Internationally educated nurses’ (IENs) transition to practice in a new country is facilitated by education programs, commonly known as “bridging programs.” IENs experiences and understanding of interprofessional collaboration, essential in today’s health care environment, is often overlooked in education and research. Therefore, this mixed methods study sought to understand the experiences of IENs enrolled in a practical nursing bridging program at an urban community college in Canada. Findings indicate a need to address IENs’ understanding of interprofessional collaboration in their entry-to-practice education to optimize their role in the receiving country’s health care system.
Key Words: internationally educated nurses, interprofessional collaboration, transitioning, workplace readiness, bridging education, nursing education, transition for new nurses
There is increasing recognition that nurses and other health care professionals need to engage in collaborative working relationships, commonly referred to as interprofessional collaboration, to enhance patient and family outcomes. The World Health Organization (WHO) (2010) defines interprofessional collaboration as a collaborative process in which health care providers from different professions work together with patients, families, carers, and communities for the purpose of achieving health goals and increasing the quality of care. The goal of interprofessional collaboration is to develop a partnership between health care providers, clients, and families to promote a participatory, coordinated approach to information sharing and decision making (Arain et al, 2017).
Literature Review
While the benefits of interprofessional collaboration have been established and are recognized in North America, Europe, Australia and parts of Asia, the concept is still relatively new in developing countries (Herath et al., 2017; Sunguya, Hinthong, Jimba, & Yasuoka, 2014). This is particularly concerning for IENs who come from developing countries, as they constitute the largest number of immigrant health professionals in North America (Organization for Economic Co-operation and Development [OECD], 2016).
While there is some literature that suggests the need to support IENs working in interprofessional teams (Atack, Cruz, Maher, & Murphy, 2012), there is a paucity with respect to IENs’ experiences with interprofessional collaboration. It is important that IENs be given sufficient education and training that will enable them to become active members of the interprofessional team (Moss, Seifert, & O’Sullivan, 2016). However, to effectively design such a program, it is important to explore and consider the actual learning needs.
Typically, IENs transition to the workforce in their host country by participating in a bridging program. Bridging programs assess prior education and training, workplace skills, and certification examination readiness (Neiterman et al., 2018). Bridging programs that transition IENs to the North American nursing role need awareness of IENs’ experiences with interprofessional collaboration to support their unique learning needs.
Theoretical Framework
This research was guided by Meleis’ Transition Theory, which has been used in nursing to investigate situational transitions in education and practice This research was guided by Meleis’ Transition Theory, which has been used in nursing to investigate situational transitions in education and practice (Meleis, 2010). Meleis (2010) suggests that when an individual transitions to a new role, a change is experienced in role relationships, expectations, or abilities. IENs educated in a country with differing social and cultural norms and practice expectations from those of the new country will experience changes in the way they practice. How IENs transition to their new role will depend on their ability to acquire new knowledge, to change behavior, and subsequently redefine themselves in their new social context (Meleis, Sawyer, Im, Hilfinger Messias, & Schumacker, 2010).
Research Purpose
The purpose of the study was to explore IENs’ experiences and knowledge of interprofessional collaboration. Insight regarding IENs’ experiences with interprofessional collaboration will offer guidelines for education and training for IENs’ to become active members of the interprofessional team. The research question is: What is the knowledge and experience of interprofessional collaboration for IENs participating in a bridging program?
Methods
A concurrent triangulation mixed methods design guided this study (Creswell & Clark, 2017). Approval for the study was granted from the College’s Research Ethics Board.
All students enrolled in the Practical Nursing Program for IENs at a community college in Toronto, Canada (N=110) were invited to participate in the study in fall 2017 and winter 2018 semesters. Informed consent was obtained prior to study participation. After completing a survey, participants were invited to participate in interviews regarding their understanding and experiences of interprofessional collaboration. The interviews were conducted within 2 weeks following completion of the survey. Participants were interviewed during the first semester of their enrollment in the program, and prior to the discussion of interprofessional collaboration in their courses. A semi-structured interview guide was used (see Table 1). All interviews were audio-recorded and transcribed verbatim. Interviews were continued until data saturation was achieved (Polit & Beck, 2017).
Table 1. Interview Guide
- Please describe to me your understanding and/or experience of interprofessional collaboration.
- What does interprofessional collaboration mean to you?
- Think about the last time you worked as a nurse. How did it look?
- Could you please tell me more about it? Can you give an example?
- Please describe to me how, where and when you learned about interprofessional collaboration.
- Could you please tell me more about it? Can you give an example?
- Think about the last time you worked as a nurse. How did it look?
- Could you please tell me more about it? Can you give an example?
- What was your perception of interprofessional collaboration before you learned about it?
- Why did you think / feel that way?
- What was your experience like with interprofessional collaboration with respect to other team members? Please describe to me your experience working with other members of the health care team in your previous nursing role outside of Canada.
- Could you please tell me more about it? Can you give an example?
- Think of a time in the past when you experienced this and tell me what happened. Who was there? What did people say or do?
- Think about the last time you worked as a nurse. How did it look?
- Could you please tell me more about it? Can you give an example?
- What was your experience like with interprofessional collaboration with respect to other nurses in your team? Please describe to me your experience working with other nurses in your team in your previous nursing role outside of Canada.
- Could you please tell me more about it? Can you give an example?
- Think of a time in the past when you experienced this and tell me what happened. Who was there? What did people say or do?
- Think about the last time you worked as a nurse. How did it look?
- Could you please tell me more about it? Can you give an example?
- What was your feeling towards interprofessional collaboration? Please elaborate.
- Why did you feel / think that way about interprofessional collaboration?
- Are you aware that interprofessional collaboration is an expectation for registered practical nurses in Ontario?
- How did you become aware of it? How do you feel about this?
- How do you think will your previous education and/or experience help you in engaging in interprofessional collaboration?
- What kind of supports, do you think, will help you engage better in interprofessional collaboration here in Ontario?
- Do you need any help to better understand your role in working with other members of the health care team in Ontario?
- What kind of help would you need? Why do you say so?
Interprofessional collaboration was measured with the Assessment of Interprofessional Team Collaboration Scale IIInterprofessional collaboration was measured with the Assessment of Interprofessional Team Collaboration Scale II (AITCS-II) (Orchard, Pederson, Read, Mahler, & Laschinger, 2018). This 23-item tool uses a 5-point Likert scale and has 3 subcategories: partnership, coordination and cooperation (Orchard et al., 2018). Construct validity has been established through exploratory and confirmatory factor analysis and Cronbach’s alpha ranged from .89 to .96 in previous studies (Caruso et al., 2018; Orchard et al., 2018). Descriptive analysis was performed using SPSS Version 22 (IBM, 2013).
Data analysis was guided by the research question and thematic analysis was used in analyzing the interview data. Data collection and analysis occurred concurrently. Four team members coded the interview data with descriptive labels to identify relative elements using ATLAS.ti (Verdion 8, ATLAS.ti GmbH). This coding was used to form categories which led to theme development (Braun & Clarke, 2006; Thomas, 2006).
Results
Survey
Eighty-seven IENs (79% response rate) participated in the survey. The average age was 37 years with an average of 7.25 years living in Canada. Over half of the participants had a bachelor’s degree with 68% reporting an undergraduate degree in nursing, 16% an associate degree/two-year diploma, and 7% a master’s degree. Most of the participants’ completed their initial nursing education in the Philippines, India, and China.
Descriptive statistics were calculated for all survey items within the 3 subscales of partnership, cooperation, and coordination. Orchard et al. (2018) recommends a mean cut-off score of 4 within each sub-scale to determine when collaboration occurs. The mean item scores for each of the subscales range from 3.99 (coordination) to 4.34 (cooperation, indicating that collaboration occurs most of the time to always (see Table 2).
Table 2. Assessment of Interprofessional Team Collaboration Scale II Results
|
Survey item |
Mean (SD) |
|
|
Partnership When we are working as a team all of my team members… |
||
|
1 |
include patients in setting goals for their care |
4.66 (.64) |
|
2 |
listen to the wishes of their patients when determining the process of care chosen by the team |
4.35 (.81) |
|
3 |
meet and discuss patient care on a regular basis |
4.25 (.84) |
|
4 |
coordinate health and social services (e.g. financial, occupation, housing, connections with community, spiritual) based upon patient care needs |
3.88 (1.03) |
|
5 |
use consistent communication with to discuss patient care |
4.44 (.82) |
|
6 |
are involved in goal setting for each patient |
4.41 (.82) |
|
7 |
encourage each other and patients and their families to use the knowledge and skills that each of us can bring in developing plans of care |
4.15 (.98) |
Assessment of Interprofessional Team Collaboration Scale II results (Orchard et al., 2018).
Interviews
A total of 9 interviews lasting 10-30 minutes were conducted. Two themes emerged from the interviews: working together as nurses and valuing interprofessional collaboration.
Working together as nurses
Participants repeatedly described working together, generally defined as cooperating and collaborating with each other. However, several participants’ descriptions of interprofessional collaboration referred more to intraprofessional collaboration. Participants described working as interprofessional team members in a team that included only members from nursing. They described nurses working together and communicating with each to meet the needs of the patient. One participant stated: “…the head nurse…briefs us on how the day’s going to go out. She gives us the assignment…when we get our separate assignments, we perform our nursing duties…and then the (head nurse) assesses how they (were done)”
Another participant also described this intraprofessional teamwork: “Among the staff nurses, we were all together. We used to help each other out and when it comes to the nursing supervisor, they are more focused on finding out our mistakes and stuff like that.”
Several participants described the need to help each other out with busy work assignments, and in these instances, they were referring to their nurse colleagues. When asked about her experience with interprofessional collaboration, one participant stated: “…back home we (have) team work…we are all joined. If I finish my work, if I see that maybe (another nurse) is struggling, she has not completed the assignment…I’ll go volunteer (to help).”
Valuing interprofessional collaboration
...interprofessional collaboration is crucial in order to solve problems in a manner that respects other team members’ opinions and views.Participants described how interprofessional collaboration is crucial in order to solve problems in a manner that respects other team members’ opinions and views. Through collaboration, participants reported that one is able to learn different ways of providing holistic care to patients.
As one nurse described:
“I think it’s very crucial because…when (people) work in coordination when they help each other, because the nurse’s view of the patient is different, (the) physician’s view is different, (the) physiotherapist views different aspects of a client. So, when they discuss among (each other), they can (provide) holistic care to the client. They can identify the different needs. I think providing care will be much better.”
In addition, participants described how being part of an interprofessional team increased their confidence as nurses. To illustrate the value of interprofessional collaboration, a participant compared working in two different countries:
“I have worked…in India…and also in…Saudi Arabia. In India, nurses are like subordinates to all (the) other professionals, like doctors or (the) physiotherapist…(the other professionals) just (write) orders and we have to carry it out. We were not given much freedom to discuss the patient’s condition or status…but while I was working in Saudi Arabia, the scenario was different, because there the doctors as well as the physiotherapist…(consulted) with (nursing). How we feel about the client, what is the current status, is it improving, how is the progress. Everything was discussed on a daily basis with us, so I felt more confident and I felt like I was involved more with the care than when I used to work in India.”
Another participant described the personal value of interprofessional collaboration when she stated: “(Interprofessional collaboration) enhanced my skills, my knowledge and also my attitude…”. Participants also described how interprofessional collaboration improved patient care. When one participant was asked about her perception of interprofessional collaboration, she stated: “I think it’s awesome because…nurses (cannot) cover everything, right? We have to cooperate with the (interprofessional team) to improve the (clients’) quality of life…”
All of the participants described the importance of cooperation with others in order to learn new ideas and to meet the needs of patients. One participant noted:
“I believe (that) we have to respect each other. We have to give time to express (an)other team (member’s) opinion then we have to involve the client or client‘s family to discuss … the problem and if we work together then we will solve any kind of problem.”
Discussion
The survey results indicate that the participants engage in interprofessional collaboration most of the time to always. This finding was consistent across each of the 3 subscales: partnership, cooperation, and coordination, although it was slightly higher for partnership and cooperation than coordination.
Interestingly, the participants interchanged interprofessional collaboration with intraprofessional collaboration during their interviews. Lankshear and Limoges (2018) define intraprofessional collaboration as nurses, with different designations, working together to achieve optimal patient and health system outcomes. The participants spoke about their experiences from a nurse-to-nurse perspective rather than as a collaborative team of different health care professionals.
Participants’ understanding of interprofessional collaboration as being intraprofessional collaboration may be due to the differences in health care models and practices of health care teams worldwide. As noted, the participant’s ratings were slightly lower for the coordination section of the survey. The items in this section relate to the development of a team, selecting a leader, and core values within a team. These are practices that may be more specific to an interprofessional team made up of professionals from different professions, as opposed to intraprofessional teams comprised of nurses that were described in the interviews.
In addition, the survey items in the partnership and cooperation sections closely align to how nurses work when collaborating in an intraprofessional manner. It is possible that the IENs’ understanding of interprofessional collaboration as congruent with intraprofessional nursing practice was influenced by the manner in which care was delivered in their home country (Limoges, Jagos, Lankshear, Madorin, & Witmer, 2018).
IENs may lack the experience of collaborating with other health care professionals to manage patients (Sherwood & Shaffer, 2014). In a study of IENs working in Canada, Atack et al. (2012) found that participants reported that in their home countries, nurses were unlikely to question workplace policies and procedures based on convenience of medical staff and doctors’ orders. These experiences likely influence IENs’ understanding of interprofessional collaboration.
In addition, IENs may be disadvantaged in understanding interprofessional collaboration as it is used in the North American practice setting as they may have minimal experience practicing in their new setting (Limoges et al., 2018). Parry and Lipp (2006) report that a challenge that many IENs face when integrating into the workforce is understanding the concept of interprofessional teams and asked for it to be included in their bridging program. Effective bridging programs not only prepare international professionals for licensure but also enhance employment opportunities (Neiterman et al., 2018). For IENs to successfully transition into their new work environment, it is necessary for bridging programs include a focus on interprofessional education and prepare students for interprofessional collaboration. This is of particular importance as the world faces an ongoing shortage of nurses, and developed countries continue to recruit IENs to supplement their workforce (OECD, 2016).
...role transition is not a linear event and is influenced by education and experience that impacts IENs’ ability to transition into new roles As Meleis’ Transition Theory posits, role transition is not a linear event and is influenced by education and experience that impacts IENs’ ability to transition into new roles (Meleis, 2010). Appropriate education and experiential training should be incorporated into bridging programs to build on IENs’ previous learning and to help them become active members of the interprofessional team.
A limitation of this study is that we did not collect data related to IENs’ previous experience in health care settings. There is growing evidence of greater interprofessional collaboration on rehabilitation units, as compared to acute care settings (DiazGranados, Dow, Appelbaum, Mazmanian, & Retchin, 2018; Petit dit Dariel, & Cristofalo, 2018). This data may have provided additional insights into participants’ experiences with interprofessional collaboration in relation to their practice setting. Furthermore, another limitation is that the study was conducted with a small sample within one institution in one academic year. However, despite the small sample size, this study provides us beginning, relevant information that can be used in future studies exploring IENs’ experiences with IPC.
Conclusion
The study findings provide insight into the experiences of a cohort of IENs with interprofessional collaboration and may be used to inform curriculum planning and development in IEN bridging programs. Ensuring that interprofessional education is included in bridging programs will prepare IENs for new health care settings. In addition, further research is needed to better understand how bridging nursing programs can contribute to IENs’ knowledge and experience of interprofessional collaboration.
Authors
Balakumaran Mahathevan, RN, MScN
Email: kmahathevan@centennialcollege.ca
Balakumaran Mahathevan is faculty and the Program Coordinator for the Practical Nursing program for Internationally Educated Nurses (IENs) at Centennial College. He has been working with IENs for the past 10 years and understands the challenges that IENs endure during their transition into the workforce. He is currently the project lead at the college looking at strategies on how to incorporate interprofessional education and work readiness resources for the IENs.
Jasmine Balakumaran, RN, MScN
Email: jbalakumaran@centennialcollege.ca
Jasmine Balakumaran is faculty in Centennial College in the collaborative baccalaureate nursing degree program with Toronto Metropolitan University and George brown College. She has taught in the classroom and clinical setting with international nursing students at Centennial College. In addition, she has engaged in many research projects, activities, and curriculum development for international nursing students.
Edward Cruz, RN, PhD
Email: Edward.Cruz@uwindsor.ca
ORCID ID: 0000-0002-6738-3072
Edward Cruz is an internationally educated nurse who has developed a program of research in the areas of health human resources and nursing education. He is currently Co-Chair of the Partners in Integration and Education of Internationally Educated Nurses (Canada), and is an assistant professor in the Faculty of Nursing at the University of Windsor.
Jennifer Innis, NP, PhD
Email: jinnis@centennialcollege.ca
ORCID ID: 0000-0002-3496-4428
Jennifer Innis NP, PhD is an assistant porfesor, teaching stream at the University of Toronto. She has taught international healthcare professionals in the Bridging to University Nursing program at Centennial College. In addition, she has been involved in numerous interprofessional educational iniatives.
Natashia Deer, RN, MN
Email: ndeer@centennialcollege.ca
Natashia Deer RN, MSc is Chair of Nursing Programs at Centennial College. Within this role, she oversees the practical nursing program for International Educated Nurses. Her experience also includes program coordination, curriculum development and online learning.
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