Internationally educated nurses (IEN) are a group who reflect Canada’s diverse population as a result of rising immigration trends. There is increasing diversity of the general population in Canada and health service disparities exist. Reducing these disparities among the healthcare workforce and the patients they care for is important to meet language and other cultural needs of patients from different ethnic backgrounds. This article describes a study that examined internationally educated nurses’ transition experiences in the field of nursing with the objective of describing their unique contributions to the patient care experience. A review of the literature provides background information, followed by the study methods, findings, and discussion. Descriptive phenomenology guided this qualitative study that included 11 participants. Findings from this study illustrate how IENs perceive themselves as an asset to nursing and patient care. Implications for the future of nursing education, practice, research, and administration are offered. Healthcare providers that reflect the diversity of Canada’s population and can offer unique cultural perspective have potential to improve the patient experience during a hospital stay.
Key Words: internationally educated nurse, integration, nurse transition, nurse recruitment, workplace diversity, patient experience, culture, culturally competent care, phenomenology, qualitative methods
Recruiting nurses from other nations has become a global practice. Recruiting nurses from other nations has become a global practice. In Canada, early in the new millennium the Canadian Nurses Association (CNA, 2002) projected a nursing shortage of approximately 78,000 nurses by 2011. Near the same time period in the United States, Martiniano, Salsberg, McGinnis, and Krohl (2004) projected a shortage of approximately one million registered nurse positions by 2012. Internationally educated nurses (IENs) are helping to fill some of these gaps in nursing personnel.
The International Council of Nurses (ICN) strongly supports provision for both culturally and clinically appropriate care, by diverse providers (ICN, 2013). Ontario, Canada is home to 10,850 IENs, representing 11.6% of the nurses in Ontario (Canadian Institute for Health Information, 2010) compared to the overall Canadian average of 8.3%. Only in British Columbia is the percentage higher, at 16.4%. Alberta ranks third with 10%. India, the Philippines, and the United States remain high source nations from which IENs have emigrated, representing 35.7%, 16.6%, and 11.8% respectively, in 2012 (College of Nurses of Ontario, 2015).
The IEN group reflects Canada’s rising trend of a diverse population. For instance, the 2011 census showed that Canada’s foreign-born population was approximately 6.7 million people. Recent immigrants who came to Canada between 2006 and 2011 comprise 17.2% of Canada’s foreign-born population (Statistics Canada, 2011a). Furthermore, 19.1% of Canada’s total population identified themselves as a member of a visible minority group, representing nearly 6.3 million people (Statistics Canada, 2011b). If current immigration trends continue, Statistics Canada (2007) experts predict that by 2017 about 20% of the total population will be in a visible minority.
...health service disparities exist... both for the IENs and for minority patients receiving healthcare. Despite increasing diversity of the general population in Canada, health service disparities exist (Lai & Chau, 2007; Premji & Etowa, 2012). These disparities exist both for the IENs and for minority patients receiving healthcare. It has been documented that IENs whose mother tongue is not English or French (Canada’s official languages) may face real or perceived challenges to effectively communicate with patients and members from other patient care teams, including their nursing colleagues (Tregunno, Peters, Campbell, & Gordon, 2009; Yi & Jezewski, 2000). From the patient perspective, linguistic minorities (those not proficient in English or French) are likely to have lower self-reported health status than their counterparts (Pottie, Ng, Spitzer, Mohammed, & Glazier, 2009). Also, research has shown that ethnic and linguistic minorities are likely to have lower levels of health service utilization (Chen, Kazanjian, & Wong, 2009; Lai & Chau, 2007; Lasser, Himmelstein, & Woolhandler, 2006) and healthcare service satisfaction (Lasser et al. 2006). Cultural barriers between patients and providers can also become safety issues in the healthcare setting (College of Registered Nurses of Nova Scotia [CRNNS], 2006; CNA, 2010).
Thus, there is a need to reduce such disparities both among healthcare providers and the patients for whom they care. This may be accomplished in one way by facilitating a successful transition of foreign healthcare providers and taking advantage of the diverse perspectives and skills that IENs can bring to the healthcare setting. Increasing the diversity of the Canadian nursing workforce promotes the provision of culturally competent nursing care and may help to meet language and other cultural needs of patients from different ethnic backgrounds (Matiti & Taylor, 2005; Omeri & Atkins, 2002). This article describes a qualitative study in the tradition of phenomenology that examined internationally educated nurses’ transition experiences within different work specialties in the field of nursing. One objective, the focus of this discussion, was to describe their perceptions of their unique contributions to the patient care experience.
Review of Literature
Lasser et al. (2006) compared access to care, health status, and health disparities both in Canada and the United States and findings suggested racial differences in access to care in both countries. Comparing the white and non-white participants in their study, the researchers stated that “non-white (participants) were less likely to receive treatment for depression; less likely to have received a Pap test [screening for early cancer detection] within the past three years; and had lower perceived quality of care and satisfaction than did whites” (p. 1303). Liu, So, and Quan (2007) suggested that health service disparities are probably influenced by a mismatch of cultural and linguistic specificities between the healthcare service provider and the patient. Cultural disparities amongst healthcare providers and its effect on patient access to healthcare services are likely to continue if the support for diversity amongst health service providers is neglected.
Additional knowledge about the contributions of IENs to the patient experience may help to support recruitment initiatives that can further increase the diversity of healthcare workforces in Canada and other countries. The need for a diverse representation (e.g., a workforce variety of race, ethnicity, gender) amongst employees on all levels within healthcare organizations is not a novel idea (Dreachslin, 2007; Collins, 2004; Etowa, Price & Debs-Ivall, 2011; Srivastava & Craig, 2007). Etowa et al., (2011) proposed that challenges associated with promotion, support, and sustenance of diversity in the workplace is due to lack of understanding of challenges to promoting workplace diversity. The authors called on healthcare organizations to “recognize, respect, and leverage ethno-cultural diversity including finding ways to attract, recruit, educate, support an increasingly diverse employee base in ways that maximize both operational effectiveness and facilitate quality service delivery” (p. 76).
Recruitment of nurses from both under developed and developed nations for work in the West is a global practice (Australian Health Ministers’ Conference, 2004; Konno, 2006; Martiniano et al., 2004). But, benefits of recruiting IENs and having a diverse workforce to provide nursing care to patients from different nationalities and ethnic backgrounds are likely to be underutilized when cultural diversity is not facilitated amongst healthcare team members and patients’ local communities. Including diversity as part of workforce strategic planning within healthcare organizations is one step towards supporting recruitment of IENs and maximizing their potential contribution toward provision of culturally competent care. For instance, IENs might educate peers about minority patients and their needs and/or lead diversity initiatives that address cultural competence.
Understanding the IENs’ unique contribution to health service delivery and supporting their effective integration at their places of work is one approach to sustain and improve access to culturally competent nursing care for the Canadian population. Additional knowledge about the contributions of IENs to the patient experience may help to support recruitment initiatives that can further increase the diversity of healthcare workforces in Canada and other countries. Greater understanding may also help inform the transition that these nurses make as they learn to practice in a foreign country, and help minimize challenges and maximize the unique knowledge and skills that they bring.
Study Purpose and Setting
The purpose of the qualitative study was to examine IENs’ transition experiences within different work specialties in the field of nursing. One objective was to describe their perceptions of unique contributions to patient care experience and the promotion of culturally competent nursing care. This article will describe the study and findings related to that objective.
The Ottawa Hospital, a major teaching hospital in the capital region of Canada, was the setting for this study. This facility describes the patient experience as one of its strategies toward achieving its corporate vision of providing world class care, exceptional service, and compassionate care for all patients (Ottawa Hospital, 2013). Attention to and development of specific strategies that promote a positive patient experience are valuable for healthcare organizations and communities that serve patients from different ethnicity and cultural background.
Descriptive phenomenology, adopted from the classical Husserlian phenomenological tradition (1913) guided this qualitative study. Recently, descriptive phenomenology as a discipline has been defined as “how objects are constituted in pure consciousness, setting aside questions of any relationship of the phenomenon to the world in which one lives” (Wojnar & Swanson, 2007, p. 173). Effective bracketing was attempted through strict journaling activities to minimize researcher bias, in order to capture thoughts and decisions made throughout the research process, and to ensure that identified themes reflected the lived experience of the participants.
For the purpose of the study, I defined IENs as practicing registered nurses in Ottawa who received their basic nursing education outside of Canada. Eligibility criteria also included a minimum of one year to a maximum of five years post-RN licensure practice.
Following approval from the University of Ottawa Research Ethics Board, eleven IENs were interviewed. Recruitment of study participants was initiated through purposive sampling and facilitated through a snowball sampling technique using local nursing networks (Morse, 1995). Study participants were restricted to currently practicing registered nurses in Ontario to maintain a common scope of practice amongst all study participants. Sandelowski (2000) describes this strategy as one that allows a researcher to search for participants who are likely to have mutual and distinct experiences, but across a broad range of different participants. Maximum variation through purposive sampling is evident in the diversity of IENs recruited. For example, I recruited IENs who were registered nurses (RN) of differing ethnicity, age, place of nursing education, and type and location of current nursing practice, with an ability to speak fluent English about their experiences as nurses in Canada.
Study participants included nurses who were trained from countries in Africa, Eastern Europe, Asia, and South and North America. All study participants were female, had landed-immigrant status (i.e., immigrants who do not have their citizenship status but have legal permanent residency status in Canada.), and all but one was married. They ranged in age from 25 to 47 years old with an average age of 34 years. This is substantially lower than the overall average age of 45.5 years for Ontario registered nurses (CNO, 2013).
Data Collection and Analysis
Data collection was accomplished through in-depth, semi-structured interviews which were recorded and transcribed verbatim; notes from a follow up discussion during data analysis and validation; and a personal research journal. Each face-to-face interview lasted approximately one hour and was comprised of open-ended questions and active listening as participants told their stories.
Data analysis was based on descriptive philosophical assumptions with emphasis on describing universal essences (Lopez & Willis, 2004; Wojnar & Swanson, 2007). This enabled me to remain receptive to data collected and their meanings. Maintaining a journal record served as an audit trail that ensured the trustworthiness of the data. Other strategies proposed by Lincoln and Guba (1990), such as critical reflection and member checking, were used to ensure credibility, transferability, dependability, and confirmability.
Upon completion of each interview, I critically reflected on the interview responses. I extensively reviewed my transcripts, field notes, and journal entries in an attempt to expose what was said and heard, and its meaning, enabling me to keep track of major themes and vital non-verbal cues. I attained descriptive validity through member-checking by validating the identified groups of themes and meanings with the IEN participants through a follow-up discussion that lasted approximately 30 minutes (Colaizzi, 1978).
During the data analysis phase of this study, I repeatedly read and listened to participant narratives, highlighted sections of transcripts, proposed ideas about the meaning of narrations, clarified and validated the proposed meanings, and organized meanings into groups of themes. Quality audits were conducted by reading each transcript while simultaneously listening to the audiotape; any discrepancies were corrected on the transcript. Audiotapes were reviewed three times for subtle expressions not readily captured in the written word and each transcript was reviewed several times to become fully immersed in the data and observe the emerging themes.
Findings: IENs’ Cross-Cultural Competence and Unique Contributions
Describing the IENs’ experiences with caring for patients of different cultural backgrounds illustrates how diversity amongst nurses themselves will likely allow providers to relate positively with a culturally diverse patient population. This section will describe, using direct quotations, the IENs’ unique contribution to promoting a culturally competent care environment for patients from diverse backgrounds. Pseudonyms are used for participant quotes. The Table briefly summarizes the IENs’ contributions, including some that are described here and a few that are not.
IENs are an asset to nursing and patient care in that they represent different nations and foreign born patients are likely to identify with them culturally and linguistically, at least to some extent. Describing the IENs’ experiences with caring for patients of different cultural backgrounds illustrates how diversity amongst nurses themselves will likely allow providers to relate positively with a culturally diverse patient population. This may be true particularly for those patients with whom they share the same cultural background. The selected quotes below illustrate unique contributions that several study participants described related to language and cultural practices.
Language. Some IENs acknowledged how their fluency in another language was a positive feature for the nursing team at their workplace. Jane’s knowledge of other languages, like Cantonese, enabled her to contribute positively to patient care by being able to communicate a certain family’s needs to her nursing colleagues. She explains:
With a family from [China], they will not ask for help even if they need it. This family expected the nurses to provide care to their loved one, but didn’t since they [the nurses] saw family members always present and they provided care to their loved one [the patient]. Even though they were fatigued from exhaustion, they were afraid to ask for help. In patient’s culture, they don’t ask for help to care for their loved ones. After talking to the family in their native language, I communicated this cultural barrier with other nurses on the floor, and they became more aware of this cultural difference [Jane].
Brenda described how her knowledge of three Eastern European languages was helpful for patient care because she was able to communicate with both patients and their families who spoke these same languages, which increased their understanding of the care and treatment plan and eased anxiety patients had about the hospital stay. She also credits her calm personality as beneficial to patient care. Brenda narrates “I have the knowledge of languages that are needed in patient care…I speak languages from three Eastern European countries [Russia, Croatia, and Slovakia]. This contributed to quality patient care on the unit.” Similarly, Jessie’s quote illustrates how her interaction with a patient from her country of origin [Japan] helped calm the worries and fears of both patient and family members:
We had a patient from [Japan] coming for an operation. As soon as I greeted the patient and family in our maternal language, they were so happy and relaxed. [The patient’s] daughter left her work that day because she was going to translate during the procedure; she was happy I was able to speak our language, and she was able to return to work that day.
Cultural practices. Some IENs felt their life and work experiences of practicing nursing in another country facilitated and enriched their understanding of certain cultural practices. Jerry described her unique contribution to the nursing team in Canada:
I bring knowledge of international nursing after working in [Russia] and in [Israel]. My knowledge about multicultural aspects enriches the patient care experience; I understand different cultures, different approaches to care and life span. Because of my twenty-five years of nursing, I am patient with differences. Nurses here [referring to Canadian educated colleagues] need to be more calm.
These findings suggest significant insights as to how IENs’ distinct contributions can positively influence the care nurses provide to all patients in the healthcare system. These IENs mobilized their culture specific influences related to language and cultural practices as a resource to transcend new experiences and the challenges associated with integrating into a different healthcare system and work environment.
Table. Summary of IENs’ Contribution to Culturally Competent Nursing Care
Major Theme: IENs cross-cultural competence and unique contributions (describes how IENs promote culturally competent work environments to patients from different ethnic backgrounds)
IEN multi-lingual benefits to the care team
IEN multi-lingual benefits for patients/families from different ethnic background
...their fluency in other languages resulted in better patient and family experiences with the healthcare system... This study has contributed a new perspective to the discourse of IEN transition experiences into healthcare systems in the West by describing their perceptions of distinct contributions they bring to the Canadian healthcare system. For example, their fluency in other languages resulted in better patient and family experiences with the healthcare system; explaining procedures and the plan of care to patients and families in their mother tongue, rather than in English, helped alleviate anxiety about their hospital stay. In another instance, their ability to both translate and explain unique cultural behaviors of patients to their nursing colleagues resulted in the provision of culturally competent nursing care.
Distinct abilities like fluency in multiple languages may promote a sense of value for IENs both in general at their places of work and specific to patient care. No research study was identified in the literature that described IENs' unique contributions and subsequent effects on patient experiences. However, Lai & Chau’s (2007) quantitative study examining predictors of health service barriers for older Chinese immigrants in Canada suggest parallel findings in that Chinese immigrants were more likely to access health services when they experienced little language barriers between patient and their respective health service provider. Lai and Chau stated that the “…cultural gap between service providers and service users has played a key role in access barriers” (2007; p. 64). With an increasingly diverse Canadian population due to immigration, there is clearly a need for more studies that explore the unique contributions IENs bring to the patient care experience in order to inform effective integration practices and policies for IENs within Canada’s healthcare system.
...there is clearly a need for more studies that explore the unique contributions IENs bring to the patient care experience... The CNA describes cultural competence as “a set of congruent behaviors, attitudes among professionals, and enables them to work efficiently in cross-cultural situations” (CNA, 2010, p. 1). In the same document, cultural diversity is defined as the “variation of cultural factors between people, not simply referring to differences but rather implies difference from the majority, which is assumed to be the norm” (p.1). As licensed nurses in Canada, IENs provide nursing care to patients from different ethnic backgrounds and are likely to promote culturally safe and innovative ideas for practice in nursing, allowing for a recognition of such diversity within the profession. Cultural safety has been defined by the CNA as “a process and an outcome whose goal is to promote greater equity, with a focus on root causes of power imbalances and inequitable social relationships in health care” (2010; p. 1). Promoting culturally diverse nursing teams that include IENs can be a platform for innovative culturally competent care strategies. For example, one instance described in this article demonstrated how IENs informed their Canadian trained nursing colleagues about certain cultural values and behaviors which pertain to the Chinese culture. The CRNNS (2006) suggests that optimal health outcomes can be attained when a patient’s culture is well understood.
Care by some IENs has been identified as a potential source of harm to patients due to their inability to have a strong command of the English language and/or speaking it with a heavy accent (Tregunno, Jeffs, & Campbell, 2007; Tregunno et al., 2009; Yi & Jezewski, 2000). However, a team approach that includes IENs is likely valuable in situations where the cultural values of patients from culturally diverse backgrounds are recognized and effectively communicated by the IENs to other team members.
...studies that examine how IENs can be fully integrated within healthcare systems in ways that very specifically improve the patient experience are necessary. These findings have important implications for the future of nursing education, practice, research, and administration in the following ways. With respect to addressing education and practice implications, IENs in this study expressed a need for Canadian-educated nurses to understand the different cultural behaviors unique to IENs (e.g., being less expressive verbally). Ongoing hospital-run educational sessions, interactive workshops, and self-directed learning designed to help nurses integrate into their places of work can highlight the significance of certain cultural behaviors which are likely to be of importance not only to IENs but also to their Canadian-educated nursing colleagues. These educational initiatives can improve the understanding of different cultural norms and practices.
Nurse administrators can encourage and enable IENs to use their talents to support productivity by valuing their expertise and contribution to the patient care experience during hospitalization. Even though findings from this study have added to the overall understanding of IENs’ experiences with patient care by uncovering their distinct contributions, research studies using an interpretive approach are needed to further explore the distinct contribution of IENs within the context of patient care experiences during hospitalization. Also, studies that examine how IENs can be fully integrated within healthcare systems in ways that very specifically improve the patient experience are necessary.
Nurse administrators can encourage and enable IENs to use their talents to support productivity by valuing their expertise and contribution to the patient care experience during hospitalization. One example might be to create an incentive recognition program whereby unique patient care interventions, such as those provided by the nurses in this study (e.g., language interpretations) can be highlighted as a resource useful to other areas of the hospital. Promotion of a positive workplace environment as a result of such recognition initiatives, in which each individual’s contribution is valued, will exist when all nursing staff has the support of their respective supervisors.
Recruiting IENs solely to manage nursing shortages is shortsighted in the sense that these nurses can offer much more to a positive patient/family experience. These strategies can foster better integration experiences for IENs within the Canadian healthcare system. They also support workplace diversity within healthcare organizations and help to meet the distinct needs of patients from different cultural backgrounds. Recruiting IENs solely to manage nursing shortages is shortsighted in the sense that these nurses can offer much more to a positive patient/family experience. Their contributions toward culturally competent care should not be underutilized.
The majority of IENs in this study worked in inpatient hospital settings. Therefore complete descriptions from IENs who work in the community at health centers which serve diverse populations are omitted.
Reflecting appropriate cultural diversity in providers may also improve patient access and the perception of quality hospital service, particularly from patients of different cultural or ethnic backgrounds. Diversity amongst nursing teams is necessary for inclusive hospital service delivery. Healthcare organizations should reflect not only Canada’s diverse population, but the backgrounds of healthcare providers. Reflecting appropriate cultural diversity in providers may also improve patient access and the perception of quality hospital service, particularly from patients of different cultural or ethnic backgrounds. Maximizing the unique contributions of healthcare providers at all levels who provide culturally competent care to those who access inpatient services is likely to improve the quality of hospital services, and thus the overall patient experience.
Ndolo Njie-Mokonya, MScN, RN
Ndolo Njie-Mokonya completed her Master’s of Science in Nursing degree at the University of Ottawa (U of O) in Ottawa, Ontario. Her research interests center on effective health human resource utilization, distribution, and integration within the Canadian healthcare system. She is a clinical nurse educator with the Ottawa Hospital and a part-time professor at the U of O. She serves on various faculty committees within the university and plans to pursue a doctoral degree in the future.
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