Challenges Faced by Refugee Nurses to Integrate into Jordan's Labor Market: A Phenomenological Study

The issue of refuge has emerged as a global concern, exerting significant economic and social pressures on countries that face high levels of migration (Arendt, 2017). Jordan hosts the second most refugees per capita worldwide and is renowned for its historical hospitality towards populations seeking refuge on its soil. A middle-income country in the Middle East, Jordan has an area of 89,342 km² and a population of more than 11 million, in which 30% of its population are non-Jordanians (Hadidi, 2017).

Some refugees have the means to earn a living to support themselves and their families, but live in poverty conditions...

One concern that professionals with refugee status often face upon relocating to a different country is the process to secure a position that reflects the credentials and previous knowledge and experience they bring from their former homeland. Some refugees have the means to earn a living to support themselves and their families, but live in poverty conditions due to the complexity of the process to vet their education and credentials that results in inability to gain professional employment in the new country (Alshoubaki & Harris, 2018; Khan‐Gökkaya & Moesko, 2021). In this article, we review challenges for refugees in Jordan, and specifically health professionals with refugee status, and discuss a research study that explored the experiences and barriers of nurses and midwives.

Review of Literature

Refugees in Jordan
Jordan is well known for its high-quality, modern health services and infrastructure, as well as its highly qualified nurses, physicians, and other healthcare providers. The country has been recognized globally as one of the world's top medical tourism destinations due to its geographical location and political stability (Jordan Royal Court, 2022). Jordan has a total of 2,307,011 registered Palestinians in the Work Agency for Palestine Refugees in the Near East (UNRWA), in addition to 1.36 million Syrian refugees who have fled to Jordan since 2011 (Ministry of Planning and International Cooperation [MoPIC], 2019) According to MoPIC (2019), only 655,435 Syrian refugees are registered in the United Nations High Commissioner for Refugees (UNHCR), the UN refugee agency dedicated to saving the lives and protecting refugee rights. In addition, 90% of all Syrian refugees in Jordan live outside of camps.

Jordan is well known for its high-quality, modern health services and infrastructure, as well as its highly qualified nurses, physicians, and other healthcare providers.

Challenges of Refugee Status
According to the International Council of Nurses (ICN), there are many health and healthcare-related challenges facing migrants, refugees, and displaced persons across the world (Catton, 2019). Conflict, poverty, disasters, urbanization, lack of rights, discrimination, inequality, globalization, and inability to find decent work are a few reasons for migration. Leaving behind their homes and belongings, family, friends, normal way of life and a loss of identity is an overwhelming traumatic experience for refugees (Colic‐Peisker & Walker, 2003; Timotijevic & Breakwell, 2000). This experience can often result in fearful, despairing, and uncertain feelings (Momartin et al., 2004). Employment, or lack thereof, in a new home definitely plays an important role in restoring refugees’ social and economic status and enabling them to build confidence and a sense of self, as well as their ability to achieve their greatest potential (Colic‐Peisker & Tilbury, 2007; Colic‐Peisker & Walker, 2003).

Employment, or lack thereof, in a new home definitely plays an important role in restoring refugees’ social and economic status...

Health Professionals with Refugee Status. As a newly vulnerable group, health professionals who are refugees face several challenges and struggle to integrate into a host country's labour market, including Jordan. Access to the labour market and legal status in terms of residency permits are among the difficult barriers and challenges faced by refugee health professionals (Williams et al., 2020). In addition, the process to gain recognition of the appropriate licensure and/or credentials in another country is complex (Khan‐Gökkaya & Moesko, 2021). Refugees may face a denial of recognition for the professional experience that they have previously acquired (Mozetič, 2018); they often lack the means to document their record of formal education (Ng Chok et al., 2018). The process of obtaining a work permit is also complex and they may encounter discrimination (Khan‐Gökkaya & Moesko, 2021; Ng Chok et al., 2018).

Access to the labour market and legal status in terms of residency permits are among the difficult barriers and challenges faced by refugee health professionals

Refugees in Jordan face difficulties in finding work due to legal issues, leading many to rely on non-governmental organizations for financial assistance. However, this assistance is mainly directed toward those registered in the UNHCR (Albu, 2019). The UNHCR (2015) reported that the majority of the Syrian refugees who lived outside camps (86%) were under Jordan’s poverty line in addition to 10% who were under the object poverty line. Work permits are typically issued in Jordan for refugees in the construction, agriculture, manufacturing, and service sectors, with low-skilled jobs and poor working conditions (Fallah et al., 2019). However, the COVID-19 pandemic in Jordan in 2021 provided work permission to some refugee Syrian medics and nurses, but only if they had all legal documentation of their credentials and degrees.

Socioeconomic insecurity and financial concerns experienced by refugees in Jordan have contributed to a higher prevalence of health problems, including non-communicable diseases (NCDs) (Albu, 2019; Ratnayake et al., 2020). Hamdan-Mansour et al. (2017) reported that refugees in Jordan have also reported social, psychological, and physical deterioration, impacting both the refugees and the host communities (Hamdan‐Mansour et al., 2017). The integration of refugees has been negatively affected, leading to more severe forms of psychological illnesses (Alduraidi & Waters, 2018; Halasa et al., 2020).

Socioeconomic insecurity and financial concerns experienced by refugees in Jordan have contributed to a higher prevalence of health problems...

Research studies have identified different factors that are barriers for refugee health professionals. For example, losing their former careers and professional status can lead to loss of skills, self-confidence, and control that impacts the ability to secure adequate employment. The combination of these factors leads to considerable loss of self-esteem (Bakker et al., 2016; Ng Chok et al., 2018; World Health Organization [WHO], 2021a; Willott & Stevenson, 2013). Studies have also found that refugee health professionals face many challenges not only resulting from the migration itself, but from the subsequent financial problems, family settlement, and general difficulty meeting household needs (WHO, 2021b)‎. According to the WHO (2021b), the problem of underemployment has forced some health workers to move into fields with fewer qualifications. The WHO (2021b) revealed that Syrian women healthcare professionals declined job offers because of long working hours, in addition to lack of support structures such as vacation time, day care, or transportation.

...the problem of underemployment has forced some health workers to move into fields with fewer qualifications.

Nurse Refugees in Jordan. Nurses have a significant role in the healthcare sector and a considerable impact on the labour markets and tertiary education systems of both developing countries and developed countries (Abuhammad et al., 2021; Buchan & Sochalski, 2004). Similar to other countries, many refugees arrived in Jordan without official identification documents from their countries (Bloch, 2008). Nurse refugees in Jordan are living in poverty conditions because of the restrictions to employ them in health sectors, and other areas, and there is no clear pathway for them to practice (Alshoubaki & Harris, 2018).

Nurse refugees in Jordan are living in poverty conditions because of the restrictions to employ them in health sectors...

Jordan has laws and licensing necessities that are specific to medical professionals, including nurses. It may be challenging for refugees nurse to achieve these standards, particularly if Jordan is unwilling to acknowledge their education and credentials (Gray Meral, 2020; Lenner & Turner, 2019). It can take time, and be challenging, to verify international credentials and work expertise. For their qualifications to be accepted in Jordan, in addition to a review of their credentials, refugees may require additional examination or training (Şahin Mencütek & Nashwan, 2021). For these reasons, it might be difficult for refugees to attain the work permits they need to legitimately work in Jordan (Alshoubaki & Harris, 2018).

It can take time, and be challenging, to verify international credentials and work expertise.

Summary
There are very few studies, especially in the Middle East region, that have explored the challenges that refugee nurses face, including integration into a new host country's labour market. Unfortunately, specific census data in Jordan regarding the number of refugee health professionals, including nurses and midwives, is not available. However, it is still crucial to identify challenges and difficulties to employment in host countries because there has not been a simple solution to mitigate the core challenges to the professional integration of refugee doctors and nurses.

In sum, the population of refugee health professionals is poorly documented, and they frequently have unrecognized skills. This study aimed to shed light on the personal and professional experiences of refugee health professionals, including nurses and midwives. The purpose of this study was to explore the challenges faced by refugee health professionals, as well as their perceptions of potential solutions to overcome in their attempts to integrate into Jordan's labour market.

In sum, the population of refugee health professionals is poorly documented, and they frequently have unrecognized skills.

Study Methods

Design
The study used a descriptive qualitative approach. The utilization of the phenomenological perspective aims to gain a fundamental understanding of participants' consciousness and experiences (Wojnar & Swanson, 2007). This approach delves into the essential aspects of lived experiences, allowing for the emergence of the true meaning behind the phenomena of interest (Wojnar & Swanson, 2007).

Setting and Sample
The research was conducted in the community and refugee camps in the north of Jordan. The study population was refugee health professionals. Inclusion criteria encompassed refugee health professionals who resided in the area of the research setting.

A total sample of 16 refugee health professionals were invited to participate in this study; participants were identified from the camps or from some employers who employed them with restrictions. Flyers were used to recruit additional participants. We also utilized a snowball sampling technique, commonly used in qualitative research, to ensure that the selected sample adequately represented the phenomena of interest (i.e., referrals from nurses who knew of other nurses who had the same experience and guided the researchers to them).

Data Collection
Ethical Considerations. Approval for the study was obtained from the Institutional Review Board (IRB) of King Abdullah University Hospital (KAUH). Refugee nurses were approached on a personal level and invited to participate in the research based on their eligibility according to the study's inclusion criteria. Once they verbally consented to participate, they were provided with an information sheet detailing the study's aim, potential risks, and benefits, and their right to withdraw at any time. Subjects in the study were assured of their voluntary involvement, with a focus on the fact that leaving the study would have no effect on any assistance they received.

As a matter of ethical consideration, the researchers explained the purpose of the focus group discussion or interview and emphasized the importance of participants' views to enhance what we know about the experiences of refugees, and especially nurses, who are seeking professional employment. All participants were asked to verbally agree to the study objectives, prospective advantages, and associated potential threats after review of a summary sheet that explained this information. 

Interviews. Data collection was conducted in a safe and comfortable location of the participants' choosing, at a time scheduled according to their preference. We offered private rooms to conduct focus group discussions or semi-structured interviews about their experiences as a refugee health professional and specifically about pursuing professional employment. Each participant was assigned a number to maintain confidentiality in the interview process and the interviews were recorded to aid with analysis. Transcriptions were stored in a locked file. The interview, whether group or individual, consisted of five open-ended questions and additional open-ended prompts, as follows:

1. Please provide a detailed description of your experience as a refugee health professional.
2. Describe the different forms of barriers/challenges you have experienced.
3. How has the war affected your experience as refugee health professional?
4. Explain your feelings about being a refugee health professional.
5. From your point of view, what actions have you taken/or proposed priority solutions to overcome to deal with these challenges?

The face-to-face discussions typically lasted between 45 and 60 minutes. Data collection was continued until data saturation (i.e., subsequent participants were answering in a similar way to earlier participants) was reached. Sessions were recorded and the data were transcribed for analysis. The information gathered was kept completely private in a locked file.

Data Analysis

Identification of Themes
Data were analysed by the authors via content analysis. Main themes were identified regarding challenges as well as priority solutions to facilitate the integration of refugee health professionals into Jordan's labour market. Data analysis followed the seven steps outlined by Colaizzi (1978). After transcribing the interviews, the first step involved immersing oneself in the participants' experiences by reading and rereading the interviews. This process facilitated the identification of unique and significant statements directly related to the phenomenon of interest. In the second step, a meaningful order was established for these significant statements. The next step involved categorizing each meaningful statement into themes. Subsequently, a comprehensive descriptive picture was developed by integrating the findings derived from these themes. The fifth step entailed formulating exhaustive descriptions to capture the essential qualities of the phenomenon. To examine and verify responses in the sixth phase, we compared them to the actual interviews. Finally, the data were compiled in a complete report that accurately reflected the opinions of the respondents.

Measures of Trustworthiness
To ensure the trustworthiness of the qualitative investigation, we utilized the measures of trustworthiness as outlined by Guba and Lincoln (1981): credibility, transferability, dependability, and confirmability. This section explains our specific actions to ensure the trustworthiness of our data.

Member Checks. To ensure that the descriptive phenomenological analysis accurately reflected the participants' own interactions, a procedure for validation was utilized. First, we called a random sample of four study participants. The selected participants were asked to schedule a call at a time convenient for them. This strategy ensured participants' psychological and physical security during the validation process, as well as the accuracy of their responses. The integrated findings were validated or altered based on the final verification or adjustments to the description of the participant responses.

Other Measures. The use of rigorous data collection and analysis procedures establishes credibility, allowing for an accurate picture of the participants' experiences (Guba & Lincoln, 1981). Transferability was addressed by including enough contextual elements and descriptions to allow readers to judge the findings' application to different situations or groups. Maintaining a clear and transparent research process through an audit trail, by recording all procedures and judgments made throughout data analysis, was utilized to ensure dependability. Finally, to reduce personal bias, confirmability was maintained by maintaining an objective attitude throughout the investigation and incorporating multiple researchers in the process.

Results

Demographic Information
Our sample size was 16 refugee nurses. Participants included 11 men and 5 women. The mean age was 29.25 (SD = 7.23). See additional demographic information in the Table.

Table. Demographic Characteristics of Refugee Nurses (n = 16)

Item	Category	Frequency	Percentage
Gender	Female	5	20.8
	Male	11	45.8
Nationality	Syrian	6	25
	Iraqi	1	4.2
	Palestinians	9	37.5
Marital Status	Widower	1	4.2
	Single	9	37.5
	Married	6	25.0
Number of Children	0	11	45.8
	2	3	12.5
	4	1	4.2
	5	1	4.2
Family Members / Number of Dependents	2	4	16.7
	3	3	12.5
	4	3	12.5
	5	3	12.5
	6	2	8.3
	0	1	4.2
Years of Experience in Field, in Home Country?               Worked in Jordan Outside Professional Field?	Less than a year	8	33.4
	12	2	8.3
	2	1	4.2
	5	2	8.3
	0	3	12.5
	No	7	29.2
	Yes	9	8.3
What do you intend to do in the next two years?	Continue working to gain more experience	9	29.2
	Continue professional development courses	4	4.2
	Continue self-employment	1	4.2
	Look for opportunities/travel abroad	2	4.2
If you were given the opportunity to start over, would you choose your current major as your primary major?	Yes	6	8.3
	No	10	12.5

Emerging Themes
The emerging themes were legal issues, financial issues, working environment issues, education and professional issues, family issues, physical and mental health issues, and gender issues. Some of the concerns voiced by the nurse refugee participants are appropriate to more than one theme, demonstrating the complexity of their challenges. Each theme is discussed in detail below, with supporting quotations.

Theme 1: Legal Issues. Most participants agreed that legal conditions were one of the most common issues that they suffered. The many examples that participants described included assuming illegal jobs in the health sector; working conditions; access to the labour market/lack of job opportunities; eligibility for job interviews (e.g., immediate interruption of work interviews after realizing that they are refugees); the legal and complex process of obtaining a work permit; lack of recognition of qualifications; inability to obtain a license to practice; inability to obtain a hospital experience certificate, Ineligibility for national identification number; lack of social security number and benefits; and lack of health coverage. For example, a male nurse said, “The experience certificate cannot be obtained from the hospital, the Ministry of Health does not recognize it, and the procedures are unfair and impossible.”

Most participants agreed that legal conditions were one of the most common issues that they suffered.

As indicated by other nurses, one nurse said, “Some employers do not adhere and respect contracts, may be because of our illegal work, so you may lose your job at any time.” Similar to the responses of many nurses, one participant said, “I do not challenge or confront anyone legally because I work illegally, and any problem may negatively affect me, even if I am the victim of the problem.” Another nurse mentioned, “There is just partial health coverage for me as refugees which is difficult to cover my physical and mental health issues in light of the economic and financial challenges.”

Theme 2: Financial Issues. Financial issues were one of the most listed challenges for male and female refugee nurses in Jordan. This included living costs in bigger cities, difficulty meeting household needs, having many family dependents, and moving into fields with fewer qualifications that did not pay enough money. Other financial issues included the need to stay at the nursing hospital residence to save the cost of transportation; having full responsibility for financial support of their families; poverty concerns; and selling personal property to live. For example, a nurse said:

My family sold our land in Syria to survive here in Jordan. I am the eldest among my brothers and sisters, and my family covered the expenses of my nursing education while 2 of my brothers had not been given the opportunity to finish their education because of the lack of money, I feel bad that I took someone else’s share from the money of our sold land.

Another nurse (39y) said:

I am the main financial supporter for my family around 70-80%. I give them all my salary and only take the cost of my transportation. That is all I get. I am happy to support my family, they need my support. They paid for my education when they did not have anything.

Another nurse commented, “I have a responsibility to financially support family members.” Moreover, four women from the participants were responsible for the main financial support of their families. A widowed I Iraqi female nurse said, “I work in cupping in addition to nursing to support my 4 children, living expenses are high and they can’t even think to go to college or university education and therefore, will not be able to find jobs.”

Theme 3: Working Environment Issues. Our analysis revealed many issues in the work environment. Some of these included: assuming illegal jobs in the health sector; long working hours; high workloads; lack of vacation time; lack of job opportunities; inability to secure adequate (decent) employment; taking odd jobs or working part-time; working outside the scope of practice; workplace safety hazards and risks; noncompliance by employers with contracts; job insecurity; and hectic work/working many shifts per day. Both male and female refugee nurses faced these concerns in the workplace. For example, four nurses noted that they have to continue looking for job opportunities and do interviews as they are not sure if they can stay at their current work.

Our analysis revealed many issues in the work environment.

A nurse (45 y) mentioned, “I worked three shifts sometimes to cover basic needs to my family.” Another refugee nurse said, ”I feel that they are stronger than me because I am a refugee and if I suffered from any problem, they would return me to the camp.”

Several nurses pointed out that they work outside of the nursing scope of practice especially in small sized hospitals. One nurse said, “In two small hospitals, in addition to my nursing duties, I did many non-nursing related work for long hours, including cleaning of dishes and floors.”

Theme 4: Education and Professional Issues. Refugee nurses agreed that educational and professional issues were another critical barrier facing refugee nurses in Jordan. This concern included the high cost of education in Jordan at both private and the public universities; taking odd jobs unrelated to their educational background to pay their fees; lack of recognition for their qualifications; “breaking” of careers; losing professional status and skills; and fear of aging, which makes it difficult to obtain job opportunities.

For example, one nurse refugee (34 y) said, “I have to sell one land property to pay university fees in Jordan, the studying here is very expensive for foreigners.” A widowed nurse said, “There is no money to support the education of my children especially at the university, they ask to pay in USD.” Moreover, another nurse commented, “My educational background and certificates are not acceptable here.”

Theme 5: Family Issues. Most women agreed that they are experiencing family issues. Their concerns related to lack of time for the family; working for a long time; the negative impact of work conditions on their connections with family members; feeling distressed because they are not able to spend enough quality time with children and family; children who are fully responsible to care for children’s needs, education and housekeeping; the feeling of depriving children of their rights to better paternal care; and culture, especially concerning legal conflict. Many male nurses indicated similar challenges related to lack of time for their families and children. Examples of comments from the nurse refugees that related to family issues included:

• I feel bad and distressed which affect my children and family.
• I don’t see my family sometime for 2-3 weeks because I work three shifts continuously in 2 hospitals. I am feeling bad and could not tell my family that I have migraine, I suffer, I get upset, and it is very painful but I will continue my work. In addition, I don’t tell my family about my migraine and suffering, I don’t want to upset them and feel sad because of me.
• In addition to the high and long cost of my transportation, I leave my children alone for 12 hours, their older sister, who is also a school student, is fully responsible for them, their homework/studies, and everything in the house.
• I do not give my children their rights, no care, I don’t spend time with them, and I have a feeling of inferiority and remorse.

Theme 6: Physical and Mental Health Issues. Many participants mentioned feeling suffering and distress; experiencing many health problems; feelings of oppression; feeling bad and destroyed inside; frustration and helplessness; ambiguity about professional career; uncertainty about future or dark job prospects; loss of identity; despair, uncertain feelings and general loss of control. For example, a nurse mentioned, “I am feeling bad and oppressed, destroyed inside, I am suffering from frustration and helplessness.” A male nurse mentioned, “I am uncertain about my future prospects/dark prospects.”

Many nurses mentioned the feeling of a loss of identity, despair, uncertain feelings and loss of control as well as the need for psychological support. A nurse said, “I badly need psychological support and consultation, but there is a culture of shame on the part of the husband, family, and society.” Another female nurse said, “I feel sometimes that I need to go out somewhere and scream to release my anger and my negative energy.”

Theme 7: Gender Issues. Another barrier that most participants mentioned concerned several issues that related to gender. Some of the comments related to earlier themes, but in this case were shared in the context of being a woman. These comments included the suffering from being a female, and especially concern for the lack of ability to stand up for their rights or any legal conflict like men; lack of support structure as women (e.g., vacation time, day care, or transportation from the employer); feelings of injustice with males; hectic work and shouldering more family responsibility in comparison with males; breaking of careers for gender issues; losing professional status and skills; losing energy just after the long working hours; feeling of inferiority and remorse for not giving attention and care to family and children; feeling guilty as women to make children shoulder the full responsibility of caring for younger sisters and brothers while away at work; having full responsibility to financially support their families; and selling personal properties to live.

Another barrier that most participants mentioned concerned several issues that related to gender equity.

In sum, all female participants agreed that they suffer from being female, if compared to the male, in long working hours, lack of support structure (as noted above), and feelings of injustice, and suffering from a higher level of family responsibility (in comparison with males). For example, one said:

It is a hectic work and I need to be energetic in work while my power and energy are off with my family and children at my own house, while my husband does not suffer like me. I wish if I am a man.

As for gender and legal issues, some female nurses felt gender inequity in taking and fighting for their rights. Several comments that illustrated this concern included:

I can’t file a lawsuit in court against my employer for any legal conflict even if I am right, there are family and cultural restrictions for women….from the point view of my family and the community also, it is unacceptable to go to court…. It is OK for men but not for women. In addition, I am afraid to lose future job opportunity if I go to court and …….I may also be further burdened with more than I can bear.

I had premature birth because of my hectic work in the hospital, with a short phone call from my employer, my 6 months’ contract he suspended me from work just after I delivered my premature baby, for no reason, I was so upset and angry, they should have gave me at least a month to recover and go back to my job…my friends told to me to file a lawsuit, but I couldn’t even dare to do it.

Discussion

Few studies exist that have specifically addressed the challenges encountered by refugees who are healthcare professionals, and especially nurses, in the process of obtaining credentials and seeking employment within the framework of labour market integration in a new host nation. This study sought to delve into the challenges faced by refugee nurses as they endeavor to integrate into the labour market of their new country, particularly as they embarked on the path to becoming registered nurses. To our knowledge, this study marks the initial attempt to comprehend the various challenges that impact the job prospects of refugee nurses.

Few studies exist that have specifically addressed the challenges encountered by refugees who are healthcare professionals, and especially nurses...

Limitations
The literature is rich in discussions about the difficulties of engaging and gathering data from refugees in general (Baird et al., 2017; Clark-Kazak, 2017). However, encouraging some refugee nurses to participate in our study posed challenges. For example, some stipulated conditions for their involvement that we could not ethically support, such as ensuring future employment and addressing personal issues. Certain individuals were apprehensive about participating, fearing potential repercussions that could affect the privileges they received from international organizations.

In Jordan, healthcare refugees, including nurses, remain largely hidden (Fallah et al., 2019). Identifying them often relied on a snowballing approach, emphasizing their relative obscurity within the healthcare landscape (Alduraidi & Waters, 2018). This situation may also reflect the limited visibility of this subgroup of nursing professionals in previous research endeavors, and thus within the current literature. This occurs despite the clear distinctions between migrants and refugees, as outlined by the UNHCR in 2016 (Albu, 2019).

In Jordan, healthcare refugees, including nurses, remain largely hidden

Relevance of Findings
Gender Concerns. Several findings in our study build on existing literature. Our study found that one of the themes that emerged from this study was related to gender issues. It is well-documented that women hailing from refugee backgrounds tend to experience a range of gender-related vulnerabilities and various forms of marginalization (Goodkind & Deacon, 2004; McMichael & Manderson, 2004). It is worth mentioning that English and Arabic sources are notably lacking in precise figures regarding the actual number of refugee nurse women who hold work permits in Jordan and those engaged in temporary employment.

It is well-documented that women hailing from refugee backgrounds tend to experience a range of gender-related vulnerabilities and various forms of marginalization

A previous study found that female interviewees consistently conveyed that they had not been employed outside their homes prior to migrating to Jordan, but found themselves compelled to work in their new environment (Şahin Mencütek & Nashwan, 2021). This shift was primarily due to economic difficulties faced by their families, the inadequacy of their husbands' incomes, and the absence of the social and familial support they had previously enjoyed in the countries from which they fled. Social problems and psychological and physical health problems can be triggered or exacerbated by unmet basic needs (El Arab & Sagbakken, 2018), and comments from the nurses in our study described many challenges in these areas. Moreover, this study revealed that women who had previously not engaged in any form of employment prior to leaving Syria shared experiences of facing criticism and being subject to gossip for their decision to seek paid work, confirming earlier evidence (Avis, 2017; Şahin Mencütek & Nashwan, 2021). The idea of women entering the workforce alongside men was perceived as culturally unacceptable by many refugees.

This shift was primarily due to economic difficulties faced by their families...

Professional Employment Opportunities. Our study found that one of the main challenges for the refugee nurses is related to employment opportunities. Similarly, the findings from the few (and dated) studies of refugee nurses found there are three challenging impact factors emerged: a sense of loss of control, disorientation in a new environment, and limited employment prospects (Casimiro et al., 2007; Winkelmann-Gleed & Seeley, 2005). Comments from these recent findings offer valuable insights into the continued difficulties encountered by refugee nurses as they seek professional employment.

Many participants in our study pointed out that their qualifications as nurses were ignored. Many previous studies have mentioned that the lack of recognition of qualifications obtained prior to resettlement further drives refugee nurses into non-nursing roles, necessitates additional study, or leads to employment in nursing positions that do not adequately recognize their professional nursing credentials (Brandt, 2010; Smit & Rugunanan, 2014). In Jordan, refugee jobs in nursing are not permitted. Only jobs in construction, agriculture, manufacturing, and service industries are allowed for refugees. Nurses' aspirations to become legally employed are hampered by the many challenges reported in this study that align with previous similar challenges reported in the literature (Al-Qdah & Lacroix, 2011; Şahin Mencütek & Nashwan, 2021).

Many participants in our study pointed out that their qualifications as nurses were ignored.

Workplace and Legal Challenges. Challenges to employment indeed confront refugee nurses, and there is empirical evidence indicating that refugee nurses often have historically faced discrimination and endured feelings of belittlement and degradation within their workplace (Casimiro et al., 2007; Winkelmann-Gleed & Seeley, 2005). It is imperative to implement strategies that nurture the professional and personal growth of refugee nurses, fostering the confidence and self-assuredness required for them to flourish as healthcare professionals in their newly adopted country. Many refugee nurses in our study are highly motivated, determined, and hopeful about finding legal employment opportunities, ensuring job security, and working towards a better life for themselves and their families in Jordan.

Illegal employment in the healthcare sector will add to the already mounting legal issues faced by these refugee nurses, as well as complicate and trigger other negative consequences related to family, financial, professional, physical, work safety, malpractice, and mental health. In spite of illegal work situations, many take the risks, and they stand strong despite the challenges they face to survive and care for their families. Nurses in this study voiced that family is highly valued; how best to financially support their families is the main concern for them.

Nurses in this study voiced that family is highly valued; how best to financially support their families is the main concern for them.

Implications for Practice
A projected growth rate of 2.7% per year (as compared to a 0.9% population growth) suggests an increase of 19 million net jobs by 2030, which could result in 84 million health workers (Ng Chok et al., 2018). In the coming years, this growing pool of employed health workers will contribute to the health economy. Refugee nurses should have the right to participate in this important and growing industry.

Promote Awareness. Engaging in such awareness-raising activities within the community and the healthcare system can promote greater understanding about the journeys of refugee nurses, underscore the challenges they face, and provide insights into overcoming these challenges. Offering opportunities for refugee nurses to volunteer and share their untold stories of resettlement and the process of re-establishing their professional identities at relevant nursing forums can offer valuable insights and enhance understanding within the profession (Alduraidi & Waters, 2018). Furthermore, recognizing the significant contributions made by refugee nurses in healthcare during national observances that celebrate and acknowledge refugees would be advantageous for the broader community.

...recognizing the significant contributions made by refugee nurses in healthcare during national observances that celebrate and acknowledge refugees would be advantageous for the broader community.

Create Legal Opportunities. Findings from our study suggest caution regarding the illegal employment of refugee nurses. These nurses represent a vulnerable group, not only due to poor living conditions and other mentioned challenges, but also to the fact that they may face serious legal consequences as a result of illegal work. For example, it is very likely that they could be abandoned by their employers and be left alone to face the problems. The situation of being illegally employed may lead to deportation; more financial difficulties leading to poverty conditions; and family, health, and psychological problems. National and international communities need to better coordinate labour market policies and ensure legal employment for refugee nurses. Refugee nurses must be provided with professional employment opportunities through revision of existing bylaws, resources and processes to vet existing nursing experience and credentials.

The situation of being illegally employed may lead to deportation; more financial difficulties leading to poverty conditions; and family, health, and psychological problems.

Inform Policy. Policy makers and researchers must learn from the COVID-19 pandemic, and from other disasters and crises facing the world today, that we cannot underestimate the issue of the severe shortage of health personnel. There is no alternative; the best course of action is not only to make a proper investment in preparing nurses for the future, but also to invest in as many existing health professionals on earth, including refugee nurses. Policy makers should consider investing in qualified refugee nurses to help them to satisfy the health needs of their camps and communities by allowing them to compete meaningfully on the labour market. Cultivating a welcoming work environment for recently hired refugee nurses can foster positive experiences to ensure health for all and by all (Abuhammad et al., 2020).

Conclusion

In summary, the themes that emerged from this study that described challenges faced by refugee nurses were related to legal employment opportunities, resulting in frustration among them as they are faced with legal, financial issues, working environment issues, professional, family issues, mental, physical, and gender issues. This means that, despite Jordan's historical reputation for hospitality towards refugees, refugee nurses, and likely other professional healthcare providers, still face numerous challenges when integrating into the labour market due to their vulnerability. This study was an important first step toward understanding barriers that hinder refugee health professionals' employment opportunities, as well as the actions they can take to integrate into Jordan's labour market.

This study, through nurses' responses, will help decision makers gain insight into perceived shortcomings in the system. Nurse refugees believe that they confront many barriers as they seek high-level employment within the healthcare industry. One of these barriers is the condition of poverty, and it is not difficult to imagine this scenario when considering the variety and complexity of the responses that they provided in this study alone.

One of these barriers is the condition of poverty, and it is not difficult to imagine this scenario...

Our study findings can inform policy related to integration of health professionals with refugee status, including nurses in education and practice. The results add to the evidence base in the international literature on the global nursing workforce by exploring the professional and personal experiences of refugee nurses who travel to other host countries, with a goal to work as professional nurses in the new countries in which they have located. Nurses, and other professional healthcare providers moving with refugee status, have the potential and the desire to contribute to the care of patients and communities. They desire and deserve emotional and financial security. To ensure better investment in and protection of nurses at all levels and circumstances, it is vital that national and international organizations work together to coordinate labour market policies and facilitate legal employment of these refugee healthcare providers.

Authors

Rowaida Al-Maaitah, DrPH, MPH, RN
Email: rowaida@just.edu.jo
ORCID ID: 0000-0003-4238-528X

Dr. Al-Maaitah is a professor and former dean of the College of Nursing at Jordan University of Science and Technology. Rowaida is President of the Board of Trustees at Yarmouk University, former Minister of Higher Education and Scientific Research, former President of the Hashemite University, former Senator in the Upper House of the Jordanian Parliament and former Director General of King Abdullah University teaching Hospital/JUST.

Sawsan Abuhammad, PhD, RN
Email: shabuhammad@just.edu.jo
ORCID ID: 0000-0002-7213-9613

Sawsan Abuhammad is an associate professor in maternal and child health nursing. She is a researcher, educator and a regulator in health and nursing. Sawsan is also a consultant for various international organizations in health and social development.

Hani Nawafleh, MSN, PhD 
Email: hnawafleh@jnc.gov.jo

Professor Hani Nawafleh is the Secretary General – Jordanian Nursing Council (JNC). Former Member of the Jordanian House of Parliament (MP). Former Dean of the Princess Aisha Bint Al-Hussein Faculty of Nursing & Health Sciences, Al-Hussein Bin Talal University (AHU). Hold a PhD in Community Health Nursing from Monash University, Melbourne, Australia 2005. Board Members, Nursing Specialties: The Arab Board of Health Specializations, Member of range of national and international Committees.

Hadeel Al-Maaitah, PhD, MSN, RN
Email: hadeel@hu.edu.jo
ORCID ID: 0000-0003-2133-8134

Hadeel Al-Maaitah is an Assistant Professor of Management Studies and the founder and director of the Center for Women Studies in the Community (CWSC) at the Hashemite University.

Laila Akhu-Zaheya, PhD, RN
Email: lailanurse@just.edu.jo

Laila Akhu-Zaheya is a professor/dean in the adult health department, and Faculty of Nursing/ WHO Collaborating Center, Jordan University of Science and Technology

Muntaha Gharaibeh, PhD, RN
Email: muntaha@just.edu.jo
ORCID ID: 0000-0002-7213-9613

Muntaha Gharaibeh is a professor in maternal and child health nursing. A researcher, educator and a regulator in health and nursing, she is also a consultant for various international organization in health and social development.

Raeda Abu ALRub, PhD, RN
Email: raeda70@just.edu.jo
ORCID ID: 0000-0003-0974-7349

Dr. Raeda AbuAlRub earned a PhD degree in nursing service administration from the University of Iowa in the United States in 2003. She is currently a professor at the College of Nursing at Jordan University of Science and Technology. Dr. Abu AlRub has over 60 articles in the area of nursing management, administration and leadership.

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