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The Strengths of Internationally Educated Nurses in Healthcare Settings:

Evidence from a Critical Ethnographic Study

Louise Racine RN PhD, Linda Ferguson, RN PhD, Sonia Udod, RN PhD, Sithokozile Maposa RN PhD, Susan Fowler-Kerry RN PhD, Yixi Lu PhD

9th Annual Partners in Education and Integration of IENs

Regina, Saskatchewan

May 1st, 2015

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Purpose of the Study

To explore the everyday experiences of internationally educated, Canadian born and educated nurses, and nurse managers in order to understand the process of professional, social, and cultural integration of IENs in their work environments in Saskatchewan.

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Study’s ObjectivesExplore internationally educated nurses’ working experience within 3 to 5 years after arrival in Saskatchewan

Identify factors that affect working relations between internationally educated (IENs) and Canadian nurses

Understand how race, gender and social class intersect with IENs’ integration in nursing workplaces.

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Background

Globalization of health labour market/health industry

Acute nursing shortages in Canada

Ethics of international recruitment

Currently, 8.6% of nurses are internationally educated (23,076)

Around 2.6% of Saskatchewan nurses are Internationally educated

Age: (X = 45.4 years for Canada, X = 44.7 years old in SK)

IENs working in Canada by Country of Education

Phillippines

UK

Other

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Problem Statement

Increase retention of IENs

Nurses’ demographic aging to counteract

Shortage acutely felt in rural/remote regions

How to manage and lead a culturally diverse nursing workforce (SK)

Create a healthy and culturally diverse workforce

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Research Questions What is the nature of internationally educated nurses’

(IENs) experiences of working in Saskatchewan 3 to 5 years after their arrival?

What is the nature of nurse managers’ experiences of working with IENs on their units?

What is the nature of Canadian-born and educated nurses’ experience of working with IENs?

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Ethics• The University of Saskatchewan Behavioral Research

Ethics Board

• The Saskatoon Health Region Ethics Board

• The Regina Qu’Appelle Region Ethics Board

• The Prince Albert Parkland Ethics Committee

• The Kelsey Trail Health Region Ethics Committee (rural health region, nursing homes, long-term care)

Confidentiality and informed consent requested for interviews and PO sessions.

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Theoretical Approach: Postcolonial Feminism

Postcolonial theories (Quayson, 2000; Hall, 1996)

Black feminism (Anderson, 2000; Hill Collins, 2002; hooks, 1984)

Postcolonial feminist theories (Anderson & Reimer Kirkham, 2002; Racine, 2003; 2009a; 2009b)

A theoretical lens “that attends to the micropolitics and macrodynamics of power” (Reimer-Kirkham & Anderson, 2002, p. 12).

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The Micropolitics of Power Personality

Race (racialization)

Ethnicity (ethnocentrism)

Gender and social class

Level of education

Age (Intergeneration clashes– Price et al. (2013)

Migration & resettlement experiences

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The Mesodynamics of Power

Settings: Urban vs. rural & acute vs. long-term care

Needs of the organization (HR, staffing mix, OT)

Organizational culture (Top down approach)

Leadership styles

Cultural diversity of the nursing staff

Institutional policies

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The Macrodynamics of Power Readiness (or lack) of the city to integrate immigrants

and refugees (Racine & Lu, in Press)

Presence (or lack) of cultural diversity in towns or rural areas

Presence of settlement immigrant agencies for support (Saskatoon, Regina, Prince Albert, Moose Jaw)

Cultural differences, Otherness/Alterity and Identity

‘Democratic racism’ in Canada (Das Gupta, 2009; Henry et al., 2006)

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Methodology Design inspired by critical ethnography

(Carspecken, 1996)

Recruitment of 3 subgroups of nurses (All RNs)

Participation of urban and rural health regions in SK

Sampling strategy: Purposeful sampling that includes criteria of inclusion.

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Sample SizeRecently hired immigrant nurses (IENs) (n = 12 = 48%)

Canadian-born and educated nurses (n = 5 = 20%)

Nurse managers (n = 8 = 80%)

Total n: 25

Participants have been recruited in 2 rural health regions—Reached the stage of theoretical sampling (variations in ethnicity, country (India), use of foreign workers’ programs or immigration paths, and practice settings)

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Demographics of IE Nurses on 8 cases

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Demographics of IE Nurses on 8 cases

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Demographics of IE Nurses on 8 cases

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Demographics of IE Nurses on 8 cases

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Data Collection

• Demographic data (Descriptive statistics)

• Individual semi-structured interviews

• Field notes

• Participant observation sessions with the use of an observation grid (debriefing b/w 2 observers)

• Focus groups (To be conducted for delineating the qualitative indicators of cross-cultural mentoring and design evidence-informed transition programs)

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Data Analysis Thematic content analysis

3 coding steps to sort out and organize data (Carspecken, 1996; Emerson et al. 2011; Hardcastle et al. 2006)

Constant comparison analyses (within, between, and across groups)

Saturation has been reached with nurse managers and IENs but we need more to increase validity

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Preliminary Results (Themes)

Similarities on the essence of nursing practice

Othering: Lack of assertiveness

Othering: Creation of the subaltern

Lack of cultural competency and safety

Appreciation of the work of IENs

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Similarities: The Nature of Nursing Practice

NM(1): “I do not believe that a nurse is a nurse is a nurse. I think that IENs share common ground with CDN nurses, like compassion, caring, understanding, and that nursing is an art and a science. On the other hand, IENs have different priorities.

Researcher: Can you tell me more about these priorities?

NM: “Our demographics play a big role. Teaching and patient education. Reciprocity, team work, an the hierarchy within the health system. How to interact and delegate to LPNs, care aids, and other colleagues.”

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Othering: Lack of Assertiveness NM: “They do not feel that they can assume the

leadership of a team. OK I can direct others and not wait to be directed, right? But part of this is the soft direction. They [IENs] don’t think they can be in charge. They cannot assume charge of the team, guide their peers, and assume leadership roles. They lack assertiveness and avoid confrontation with peers.”

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Othering: Creation of the Subaltern

“Hierarchy in the Philippines is very direct and submissive. Right? They [IENs] are taking their directions from the physician and they don’t value, hum, expressing concerns and teaching opportunities are left to a colleague, a matron, that kind of thing.” Our [CDN] nurses are used to question authority, to ask questions and to be patient advocates”.

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Lack of Cultural Competency & Safety

R: What resources are available to you to deal with issues (with IENs)?

P: “Um, I guess, uh, a conflict management course that I took. I don’t know there’s anything other than that. I guess that if I had an issue, like a specific issue, I would access either my labor relations resources or people, or employee wellness”.

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Fieldwork Tale: Double Racialization

A young toddler came from the (x). He/she is crying. There are 5 nurses at the nurse station. 1 is an IENs. 2 nurses go to check the child’s vital signs. “Just making a tantrum.” Nurses did not talk to the child nor did they try to appease his or her cries. Charge nurse asked the IE to get the mother in the waiting room. The mother came in and it is obvious that she is Aboriginal.

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Fieldwork Tale: Double Racialization

Nurses talk to each other but never addressed a word to the child, nor to his or her mother who sat besides the stretcher.

IE: I will get a toy for him or her.

Nurse: He is about to go...

Only the IE nurse talked to both the child and the mother. Other nurses did not even utter a word.

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Discussion From PO sessions, we observed and collected

comments about IENs as:

Caring and having a good approach to the patients (see the fieldwork tale)

Respectful of senior patients

Hard workers and strong work etic

Nursing is caring for patients (the wife of on male IEN does not want to die in Canada)

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Implications of the Study (1)

Try to put oneself in the Other’s shoes: It is called “cultural alterity” or experience of self-Otherness (Schutte, 2000);

Migration and settlement are major stressors among IE nurses;

Avoid replicating racist discourses towards Aboriginal peoples within the organizations.

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Implications of the Study (2)

Know the culture of immigrant RNs Know immigrant nurses’ views of nursing practice; Be ready to assume roles of mentor, leader, problem-

solver, conciliator, role model and cultural broker especially in rural areas

Know the impact of migration on nurses’ personal lives Avoid dictatorial leadership styles Underline the contributions of IE nurses to the

organizations.

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ConclusionIntegration of IENs in nursing workplace is not a

linear process: Process is multifactorial and complex (Kolawole, 2010; Zhou et al., 2010);

Racial stereotypes must be acted upon diligently by leaders and educators, and nurse colleagues;

Cultural competency and safety represent ethical and moral requirements for creating inclusive healthy work environments.

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Acknowledgements (1)

The Canadian Institutes of Health Research (CIHR) and The Saskatchewan Health Research Foundation (SHRF) for funding the study

Communality settlement agencies (SODS & RODS)

Individual participants for taking precious time to meet with us

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Acknowledgements (2)

• The Saskatoon Health Region

• The Regina Qu’Appelle Health Region

• The Prince Albert Parkland Health Region

• The Kelsey Trail Health Region (rural health region, nursing homes, long-term care)

• All our participants

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The Research TeamLouise Racine, RN, BScN, MScN, PhD, Principal Investigator, Associate Professor, College of Nursing, Expertise in immigrant and refugee health, cultural competency

Linda Ferguson, RN, BSN, PGD (Cont. Ed.), MN, PhD, Co-Principal Investigator, Professor, College of Nursing, Expertise in nursing education, preceptorship and mentorship programs

Sonia Udod, RN, BSN, MS, PhD, Co-investigator, Assistant Professor, College of Nursing, Expertise in nursing leadership and quality of nurses’ work environments

Sithokozile Maposa , RN, PhD, Co-Investigator Assistant Professor, College of Nursing, Expertise in HIV/AIDS prevention and global health nursing

Susan Fowler-Kerry, BA, BSN, MN, PhD, Co-investigator Professor, College of Nursing, Expertise as an International nurse consultant and preceptorship in the Philippines

Yixi Lu, PhD, Research coordinator, SHRF Post Doctoral Fellow, College of Nursing

Melissa Smith, RN BScN, Research Assistant, College of Nursing and RN in the SHR

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The Strengths of Internationally Educated Nurses in Healthcare Settings:

Evidence from a Critical Ethnographic Study

Louise Racine RN PhD, Linda Ferguson, RN PhD, Sonia Udod, RN PhD, Sithokozile Maposa RN PhD, Susan Fowler-Kerry RN PhD, Yixi Lu PhD

9th Annual Partners in Education and Integration of IENs

Regina, Saskatchewan

May 1st, 2015