti and Taylor112
reinforce this need as they describe how the nurses in their study valued the
supporting ward environment and felt like it was like a family as they always had
138
somebody they could talk to. This had the effect of assisting their cultural
adaptation at work and in the overall UK way of life.
In the report titled “We need respect”, Allan and Larsen122 found that most
participants experienced feeling of loneliness and home sickness with limited
support available from both their colleagues and their nurse managers. It
however also reported that they obtain valuable support from other OQNs which
was very helpful professionally and morally to new migrant nurses. Smith et
al’s114 REOH report reflects this finding. They explained how what they called
‘batch recruitment style’, where overseas nurses are acquainted with other
migrant nurses, to be most appreciated and helpful. In sharing their analogous
circumstances in the workplace and in the host country migrants nurses are
seen as an excellent resource to ease new migrant recruits’ adjustment to the
UK way of life and hospital setting.
Support to migrant nurses has however also been acknowledged in the
literature. Teschendorff’s108 research reveals that, despite having to take charge
of a patient load and therefore having to work alone, the Filipino participant
nurses felt accepted and supported by their Australian colleagues who were
nice to them and helpful when they needed help. Under the theme ‘Pastoral
support’ Taylor7 discussed how local UK nurses, aware of their overseas
colleagues loneliness, offered support with transportation after work.
Furthermore, as mentioned before, newly employed NESB nurses’ affinity with
overseas nurses who had been in the system for a while was stated as a
valuable source of support.
139
In the literature the role of the nurse manager in providing the support and tools
in assisting migrant nurses is often discussed in the negative. Reports highlight
that they do not fulfil their duties as an ethical and effective manager in
accommodating and valuing their overseas nursing staff. In O’Brien’s116
research results, line managers were reported to stop migrant nurses access to
short courses favouring local nurses. The RCN report122 detailed how ward
managers should actively facilitate the transition of new migrant recruits on their
ward. It explained that managers should welcome them and should make sure
that they were understood by the local staff and the patients as competent
nurses. However in reality the report stated it did not occur. These findings are
also in accordance with Aboderin’s139 recorded statement of one of his
participants when recalling difficulties experienced by ‘dark skin’ migrant nurses
in working and managing white skin carers that: ”…the tacit support or lack of
intervention of ‘white managers’, who inevitably ‘side with their own’ along
colour lines”.139(p2243)
The results from the review of the literature do not reflect the findings of the
current WA research reported in this thesis. However, positive accounts with
nurse managers have also been expressed in research findings. Gerrish and
Griffith2 have commented how their participants who hesitated at first to
approach their manager for assistance, were happily surprised, after they finally
gained the courage to talk to them, by their very supportive and encouraging
manners. There is, therefore, evidence in the literature that some nurse
managers are instrumental at providing assistance. This is despite the bulk of
the literature putting the emphasis on their negative impact, in slowing and/or
limiting the professional growth and integration of migrant nurses. Nurse
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managers are, as mentioned by Aboderin,139 in the hierarchal nursing position
not only to guide and support their nursing staff but also to make sure that the
dynamic amongst them is functional and equitable. They can trouble shoot and
lead by example. In fact the work dynamic on their ward is a reflection of their
leadership style.
7.3 I can rely on myself
While the participants recognised that the multiple layers of external support
had provided them with immense assistance, they also realised that they were
very active participants in adjusting to their new work environment. They felt
that they had resilience and agency over the integration process they went
through or were still going through.
7.3.1 I have resilience
The participants were determined, strong and confident they would overcome
the difficulties and stress they experienced at work. They worked very hard to
integrate into their WA RN role and to regain a full professional status. Barbara
wanted to overcome her work problems as soon as possible, but it was not
easy. All the new things she had to learn were hard and tiring. It nonetheless
motivated her because she could see the ‘gaps’ and she set her goals and
wanted to achieve them. She pushed herself hard but she said that she also
enjoyed it.
The participants often felt that they had to prove that they were a good nurse.
141
Cathy sensed that her patients did not value her professionalism and skills so
she felt that she had to show them that she was a good nurse: ”… I do nursing
stuff and I’ll be very very particularly careful... I make sure they see it... they feel
comfortable with you... once you have proved yourself to them they just like you
so much.”
Fleur felt that she had to prove herself to her colleagues:
”... I want to impress them to tell them ... you’re OK... you feel
like that person looking down on me.... you want to do
something to impress...I don’t feel like I’m forced ... I’m willing to
do it... you do things a little bit faster..., do some extra work... I
always helped others I just quickly finish... I won’t sit at a
counter even though I feel... tired...”.
They learnt to reflect following some difficult and stressful situations and to
move forward. Debbie realised that:
” … it is not that they [PCA ] don’t want to work with you but
when you just started you might feel like that because you don’t
know what there is... I do sometimes get scared and then I go
back and pick myself up and say well I have to get used to it...”.
Lucy displayed strength and acceptance of self and others by the way she
reacted to one of her patient’s racial statement:
“… ‘I don’t want that black nurse to look after me’…if they give
me the patient the next day I just say ‘I can’t look after him or
her’ I am not going to apologize I just want a peace of mind for
myself... I respect that I don’t force myself onto the patient…”.
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Melissa noted: “…I believe that everyone is not born with skills... everybody
learnt so I can learn …it is taking me lot of work to learn... I don’t want to give it
up”. Overall Eileen’s statement highlighted participants’ feeling that hard work
and determination were the ingredients to success;
“...When you work in a different country from your mother
country you have to be prepared to work hard and work smart...
When the local people input 100% you have to put 200%... yes
more than 200%... you... use initiative learning… the more you
do the more knowledge, experience, skills... the more confident
you are”.
7.3.2 I have agency
The participants at times felt intimidated by the WA nursing milieu.
Nevertheless, they exhibited agency, as they did not change their whole
practice to fit the WA nursing setting. They assessed their current work setting
against their nursing knowledge and personal values and adjusted their practice
accordingly. They were assertive, they felt they had power and overall a deep
sense of professionalism which did not impinge on their ability to practice
nursing in WA.
Debbie liked the practice of nursing in WA; however she did not agree with the
familiarity of language displayed by the staff and therefore chose not to call her
patients ‘love’, but call them by their names. Similarly Cathy did not want to call
her patients ‘love’ or ‘darling’ she decided to continue to address them like in
her home country Mr and Mrs:
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”… I’m feeling lot more comfortable …I know I am doing the
correct thing… I have seen something different before I come
here so I keep the good things... [And] I pick up the good things
from here ... and you tell yourself that what you are doing is
right...”.
Julie and Lucy did not want to do the compulsory IV cannulation course
because they already had the skills so they contacted their nurse manager,
demonstrated their skills, and therefore were exempted. Likewise, Melissa who
worked in the operating suite indicated to her preceptor her preference not to do
orthopaedic surgery because she had a bad experience in her home country.
Lucy felt that she had something to contribute as she explained: “…[I] had a
research suggestion that we’ve been actually trying to get off in [home country]
… so I suggested it here … they were quite interested in listening… it’s a
project now going… so that was quite nice…“.
7.3.3 Relationship and discussion of findings to ex isting literature
There is little evidence in the current literature on the resilience and agency
displayed by NESB OQNs when working in Australia and/or other Western
dominated English speaking countries. This current research is thus able to
make an original contribution to extending knowledge.
In “We need respect” document Allan and Larsen122 report statements of
migrant nurses who explained how they had to consciously remain strong,
display self control and show self-confidence in order to survive the UK
workplace. However these were made in the context of a coping mechanism in
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order to alleviate the hurdles and discrimination they experienced. This was
made evident as they first described how their initial reaction to the difficulties
they were faced with in the workplace was to go back to their home country;
something that they soon realised they could not do. However Larsen’s136
recount of two African black migrants working in a nursing home in the UK could
be understood as a sign of resilience and agency. Both participants felt
unhappy with their first work assignment in aged care facilities and eventually
had the courage to apply for and acquire employment within the NHS system.
Nevertheless these accounts do not provide sufficient strength in the argument
of resilience and agency displayed by nurses as they migrate overseas. The
current lack of evidence on resilience and agency may be due to the fact that
research has primarily been focusing and elaborating on the discrimination and
on the vulnerability experienced by overseas nurses. Once again this has been
regularly reported in the literature but it has been at a relatively low level in the
account of WA participants in this research.
7.4 I am one of them
7.4.1 Acculturation to the WA workplace
As participants became acculturated to the WA workplace, the changes they
experienced were relatively smooth. They felt that they had adapted some
elements of their previous practice to the new working environment and they
liked it. The changes that occurred were relatively smooth as they were not
necessarily conscious of their acculturation process
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They felt positive and satisfied with working in WA and expressed how it
became easier over time. Alice commented: “…I like the WA way… delivery
nursing because you treat [patients] as a single person… I quite like this
communication sort of time…I must say that overall I had a positive
experience…”. Georgie’s experience was similar: ”… [I’m] exposed to people
everyday so I am beginning to understand how they pronounce the words… [I]
enjoy nursing here ... the ward I am working at now I am very satisfied...”.
Some participants were surprised how much they had changed. When Barbara
went back to her home country, she felt that she was different:” … it was a
reverse culture shock… I feel more comfortable here [Perth] than when I go
[home]…”. Comparing her home country with WA, Fleur chose and valued the
WA nursing care approach: ”... here it is more friendly ... that’s really touched
me a lot and actually changed my working attitude...”. When she went back
home: ”… I went gosh I couldn’t fit in... that environment or the way they work...
no I have to go out...”.
7.4.2 I am different but so what
The adaptation process that the participants went through encompassed a
general and self acceptance of their ethnicity and culture. They felt that their
ethnicity was acknowledged and accepted by their co-workers. Barbara felt
embraced by the team and felt that she belonged: “…it happens quite naturally
because everybody get used to being with someone from a different culture
because it is a multicultural country... Australian means people have different
backgrounds…”. Georgie sensed that her otherness was valued: ”…my
colleagues have started to accept now my American accent … they like the
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accent… I am very encouraged by that… people tell me that my accent is like
music to their ears…”.
Helen found her colleagues very encouraging:
“... during presentation... they smile even if they don’t
understand you, they don’t upset you... they always encourage
you and try to understand you and say how good you are, I think
it is very good…they don’t try to embarrass you always say
good things about you. …”.
Melissa’s ethnic background was acknowledged and discussed during the tea
breaks: “… they talk like ‘how is things in your country’… most of the people
know [home country] that there are murders and things and they also know
there are some problems, lots of problems…”.
Participants knew that they were different from the dominant Anglo-Saxon
population however they also realised that their differences were similar to
some of the people living in Perth. In fact they felt that their ethnic, cultural and
language differences were congruent with the WA multi-ethnic population. With
this in mind they started to accept and to be more comfortable with their
‘otherness status’ because it fitted within the multicultural context of Australia
they migrated to. As a result they developed a sense of belonging. Kerry felt
accepted by her patients but she also accepted herself when she said: ”… they
all understand me, the only things I not explain in the Australian way I explain in
Chinglish, I mean Chinese English…’ Barbara was: ” always aware ... and
focusing on the language but I know I don’t have to be perfect”. Cathy was
adamant:”... even 10 years, 20 years, 30 years later I would still have the same
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accent you know ... I am comfortable now with my English...”. Similarly Georgie
stated: “…I could never speak Australian English... [But] they [staff] are used to
multicultural staff...”. Assertively Eileen said: “... They talk the language; I can
talk the language, so it’s good…”. Melissa affirmed: “…most of the people
migrated so [if] they can understand, I can understand [too]”.
7.4.3 I am a WA Registered Nurse
Since their arrival in WA some of the participants had developed professionally,
others expressed their desire to further their career with growth. Overall the
participants felt that they had the same opportunity as their WA nursing
colleagues to progress professionally. They experienced continuity in their
career path and were comfortable and secure in their role as WA RN.
Since migrating to WA Helen has studied midwifery and she was currently doing
a health education diploma. She wanted to start teaching nursing students.
Eileen had been promoted to a level two; she was an active member of the
Head and Neck Association. She went to regular seminars. She was: ”
...interested to do a wound management course, some counselling course or
some clinical... teaching...Yes I’m a good nurse... I am still learning... ”. Fleur
was also a level two: “... you have equity [here] and the chances are open to
everybody if you say yeah... go ahead it’s yours...”. After working 5 years in WA
Alice applied to become a clinical nurse last year and was promoted: “… I
definitely gained the confidence… it made a huge difference on my life … I felt
very satisfied and also felt that it is all worth it…”. Ines, while working was
studying part time to become a nurse practitioner. Cathy noted: “…I am doing
good, quite well. I think I have been through all the difficult time... I would like to
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be more in a management position to make a change…”. Georgie discussed:”...
I don’t want to be a bedside nurse for the rest of my life; I would like to improve
myself ... to advance my career... [Be] promoted to a much higher level...”.
7.4.4 Relationship and discussion of findings to ex isting literature
The current literature provides limited information on the progress and
adjustment migrant nurses go through in their endeavour to work in their new
host country. It discusses the acculturation process within the context of time
where participants slowly found their feet within the new health and work
environment. Furthermore access to professional development is elaborated
upon as a contributing factor for migrant nurses as they search to develop and
expand their nursing career path in the host country.
Teschendorff108 explained how the Filipino nurses’ initial setback in their ability
and lack of confidence in performing their nursing duties adapted over time.
They observed and chose to learn from their local colleagues, thereby adopting
the Australian way of nursing. However they nonetheless described how the
whole process was slow and painful. Similarly Yi9 described also how the
Korean nurses in the USA study adjusted to their new nursing environment. In
relation to nursing tasks the participants expressed satisfaction in achieving the
USA nurses standards, however they continue to express great difficulties with
communication skills, in particular with arguing and problem-solving strategies
when dealing with their patients. Participants explained that even after more
than ten years of working in the USA they found they still had great difficulties
in dealing with these issues. However over time they adopted styles of
individualistic behaviour that mirrors the American nurses. They felt more at
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ease to express their personal feelings and emotions. They became more
confident in using the pronoun ‘I’ and also learnt to say ‘no’. They recognised
that their non-assertive behaviours, which were the legacy of their home
country cultural background, were perceived by their American colleagues and
patients as a sign of weakness which was, therefore, detrimental to their
professional status as nurses.
The process of acculturation discussed above appears to occur over time more
or less naturally as migrant nurses are immersed within their new workplace.
They have access to professional development and promotion, which assist
migrant nurses to adapt, to progress and to develop into their new nurse’s
identity. These finding are also examined in the literature. In the UK, Withers
and Snowball’s117 study found that their Filipino respondents believed they
could access professional training enhancement. They felt supported by their
nurse manager and also found the strong Filipino nurses’ network highly
valuable. They nonetheless explained that it was their own responsibility to first
search for information and to make the application. Interestingly, Taylor’s140
research on Filipino nurses in the UK argues that overseas nurses are
progressing well in the NHS Trust in London. She provided the example of a
respondent who took advantage of a nursing training course in ophthalmology
which, as a result, facilitated her appointment to a higher nursing grade and,
therefore, better work status and higher income.
However, the REOH study report114 highlights that despite the UK equal
opportunity policies, the chances of minority ethnic nurses gaining promotion
within the NHS were very slim. In fact the findings reveal how the standards
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and measures for promotional advancement lack transparency especially for
managerial nursing positions, where patronage and sponsorship are based on
subjective and cultural criteria which gave impetus to exclude minority nurses.
These procedures are perceived to contribute to racial and ethnic discrimination
against migrant nurses. Respondents have explained how the interview
process linked to promotion was difficult and biased as it encompassed the
dominant group’s communication skills and cultural knowledge that the
respondents were unfamiliar with. The overall structural format was described
as prejudiced against migrant nurses. This understanding was reinforced
through Henry’s141 analysis of twenty older Ghanaian nurses working in the
NHS who encountered difficulties in accessing managerial positions. Their
dilemma was related to a system of promotion that did not value meritocracy as
such but, instead, was blurred and based on patronage, leaving little hope for
their prospect of nursing advancement.
It seems that once again the issues of racial discrimination and ethnocentrism
described in the literature jeopardise migrant nurses’ progression on the
professional ladder bringing to a halt their journey towards feeling and
functioning on the same path as their local nursing colleagues. This is
highlighted in Gerrish’s2 study which recounts the concept of equality of
opportunity in accessing nursing courses and further education for overseas
nurses in the UK. Participants expressed their willingness and need for
professional development. As mentioned by Alexis142, migrant nurses ought to
be given the same opportunity for professional training and development and
promotion as the UK nurses. However the research shows that these
recommendations are not actively applied in the health care system.
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The current literature explicates some of the lived experiences of migrant
nurses in their search to accommodate and fit into their new country and work
place. While an acculturation process seems to happen, the ability of migrant
nurses to fully feel part of the new society and fulfil their new nursing identity
requires a need for their nursing status to become close to that of the local
nurses. This appears to be jeopardised by the difficulties they have in
accessing the same professional growth as their counterparts. However while
broadly reported these findings do not reflect the experience of the WA
informants from this research. In fact they stated and felt that access to
education and courses was available to them regardless of their ‘otherness’
ethnic background.
7.5 Phenomenological explanation of the participant s’ experiences
When the participants in this research first entered the WA workforce they
experienced difficulties and were overwhelmed by the amount of learning and
adjusting they had to do so that they could function professionally and
comfortably as WA RN’s. They nonetheless were able to over time identify that
they were not alone and that support was available to them. The hospital setting
had multiple layers of support available to assist their integration and while
education sessions and extra clinical and education staff were available to
guide their learning into the new system, they found their colleagues highly
supportive, which they valued. While some did not want to help, the participants
were always able to find nurses that would happily guide them, answer their
questions and/or direct them towards the resources to answer their queries.
Even the few nurses who declined to help were not detrimental to their
integration because they knew that nurses as a group were always very
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supportive. The odd one did not matter as they were somehow absorbed within
the larger group and there was always somebody available to help them.
They received extensive professional and emotional support from their ward
managers. They felt safe in approaching them as they were encouraged to
discuss their concerns and feelings. The ward managers would listen and
respond in a genuine and helpful manner and the respondents recognized that
they were not only interested in their professional integration but also in their
personal welfare.
The participants craved to have their need of belonging fulfilled and while some
of them had friends from their home country, they also wanted to develop some
new friendships. It was very important to them to be accepted by their work
colleagues. They happily described how they sensed that they belonged and
how friendly the WA nurses were towards them. They also emphasised that
they did not want to be left out and that they consciously wanted to be with their
colleagues especially during the tea breaks and other social times. However,
while they would have liked to take part in the out-of-work socialising, they
found the ‘pub’ sessions off putting. Nevertheless they did not believe that
socialising outside work was detrimental to them being accepted by the team.
In fact the participants, in their search to integrate, recognised that they put in a
lot of effort to fit into the system. They were resilient because while the system
and the nurses were supportive, they nonetheless had to rely on themselves to
deal with the everyday difficulties they encountered. They had to be strong,
confident and self reflective to move forward and to feel respected and valued.
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They acknowledged that they had to work very hard to sustain their integrity as
nurses. They realised that despite their initial emotional and professional turmoil
they had agency and came forward in their own time in bringing forward their
professional values and assertiveness in what they believed was right.
Finally the participants felt that they successfully adapted to their new
workplace which was expressed through professional contentment in relation to
their nursing practice and their work environment. They were surprised
however, how much they changed without realising it. It appeared that the
support, their hard work and their everyday work dynamic had shaped them
progressively into a WA nurse. They also believed that their cultural and ethnic
differences, while still present and acknowledged by others were not seen as
detrimental to their integration anymore. People adapted to them, but most
importantly the participants themselves believed that they were an integral part
of the WA population. Their ethnic and cultural status was in fact a major
contributor to their feeling of belonging as it matched the larger multi ethnic WA
community. They, therefore, believed that they integrated in their WA RN status
and were able to progress professionally. They realised that they had
reintegrated their role and professional status of RN and they had a vision for
their professional journey and growth similar to that of their WA colleagues.
In the next chapter an overview of experiences and conclusion to this research
project is presented. It includes the overall phenomenological explanation of the
lived experience of WA NESB OQNs interviewed for this research study.
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8 CHAPTER EIGHT – OVERVIEW OF EXPERIENCES AND CONCL USION
8.1 Overall Phenomenological explanation of the par ticipants’
experiences
The NESB OQNs who participated in this research study experienced a journey
as they tried to settle into their role and status as registered nurses in WA. It
was a journey of discovery into a work environment in which they had to learn to
find their way so that they could work and fulfil the professional requirements of
their employment. Furthermore, it was a journey of self discovery as they had to
adjust their own sense of self as unique individuals as well as their nursing
identity to fit within the WA hospital context.
At the beginning the journey was characterised by feelings of being
overwhelmed by multiple layers of differences experienced in the workplace.
Participants struggled to work; they felt fearful, confused and frustrated and
developed self doubts which gave impetus to feelings of professional loss. As a
result they resumed a ‘learner’s’ role, which left them feeling vulnerable and
powerless.
As their journey progressed further they identified two major challenges within
the WA workplace; namely the culture and language, and the practice of
nursing. With English not being their first language the participants knew that a
cultural and linguistic shift had to occur. However, the multiple communication
difficulties they experienced resulted in ‘Feelings of Otherness’. They could not
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understand local people and could not be understood. They had to concentrate
at all times focussing on body language and surroundings to make sense of
what was said. Verbal handovers and answering the telephone were very
stressful. Their sense of otherness was also at times reinforced by some of
their WA colleagues’ remarks about their accents and/or ways of working.
In addition they were set back by some the differences in nursing practice they
encountered in WA. They could not apply all their clinical skills; they had to
implement holistic care and treat patients like customers which was new to most
of them. They felt that doctors had power over nurses and that WA nurses’
lacked unity as a professional body. The result was feelings of professional loss
when working in WA.
However as their journey continued participants identified their difficulties, and
realised that they were not alone and that multiple layers of support were
available in the hospital setting in forms of education sessions, nursing staff and
the ward managers. However they also displayed resilience and agency in their
search to overcome their difficulties. Over time ‘It all worked out in the end’ as
participants changed and acculturated. While they realised they did not belong
to the dominant Anglo Saxon population they could, however, identify
themselves with the multi-cultural nature of the WA population. As their journey
of discovery eased they felt integrated into their WA RN status and developed a
similar vision of professional growth as their local colleagues.
The lived experiences of the thirteen NESB OQNs in this study appears to be in
line with ‘les rites de passage’, a concept that was coined and elaborated upon
by Arnold van Gennep.143 The three major phases that correlate with van
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Gennep elaboration of a rite of passage can be found in the participants’
experiences. These phases are separation, transition and incorporation. The
separation phase was their migration to Australia and their initial acquaintance
with the WA hospital workforce, where their nursing identity and sense of worth
were in turmoil. The transition phase reflects the struggles they endured and the
learning and adaptation processes they went through in their search to regain
their full professional identity as RNs. Finally the incorporation phase was, as
stated by them, their success and ability to work comfortably as WA RN’s.
8.2 Limitations of the study
While the findings from this study and the themes that were developed are
instructive, it nonetheless has its limitations. Firstly the number of respondents
was small and whilst this enabled an in depth exploration of their experiences,
the findings cannot be generalised to all NESB OQNs working in WA. Secondly,
the positive outcomes for the participants in this study may not reflect the
experiences of the NESB OQNs who, because of the difficulties experienced in
working in Western Australia, might have left the nursing workforce or returned
to their home country.
The results from this study are, however, important because they are consistent
with some of the current knowledge in relation to communication and cultural
issues experienced by overseas nurses. The study also reiterates how nursing
practice is not universal and reflects current social, economic and power
structures. However, unlike the findings of other research, this study did not find
experiences of discrimination, ethnocentrism and racism in the workplace.
While difficulties with patients and colleagues were spoken about, it was
157
described as minor. In fact all participants felt that they were equal to their local
colleagues with regard to opportunities for promotion and access to further
education. This is further highlighted as all participants worked on different
wards and came from five different hospitals.
8.3 Significance for nursing knowledge
This thesis highlights the experiences of NESB OQNs and explores their
experiences of nursing in WA. It provides a perspective on their inner feelings
and sense of self but also shows how nursing practice is not universal but rather
is shaped within the social context of the setting. Therefore, this knowledge
should be incorporated to assist migrant nurses to integrate into the workplace.
A culturally sensitive approach is necessary and could start with an introduction
to the WA culture and nursing culture, where communication skills and the
practice of nursing would be emphasised. This information would provide a
framework for them to understand the new social and work environment. They
could then evaluate and compare this against their own values, norms and
nursing practice. Local nurses should also be educated on cultural diversity, so
that they could display empathy and be aware of their own possible
ethnocentrism. In addressing these two broad concepts, agencies and
employers might ease the integration of migrant nurses, into the work
environment. This could assist with work satisfaction and/or sustainability of the
workplace.
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8.4 Further research
The persistent nursing shortage and the Australian initiative to actively recruit
overseas qualified nurses should give impetus for further research. In fact the
experiences of other NESB OQNs working in Western Australia should be
studied to enhance knowledge on the topic. It would, however, be valuable to
obtain perspectives from local nurses and nurse managers working with migrant
nurses. This would provide richness and depth in understanding the
interpersonal and work dynamics between migrant nurses and their colleagues.
However NESB OQNs are not confined to working in WA metropolitan
hospitals, they also work in regional, rural and remote areas. It would therefore
be valuable to conduct research that would investigate their experiences, given
the need for health professionals in rural and remote WA.
8.5 Concluding statement
The global shortage of nurses has given impetus to nurse mobility. In Australia
the need for nurses and the changes in immigration laws in the 1980s, has
facilitated the migration of overseas qualified nurses including Non English
Speaking Background nurses to Australia. While research on migrant nurses
working in Australia has been conducted in the Eastern states of Australia,
there is very little research about the experiences of NESB OQNs working in the
Western Australian hospital system. This thesis was a first step in addressing
this gap in knowledge.
159
The findings from this research highlight the personal and professional journey
of the participants and differences from current knowledge where migrant
nurses have often been reported as vulnerable and discriminated against by the
host country nurses. This study emphasised the participants’ resilience and
agency in terms of their willingness and determination not only to adapt and to
learn from the new country and work practice but also to maintain their integrity
as unique professional individuals practising nursing.
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9 APPENDICES
Appendix A: Information Sheet
How do Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) Experience Nursing in Western Australia?
PARTICIPANT INFORMATION SHEET
Introduction Thank you for expressing interest in participating in a research study that will review how Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience working in WA. Before you make your decision, it is important for you to understand why the research is being done and what it would involve for you. Please take as much time as you need to read the following information carefully and discuss it with friends and colleagues if you wish. Do not hesitate to contact me if there is anything that is not clear or if you would like more information. What is the purpose of the study? This study is to look at how NESB OQNs’ socio-linguistic background influences their working experience in the WA hospital environment. The aim is to gain a better understanding of potential difficulties that may be detrimental to their smooth integration into the nursing workforce. Do I have to take part? Your participation in this study is voluntary and you can withdraw at any time. If you decide not to participate, or decide later to withdraw, it is your right and you do not have to give a reason for your decision. However if you decide to take part you will be asked to sign a consent form. You will be given this information sheet to keep and you will receive a copy of your signed consent form. Your participation in this study will not prejudice any right to compensation, which you may have under statute or common law. What would happen in this study? If you decide to take part in this research you will be asked to participate in one or two semi-structured individual interviews of approximately one hour each. Broad open ended questions will guide and facilitate the conversation however you will be able to elaborate and extrapolate at ease on valuable information. The overall interview process is to capture the complexity and the richness of your working life experiences. Furthermore I may come and observe your work dynamic during one shift in order to provide information about how you interact with staff and patients. This observation may take a couple of hours.
161
All interviews will be audio taped, in order to facilitate accuracy of data collection. Notes will be taken during the interviews. All transcripts of interviews and notes from the observation will be given to you for verification and adjustment if necessary. Please be reassured that a pseudonym will be used to protect your identity. All information that you provided will be treated as highly confidential and will only be utilised for the proposed research. What are the possible benefits of taking part? You will contribute to developing research in nursing which is part of your professional role. On completion of the research you will receive a certificate for participation which you will be able to add to your professional portfolio. Your input combined with those of other participants will enhance our understanding of the situation faced by NESB OQNs working in the WA health care system. With this knowledge we will be able to develop educational, organisational and structural strategies at government and health care levels to support these nurses integration into the nursing workforce. What are the possible risks of being involved? There is no risk as all information will remain highly confidential. What happens at the end of the study? At the end of the study you will be asked to verify the authenticity of the transcript of your interviews. You will receive a letter thanking you for your participation and a professional certificate. Who will see my records and what will happen to them? All audio tapes, notes and data analysis will be securely stored in a locked filing cabinet at UWA. Transcripts will be in word documents and protected by a password. Only people who are directly connected to the study will be permitted access to these records. After the study, the records will be kept in a locked archive for at least 7 years from the time the study is closed, and will be destroyed after that time. By taking part in this study you agree not to restrict the use of the data even if you withdraw. Your rights under any application data protection laws are not affected. Study costs Transportation to and from interview locations will be subsidised. Further information and contacts during the study If you require more information about this study before you decide to join (or at any other time), or if you decide to take part in the study and you experience any stress please do not hesitate to contact me on the number below. Christine D.A Smith Phone: 6488 7372 Email: [email protected]
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Appendix B: Consent Form
Thank you very much for your time in considering this research study
PARTICIPANT CONSENT FORM Masters Thesis Study Topic: “ How do Non English Speaking Background (NESB) Overseas Qualified Nurses
(OQNs) Experience Nursing in Western Australia?” I ________________________________________( print your name), agree to volunteer to take part in the above named study being supervised by the Clinical Teaching and Education Centre in the Faculty of Medicine, Dentistry and Health Sciences at the University of Western Australia (UWA). I am aware of the purpose of this study. Further, I have read a copy of the Participant Information Sheet and the procedures involved. I am aware that the data collection will involve one or two individual interviews that will be audio taped and that notes will also be taken during that process. Data may also be collected in an observation session. It has been explained to me that I am free to withdraw my participation from the study at any time, and that withdrawal will not result in prejudice of any kind. I am aware that at no time will my name be reported with the results of the study and that the information I supply will be kept confidential. I understand there will be no re-imbursement made to me for participation in this study. Participant’s Signature Signed: _________________________ Date: _________________________ Phone number: __________________ (It is optional but valuable if I need to clarify any issues at a later time)
16
2
163
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� The times, length of meeting and place of the The times, length of meeting and place of the The times, length of meeting and place of the The times, length of meeting and place of the
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details and information will be kept confidential.details and information will be kept confidential.details and information will be kept confidential.details and information will be kept confidential.
Appendix C: poster for SCGH
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A Participant Information Sheet and Consent Form will be provided upon your acceptance to this study.... This research has This research has This research has This research has been approved by the Human Research Ethics Committee of the University of Western Australia been approved by the Human Research Ethics Committee of the University of Western Australia been approved by the Human Research Ethics Committee of the University of Western Australia been approved by the Human Research Ethics Committee of the University of Western Australia and the and the and the and the cooperation of the Administration of HPH. cooperation of the Administration of HPH. cooperation of the Administration of HPH. cooperation of the Administration of HPH.
Are you a Female Nurse (EN or RN) from a Are you a Female Nurse (EN or RN) from a Are you a Female Nurse (EN or RN) from a Are you a Female Nurse (EN or RN) from a
Non English Non English Non English Non English Speaking BackgroundSpeaking BackgroundSpeaking BackgroundSpeaking Background????
Did you do your nursing education and Did you do your nursing education and Did you do your nursing education and Did you do your nursing education and
qualified in a qualified in a qualified in a qualified in a language otherlanguage otherlanguage otherlanguage other than English? than English? than English? than English?
Would you like to reflect upon your Would you like to reflect upon your Would you like to reflect upon your Would you like to reflect upon your
experiences AND contribute to research experiences AND contribute to research experiences AND contribute to research experiences AND contribute to research
concerning crossconcerning crossconcerning crossconcerning cross----cultural communication in cultural communication in cultural communication in cultural communication in
� If you meet thIf you meet thIf you meet thIf you meet these criteria please come and share your ese criteria please come and share your ese criteria please come and share your ese criteria please come and share your
work experiences with the researcher.work experiences with the researcher.work experiences with the researcher.work experiences with the researcher.
� The times, length of meeting and place of the The times, length of meeting and place of the The times, length of meeting and place of the The times, length of meeting and place of the
interview can be organised to suit youinterview can be organised to suit youinterview can be organised to suit youinterview can be organised to suit you. Y. Y. Y. Your personal our personal our personal our personal
details and information will be kept confidential.details and information will be kept confidential.details and information will be kept confidential.details and information will be kept confidential.
Appendix D: poster for HPH
164
165
Appendix E: Flyer for SCGH
Attention: NON ENGLISH SPEAKING BACKGROUND NURSES
� Are you a Are you a Are you a Are you a Female NurseFemale NurseFemale NurseFemale Nurse????
� Did you do your Did you do your Did you do your Did you do your NNNNursing ursing ursing ursing EducationEducationEducationEducation and and and and
qualified in a qualified in a qualified in a qualified in a LLLLanguage other than English?anguage other than English?anguage other than English?anguage other than English?
Would you like to Would you like to Would you like to Would you like to share share share share your experiences your experiences your experiences your experiences andandandand add to add to add to add to
our understour understour understour understanding of Canding of Canding of Canding of Crossrossrossross----culturalculturalculturalcultural CCCCommunication ommunication ommunication ommunication
in in in in NNNNursing?ursing?ursing?ursing?
PPPPlease contact lease contact lease contact lease contact ChristineChristineChristineChristine: : : : Participants will receive a Participants will receive a Participants will receive a Participants will receive a
EmailEmailEmailEmail:::: [email protected]@[email protected]@uwa.edu.au Certificate of Participation Certificate of Participation Certificate of Participation Certificate of Participation
TTTTel:el:el:el: 6488 76488 76488 76488 7372372372372 which can be included in which can be included in which can be included in which can be included in theirtheirtheirtheir
Professional PortfolioProfessional PortfolioProfessional PortfolioProfessional Portfolio I lI lI lI look forward to hearing from youook forward to hearing from youook forward to hearing from youook forward to hearing from you....
This This This This Master Master Master Master research research research research project project project project has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of Western Australia and SCGHWestern Australia and SCGHWestern Australia and SCGHWestern Australia and SCGH
165
166
Appendix F: Flyer for HPH
Attention: NON ENGLISH SPEAKING BACKGROUND NURSES
� Are you a Are you a Are you a Are you a Female NurseFemale NurseFemale NurseFemale Nurse????
� Did you do your Did you do your Did you do your Did you do your NNNNursing ursing ursing ursing EducationEducationEducationEducation and and and and
qualified in a qualified in a qualified in a qualified in a LLLLanguage other than English?anguage other than English?anguage other than English?anguage other than English?
Would you like to Would you like to Would you like to Would you like to share share share share your experiences your experiences your experiences your experiences andandandand add to add to add to add to
our understour understour understour understanding of Canding of Canding of Canding of Crossrossrossross----culturalculturalculturalcultural CCCCommunication ommunication ommunication ommunication
in in in in NNNNursing?ursing?ursing?ursing?
PPPPlease contact lease contact lease contact lease contact ChristineChristineChristineChristine: : : : Participants will receive a Participants will receive a Participants will receive a Participants will receive a
EmailEmailEmailEmail:::: [email protected]@[email protected]@uwa.edu.au Certificate of Participation Certificate of Participation Certificate of Participation Certificate of Participation
TTTTel:el:el:el: 6488 76488 76488 76488 7372372372372 which can be included in which can be included in which can be included in which can be included in theirtheirtheirtheir
Professional PortfolioProfessional PortfolioProfessional PortfolioProfessional Portfolio I lI lI lI look forward to hearing from youook forward to hearing from youook forward to hearing from youook forward to hearing from you....
This This This This Master Master Master Master research research research research project project project project has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of Western Australia and Western Australia and Western Australia and Western Australia and the cooperatiothe cooperatiothe cooperatiothe cooperation of the Administration of HPH. n of the Administration of HPH. n of the Administration of HPH. n of the Administration of HPH.
166
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Appendix G: Letter of invitation
Letter of invitation
Dear Colleague, 03/05/2009
Invitation to participate in a study to determine how Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience nursing in Western Australia.
I am writing to gain support from you to participate in a study that would review how Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience working in WA. This project is a Masters Thesis Study that would be supervised by the Clinical Teaching and Education Centre in the Faculty of Medicine, Dentistry and Health Sciences at the University of Western Australia (UWA). This study is to look at how NESB OQNs’ socio-linguistic background influences their working experience in the WA hospital environment. The aim is to gain a better understanding of potential difficulties that may be detrimental to their smooth integration into the nursing workforce. If you meet the following criteria:
• Female Registered or Enrolled Nurse • Trained and gained your initial nursing qualifications in a language other
than English, • Lived in Australia for a maximum of 10 years • Registered with the NMBWA and currently working in Perth
Please contact me on: 6488 7372 or by email at: [email protected] If you chose to participate a Participant Information Sheet and a Participant Consent Form will be sent to you. Participants will receive a Certificate of Participation which can be included in their Professional Portfolio I look forward to hear from you. Yours truly, Christine D.A. Smith
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Appendix H: Demographic form
DEMOGRAPHIC DATA
Date:
Name:
Age:
Place of Birth
1st language
Where did you gain your nursing qualifications?
Which language was used in your nursing training?
How long have you been learning English?
Which hospital do you work in now?
How long have you been in Australia?
Reasons for working in Australia
Optional:
Citizenship
Religious beliefs
Marital status
Do you have children?
If yes, what are their ages?
Telephone number
Email address
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Appendix I: Guiding Questions
Preamble to interview:
I am interested in your experiences and feelings about your work as a RN in Perth. I
would like to hear about how your working life here compares with your working life
in your home country, and in particular any aspects of your working life that you
have found particularly interesting and/or challenging in Perth.
The following questions are to give you an idea of the issues the researcher is
interested in. They are guidelines, rather than being prescriptive.
Guiding Questions:
• Think about your 1st day working as a registered nurse in WA? Tell me about
your experiences and feelings at the time.
• Tell me about an encounter with an Australian patient which highlights some
cultural / linguistic differences / difficulties.
• Tell me about an encounter with an Australian colleague which highlights
some cultural / linguistic differences / difficulties.
• Tell me about some similarities and differences in practicing nursing in your
home country and in Perth. What did you find easy to adjust to? What did you
find difficult to adjust to?
• Looking back now can you tell me about your preparation to practice nursing
in WA. Were you well prepared? Were you not so well prepared? Can you
explain why?
• Were there any barriers to working effectively as a RN in WA?
• At work what aspects of the Australian cultural and communication styles do
you find challenging / different / difficult to understand / to adjust to? Can you
explain why?
• Can you elaborate on your current level of professional satisfaction?
Thank you.
170
10 REFERENCE LIST
1. Chandra A, Willis WK. Importing Nurses: Combating the nursing
Shortage in America. Hospital Topics. 2005; 83(2):33-37.
2. Gerrish K, Griffith V. Integration of overseas registered nurses:
evaluation of an adaptation programme. Journal of Advanced Nursing.
2003; 45(6):579-587.
3. Hawthorne L. The globalisation of the nursing workforce: barriers
confronting overseas qualified nurses in Australia. Nursing Inquiry. 2001;
8(4):213-229.
4. Kline S. Push and pull factors in international nure migration. Journal of
Nursing Scholarship. 2003; 35(2):107-111.
5. Omeri A, Atkins K. Lived experiences of immigrant nurses in New South
Wales, Australia: searching for meaning. Journal for Nursing Studies.
2002; 39:495-505.
6. Smith P. Editorial: Overseas-trained nurses, diversity and discrimination:
perceptions, practice and policy. Journal of Clinical Nursing. 2007;
16(12):2185-2186.
7. Taylor B. The experiences of overseas nurses working in the NHS:
results of a qualitative study. Diversity in Health & Social Care. 2005;
2(1):17-27.
8. Walters H. The experiences, challenges and rewards of nurses from
South Asia in the process of entering the Australian nursing system.
Australian journal of advanced nursing. 2008; 25(3).
9. Yi M. Korean nurses' adjustment to hospitals in the United Sates of
America. Journal of Advanced Nursing 2000: 32(3):721-729.
10. Australian Nursing and Midwifery Council. Annual report 2007-2008.
Canberra: Australian Nursing and Midwifery Council. 2008.Available
from: www.anmc.org.au
171
11. Jackson D. Constructing nursing practice: country of origin, culture and
competency. International Journal of Nursing Practice. 1995; 1(1):32.
12. Hawthorne L. Credential recognition for skilled migrants in Australia. 11th
Metrolpolis Conference; Oct.; Lisboa. 2006.
13. Australian Nursing and Midwifery Council. Standards for assessment of
nurses and midwives for migration purposes. [cited 2009 May 29].
Available from: http://www.anmc.org.au
14. Australian Nursing and Midwifery Council. National Competency
Standards for the Registered Nurse. 2005 [cited 2009 May 29]. Available
from: http://www.anmc.org.au
15. Australian Nursing and Midwifery Council. Competency based
Assessments for Internationally Qualified Nurses and Midwives. 2008
[cited 2009 May 29]:4.
16. Australian Peak Nursing and Midwifery Forum. Peak nursing and
midwifery bodies support national registration. 2008. Available from:
http://www.anmc.org.au
17. Australian Institute of Health and Welfare. Nursing and midwifery labour