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The experience of China-educated nurses working in Australia: A symbolic interactionist perspective
Yunxian Zhou
BN (Nursing), MM (Medicine)
A thesis submitted in partial fulfilment of the requirements for the degree of
Doctor of Philosophy
School of Nursing and Midwifery, Faculty of Health
Institute of Health and Biomedical Innovation
Queensland University of Technology
Brisbane, Australia
February 2010
I
Abstract Transnational nurse migration is a growing phenomenon. However, relatively little
is known about the experiences of immigrant nurses and particularly about non-
English speaking background nurses who work in more economically developed
countries.
Informed by a symbolic interactionist framework, this research explored the
experience of China-educated nurses working in the Australian health care system.
Using a modified constructivist grounded theory method, the main source of data
were 46 face to face in-depth interviews with 28 China-educated nurses in two major
cities in Australia.
The key findings of this research are fourfold. First, the core category developed in
this study is reconciling different realities, which inserts a theoretical understanding
beyond the concepts of acculturation, assimilation, and integration. Second, in
contrast to the dominant discourse which reduces the experience of immigrant
nurses to language and culture, this research concludes that it was not just about
language and nor was it simply about culture. Third, rather than focus on the
negative aspects of difference as in the immigration literature and in the practice of
nursing, this research points to the importance of recognising the social value of
difference. Finally, the prevailing view that the experience of immigrant nurses is
largely negative belies its complexities. This research concludes that it is naïve to
define the experience as either good or bad. Rather, ambivalence was the essential
feature of the experience and a more appropriate theoretical concept.
This research produced a theoretical understanding of the experience of China-
educated nurses working in Australia. The findings may not only inform Chinese
nurses who wish to immigrate but also contribute to the implementation of more
effective support services for immigrant nurses in Australian health care
organisations.
II
Key Words Immigration
Nurses
Immigrant nurses
Chinese nurses
Experience
Australia
Symbolic interactionism
Grounded theory
III
Table of Contents Abstract........................................................................................................................ I
Key Words .................................................................................................................. II
Table of Contents.......................................................................................................III
List of Figures.........................................................................................................VIII
Statement of Original Authorship..............................................................................IX
Acknowledgements.....................................................................................................X
Chapter 1 Introduction.................................................................................................1
1.0 Introduction........................................................................................................1
1.1 Research background.........................................................................................1
1.2 Research question and aims...............................................................................3
1.3 Significance of the study ...................................................................................3
1.4 Role of the researcher ........................................................................................4
1.5 Definition of terms.............................................................................................6
1.6 Structure of the thesis ........................................................................................7
Chapter 2 Literature Review......................................................................................11
2.0 Introduction......................................................................................................11
2.1 Labour migration .............................................................................................11
2.1.1 Driving forces ...........................................................................................11
2.1.2 Facilitating factors ....................................................................................12
2.1.3 Global situation of labour migration.........................................................14
2.2 Nurse migration ...............................................................................................15
2.2.1 Nurse shortage ..........................................................................................15
2.2.2 China as a source for nurse recruitment ...................................................21
2.3 Issues related to nurse migration .....................................................................22
2.3.1 The ethics of overseas recruitment ...........................................................22
2.3.2 Safety and quality of nursing care ............................................................23
2.3.3 Valuing of overseas nurses .......................................................................24
2.4 Experience of overseas nurses .........................................................................25
2.4.1 Language barriers .....................................................................................26
2.4.2 Cultural issues...........................................................................................27
2.4.3 Difficulties in working relationships ........................................................29
2.4.4 Lack of support .........................................................................................29
IV
2.4.5 Isolation and alienation .............................................................................30
2.4.6 Racism and exploitation............................................................................30
2.4.7 Assimilating ..............................................................................................31
2.4.8 Unequal opportunities, deskilling, and undervaluing ...............................33
2.5 Summary ..........................................................................................................34
Chapter 3 Theoretical Perspective .............................................................................37
3.0 Introduction......................................................................................................37
3.1 General introduction of SI ...............................................................................37
3.2 The pragmatist tradition...................................................................................38
3.3 Intellectual influence of Mead .........................................................................42
3.4 Mead and mind, self, and society.....................................................................44
3.5 Blumer and SI ..................................................................................................47
3.6 Critics and contemporary development of SI ..................................................49
3.7 Key concepts drawn from SI............................................................................53
3.8 Summary ..........................................................................................................59
Chapter 4 Methods.....................................................................................................61
4.0 Introduction......................................................................................................61
4.1 Justification of GT methods.............................................................................61
4.2 GT methods......................................................................................................62
4.2.1 Background of GT ....................................................................................62
4.2.2 Modified constructivist GT.......................................................................63
4.3 Recruitment procedure.....................................................................................66
4.4 Ethical considerations ......................................................................................66
4.5 Sampling strategy.............................................................................................68
4.6 Participant demographics.................................................................................71
4.7 Data generation strategies and sources ............................................................72
4.7.1 In-depth interview.....................................................................................72
4.7.2 Other data sources.....................................................................................75
4.8 Data analysis ....................................................................................................77
4.8.1 Initial coding .............................................................................................78
4.8.2 Focused coding .........................................................................................78
4.8.3 Theoretical coding ....................................................................................79
4.8.4 Memos.......................................................................................................81
V
4.8.5 Translation ................................................................................................82
4.8.6 Theoretical sensitivity...............................................................................83
4.8.7 Treatment of the literature ........................................................................84
4.9 Rigour ..............................................................................................................85
4.10 Summary........................................................................................................89
Chapter 5 Realising....................................................................................................91
5.0 Introduction......................................................................................................91
5.1 It is indeed different.........................................................................................92
5.1.1 More decision making ..............................................................................93
5.1.2 More basic nursing care............................................................................98
5.1.3 Less technical nursing.............................................................................102
5.1.4 No need to consider the cost ...................................................................103
5.2 This is the Western way.................................................................................106
5.3 You are you and I am I ..................................................................................115
5.3.1 We cannot live a life like that .................................................................115
5.3.2 We are among but not in.........................................................................119
5.3.3 It is courteous but not close ....................................................................122
5.4 Summary........................................................................................................125
Chapter 6 Struggling................................................................................................127
6.0 Introduction....................................................................................................127
6.1 Caught between two worlds...........................................................................128
6.1.1 Living between two cultures...................................................................128
6.1.2 To be Chinese or to be Australian ..........................................................137
6.2 You have a lot to learn...................................................................................142
6.2.1 Not knowing ...........................................................................................142
6.2.2 Coming to be recognised ........................................................................148
6.3 This is your own business..............................................................................154
6.3.1 To save face or to ask .............................................................................155
6.3.2 Becoming self-reliant..............................................................................158
6.4 Summary........................................................................................................163
Chapter 7 Reflecting ................................................................................................165
7.0 Introduction....................................................................................................165
7.1 A sense of loss ...............................................................................................166
VI
7.1.1 Loss of life components ..........................................................................166
7.1.2 Loss for the family ..................................................................................168
7.1.3 Loss of career opportunities....................................................................172
7.2 Reconstructing the self...................................................................................176
7.2.1 Leaving pieces of old self behind ...........................................................176
7.2.2 Sense of vulnerability .............................................................................178
7.2.3 Growing through adversity .....................................................................183
7.3 It is hard to go back........................................................................................185
7.3.1 Dream of migrating.................................................................................185
7.3.2 It is not that good ....................................................................................187
7.3.3 It is hard to move backwards ..................................................................189
7.4 Summary ........................................................................................................196
Chapter 8 Reconciling Different Realities...............................................................197
8.0 Introduction....................................................................................................197
8.1 Core category: reconciling different realities ................................................197
8.1.1 The concept of reconciling......................................................................198
8.1.2 The properties of reconciling ..................................................................199
8.1.3 The strategies of reconciling...................................................................201
8.1.4 The selection of the core category ..........................................................204
8.1.5 Situating the core category in existing knowledge .................................205
8.2 Revisiting the literature..................................................................................208
8.2.1 Acculturation, assimilation, and integration ...........................................209
8.2.2 It is not just language and culture ...........................................................214
8.2.3 The potential value of difference ............................................................218
8.2.4 Ambivalence as a theoretical concept.....................................................222
Chapter 9 Conclusion...............................................................................................229
9.0 Introduction....................................................................................................229
9.1 A summary of the research ............................................................................229
9.2 Study limitations ............................................................................................238
9.3 Methodological tensions ................................................................................238
9.4 Implications and recommendations ...............................................................239
9.4.1 Implications and recommendations for practice .....................................240
9.4.2 Implications and recommendations for future research..........................241
VII
9.4.3 Implications and recommendations for policy consideration.................242
References................................................................................................................245
Appendices ..............................................................................................................283
Appendix A: Publication in the Queensland Nurse.............................................283
Appendix B: Publication in the Australian Nursing Journal ...............................284
Appendix C: Participant Information Sheet ........................................................285
Appendix D: Participant Consent Form ..............................................................287
Appendix E: Demographic Information Sheet ....................................................288
Appendix F: Interview Checklist.........................................................................289
Appendix G: Interview Questions for the Seventh Interview .............................290
Appendix H: Examples of Reflexive Journal ......................................................291
Appendix I: Examples of Initial Coding..............................................................292
Appendix J: Examples of Focused Coding..........................................................293
Appendix K: Examples of Memo ........................................................................294
VIII
List of Figures Figure 1. The category and sub-categories of realising .....................................92
Figure 2. The category and sub-categories of struggling.................................128
Figure 3. The category and sub-categories of reflecting..................................166
Figure 4. The core category of reconciling different realities..........................197
Statement of Original Authorship The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the
best of my knowledge and belief, the thesis contains no material previously
published or written by another person except where due reference is made.
Signature: _________________
Date: _____/______/______
IX
X
Acknowledgements Thank you to the China Scholarship Council and Queensland University of
Technology for offering me the scholarship for my PhD study. Thank you, Fiona
Coyer, for having confidence in me, and being patient and encouraging along the
way. Thank you, Carol Windsor, for your intellectual stimulation, dedication, and
ongoing support. Thank you, Karen Theobald, for your knowledge, caring, and
guidance. Thank you to those Chinese nurses for sharing your joys and sorrows.
Thank you to my family for the love, understanding, and unyielding support. Thank
you to my friends for adding fun to my life and making my research journey not so
lonely.
1
Chapter 1 Introduction 1.0 Introduction The objective of the present research was to explore the experiences of China-
educated nurses working in the Australian health care system. The purpose of this
starting chapter is to pose and develop a justification for the research, to set out the
research question and aims, and to situate the role of the researcher within the
research process.
1.1 Research background Driven by developments in technology and communication, and by international
social, political, and economic disparities, the level of global labour migration has
risen significantly in recent years (Arends-Kuenning, 2006). It is estimated that there
were 191 million international migrants worldwide in 2005 which approximates to 3
per cent of the global population (United Nations, 2006). Characteristic of this trend
is the increased proportion of skilled migration, women migration, and migration
from developing to developed countries (Lowell & Martin, 2005; Martin, 2005;
United Nations, 2006).
Nurse migration is part of this phenomenon. Historically, nursing has been depicted
as a “portable” profession or one which enables individuals to move across national
borders (Buchan, Kingma, & Lorenzo, 2005). Until quite recently, however, the
international flow of nurses was largely from one developed country to another and
was relatively short term.
An element of change in migration is the chronic and severe global shortage of
registered nurses (RNs) (Buchan & Calman, 2004). In Canada, it is predicted that the
nursing labour force will be short 78,000 nurses by 2011(Nelson, 2004). In the US, a
nursing shortage of more than 1 million by the year 2020 has been projected (HRSA,
2006). In Europe, it is reported that Germany and the Netherlands both have a
shortfall of 13,000 nurses and Switzerland has a shortfall of 3,000 nurses
(International Council of Nurses, 2003). Importantly, the impact in developing
countries is far more severe. Across Africa there are on average fewer than 50 nurses
2
per 100,000 of the population, less than half the number required to deliver even
basic health care (Eastwood et al., 2005). In the Philippines, the country which
supplies the largest number of nurses to the US and the UK, the nursing shortage is
projected to increase to 29 per cent by 2020 (Marchal & Kegels, 2003).
In Australia, if remedial measures are not put in place, it is estimated that there will
be 40,000 nursing vacancies by 2010 (Karmel & Li, 2002). In seeking to address this
problem, governments and professional organisations have turned to the strategy of
overseas recruitment of nurses (Hawthorne, 2001). Indeed, statistics indicate that
Australia received 11,757 overseas qualified nurses between 1995 and 2000
(Hawthorne, 2001) and the number of overseas nurses almost tripled from 1,188 in
2000 to 3,233 in 2004 (Jeon & Chenoweth, 2007). For the foreseeable future,
overseas recruitment will play a significant role in augmenting nursing numbers in
Australia (Jeon & Chenoweth, 2007).
It is generally supposed that a range of issues come to the fore when immigrant
nurses practice in the Australian health care settings. Despite the demand for their
services, Australian nurses may have ambivalent feelings towards nurses from other
countries (Hawthorne, 2001). Domestic nurses may be unprepared to work with
them and may expect conformity in behaviour and thinking as far as nursing practice
is concerned (Menon, 1992). Australian patients may also exhibit some prejudice
towards other than Australian nurses (Menon, 1992). Immigrant nurses, in turn, may
sense that the expertise and knowledge gained in their own home country is
undervalued (Teschendorff, 1993a, 1993b). Furthermore, it can be reasonably
presumed that immigrant nurses from various backgrounds have their own particular
issues and needs when working in the Australian health care system (Jackson, 1995).
Although the number of overseas nurses entering Australia is rapidly increasing
(Jeon & Chenoweth, 2007), relatively little is known about the experiences of these
nurses, and particularly those migrating from China. Thus, the purpose of this
research was to explore, through the lens of a symbolic interactionist framework, the
experiences of China-educated nurses who are currently employed as RNs in
3
Australia.
1.2 Research question and aims This study focused on the experiences of China-educated nurses working in the
Australian health care system. The theoretical perspective of symbolic
interactionism (SI) informed the research question and aims. The research question
addressed in this study is: How do China-educated nurses construct the meaning of
the experience of working in the Australian health care system?
The aims of this research were to:
• explore the experiences of China-educated nurses in relation to their
employment in the Australian health care system;
• analyse the experiences of China-educated nurses working in the Australian
health care system;
• generate theoretical understandings of the experience of China-educated
nurses working in the Australian health care system; and
• make recommendations on services appropriate to support China-educated
nurses while working in the Australian health care system.
1.3 Significance of the study The significance of this study arises out of the growing number of overseas nurses,
particularly those from non-English speaking backgrounds who are being recruited
to fill the nurse shortage worldwide. It is projected that China, with its very large
labour resource, will become a key player in the export of RNs (Chatterjee, 2005;
Fang, 2007; Pittman et al., 2007; Xu, 2003; Xu & Zhang, 2005).
In spite of an increase in the international movements of labour from China, very
little is known about these immigrants who work in other countries. This research
sought to address this gap in current knowledge concerning China-educated nurses’
experiences of working in the Australian health care system. As Australia represents
an attractive employment opportunity, it is hoped that the findings of this research
will contribute to the preparation of Chinese nurses who seek employment in this
4
country. The findings are of significance for and interest to, not only China-educated
nurses but those in similar situations worldwide.
Understanding the experience of China-educated nurses from an emic perspective is
also critical to any consideration of the strengths and limitations of existing support
services in Australia. Evidence in relation to these issues is scant (Konno, 2006;
Sherman & Eggenberger, 2008). The successful integration of immigrant nurses
would also engender a far more effective multicultural Australian health care system.
Lastly, this research has generated a theoretical understanding of the experience of
China-educated nurses working in Australia. The application of SI added depth to
the analysis. The study contributes to a nascent area of knowledge and it is hoped
that the insights that emerged from this thesis will give rise to further research. The
implications of the study are further developed as part of the review of literature in
Chapter 2.
1.4 Role of the researcher This study adopted a modified constructivist grounded theory (GT) method informed
by a combination of the Glaserian and constructivist positions. The researcher is the
instrument of data generation and analysis in the research. It is thus appropriate that
some reflection is given to the role of the researcher and associated values and
assumptions.
Before I came to Australia to study, I understood that many Chinese nurses were
eager to come and work in developed countries. They considered this a great
opportunity to make life changes. I was one such nurse but always hesitant about
this choice. What does being an immigrant nurse mean? What does the life of an
immigrant nurse look like? Is everyone suitable to be an immigrant nurse? After I
commenced study in Australia, some colleagues and friends back home asked me
about coming to Australia to work as RNs. I really did not know much about this and
I began to feel curious about the experiences of Chinese nurses working in Australia.
5
Before commencing my PhD study in Australia, I had worked as an RN and nurse
educator in China for more than 10 years. I perceived the greatest weakness in
Chinese nursing education to be the dominance of the medical approach and the
minimal presence of the humanities and social sciences. This situation persists partly
because of a shortage of qualified nurse educators in China. It is also the case that
many specialty nursing courses in baccalaureate nursing programs are taught by
physicians who lack a nursing perspective. As a result, nursing curriculum in China
is predominantly physiologically based and disease-oriented (Chan & Wong, 1999).
In addition to this, full-time clinical practice is often arranged for the final year of
the curriculum and is heavily focused on the acute care setting. In most cases,
clinical preceptors serve as clinical instructors and nursing care is often task-oriented
(Anders & Harrigan, 2002). Administratively, nursing departments and more
recently schools of nursing are situated in medical colleges or universities. Further to
this and external to the profession, nursing in China is still perceived, in both
economic and social terms, as a less desirable career (Thobaben et al., 2005).
From a research training perspective, I came from a very quantitative oriented
background. Ontologically, I am a critical realist since I believe in the existence of
an objective world independent of our perceptions. However, I also understand that
this objective world is known through interpretation. Although appreciating the
importance of numbers in research, my past research experience has prompted me to
question the neutral position a researcher could and should adopt with research
participants. That is to say, epistemologically, I believe that the researcher and the
researched influence each other and thus, the research process cannot be value free.
In addition to my Australian study, I undertook two semesters of coursework
towards a Master of Nursing Education in a US university in Thailand. My overseas
student life made clear the reality and difficulties of living in another country. The
cultural differences were acute. In contrast to Western populations, where the focus
is on individual needs, Chinese people place a strong emphasis on collectivism
(Chen, 2001). Hence, Chinese people traditionally are less inclined to express
individual needs unless encouraged to do so. The virtue of family values in Chinese
6
culture usually renders one to sacrifice his or her personal interest if it does not
benefit the family as a whole (Chen, 2001). Confrontation is avoided whenever
possible and conflicts are usually not openly expressed. Challenging an expert is
also considered inappropriate. These observations and other experiences as an
international student contributed to my theoretical sensitivity in data analysis.
Furthermore, I believe that my experience allowed me to function well with
participants. Sharing a cultural and professional background has enabled me easy
access to the participants. I am familiar with the experience of living overseas as a
Chinese person. Yet I am different in that I do not have experience in clinical nursing
work in Australia. The nurses felt free to share their experience because they could
communicate in Chinese rather than English. The sharing of language and culture
also allows the researcher to better view the world from the perspective of the
participants.
A further pre-occupation while conducting the research was a desire to produce
findings that would be beneficial to both the Australian health care organisations and
the study participants. I owe much to the participants and continue to feel a strong
obligation to the participant community. All of the above comes to the research
process as additional and important data.
1.5 Definition of terms There is a range of terms that describe nurses who are educated in one country and
immigrate to another to practice, including overseas (qualified/educated/trained)
nurses (Hawthorne, 2001, 2002; Larsen, Allan, Bryan, & Smith, 2005), foreign
(educated/trained) nurses (Bola, Driggers, Dunlap, & Ebersole, 2003; Brush,
Sochalski & Berger, 2004; Davis & Nichols, 2002; Polsky, Ross, Brush, & Sochalski,
2007), immigrant nurses (Hagey et al., 2001; Omeri & Atkins, 2002), migrant nurses
(Jackson, 1996), and internationally (educated/recruited) nurses (Allan & Larsen,
2003; Allan, Larsen, Bryan, & Smith, 2004; Xu & Kwak, 2005, 2007). In this study,
these terms are used interchangeably. However, we have also selected the term
China-educated nurses to reflect the study population. China-educated nurses are
7
defined as nurses who received their basic nursing education in China and who are
currently registered and working as RNs in Australia.
Other terms that were also considered included Chinese-educated nurses and
Chinese nurses. The term Chinese-educated nurses focuses more on the language or
medium of education and the term Chinese nurses refers to nationality or ethnicity.
Neither term adequately served the study purpose. The term China-educated nurses
was selected because it more obviously identifies place of education and thus is
more appropriate to the study aims. The term nurse also has a variety of meanings
depending upon context. In this thesis, the word nurse refers to the RN when not
specified otherwise.
1.6 Structure of the thesis The thesis consists of nine chapters and several appendices. The first chapter
provides an introduction to this study which includes the research background, the
research question and aims, the significance of the study, the role of the researcher,
and definition of terms.
Chapter 2 contextualises the phenomenon of nurse migration and reviews literature
broadly related to the area of inquiry. Here, the driving forces, facilitating factor, and
overall situation of international labour migration are addressed. This is followed by
an examination of the global and Australian situations of nurse shortages and
strategies that have been put in place in an attempt to address this problem. Finally,
the research is situated and justified within an analysis of a range of issues related to
nurse immigration, including the experiences of immigrant nurses practicing in other
countries.
Chapter 3 justifies the choice of SI as the theoretical perspective for this research.
The chapter specifically engages with the assumptions underlying the research
which draw on the pragmatist origins of SI and key theoretical concepts in the works
of Mead, Blumer, and Goffman.
8
Chapter 4 presents a justification of the modified constructivist GT method as it has
been applied in this research. From here, the recruitment procedures, sampling
strategies, data generation and analysis processes, and issues of rigour are detailed.
The research findings are organised around three categories and one core category.
The focus of Chapter 5 is the first category realising where the participants
recognised the discrepancies between different realities. The first two sub-categories,
it is indeed different and this is the Western way, captured a sense of difference in
nursing work and care delivery. It is argued that the difference situated the
participants differently. More significantly, a depiction by the participants of an
“Australian way of nursing” as “the norm” predisposed these nurses to be
constructed and self-constructed as inadequate. The experiencing of superficial
collegial relationships was reflected in the third sub-category you are you and I am I.
Without common experiences, meaning is not readily shared and community
building difficult.
Chapter 6 explores the second category struggling where the participants
experienced the “middle position” dilemma and being situated as “the other”. The
first sub-category caught between two worlds highlighted the dilemma of the middle
position of participants. The resultant feelings of alienation saw participants form a
community with other Chinese and as such live a “Chinese life” overseas. The sub-
categories you have a lot to learn and this is your own business captured the
participants’ strong motivation and determination to turn challenges into
opportunities of learning and to remain hopeful while facing hardship. Being the
other, the nurses needed to prove themselves to be accepted and recognised. They
were given little support in overcoming unknowns.
Chapter 7 examines the final category reflecting where participants deliberated on
the gains and losses of immigration and making sense of the experience. The first
sub-category a sense of loss captures the losses of life components, for the family,
and of career opportunities, all as part of the immigration experience. Here it is
noted that loss is both invisible and ambiguous. A further sub-category
9
reconstructing the self explains the process of renegotiating a new sense of self in a
new society by leaving behind aspects of the old self, encountering vulnerability, and
growing through adversity. The last sub-category it is hard to go back captures the
ambivalence of participants towards immigration.
Chapter 8 explores the core category reconciling different realities, a process of
ongoing negotiation over the differences by the participants. While the three phases
(realising, struggling and reflecting) remain essential ingredients of reconciling, they
are non-linear. Literature on reconciling, immigration, and the experience of
immigrant nurses was revisited in light of the findings of the research. Four analytic
points were drawn from this study: the concepts of acculturation, assimilation, and
integration are relevant but inadequate to explain the experience of the participants;
it is not just language and culture; the potential value of difference is not appreciated;
and ambivalence as a theoretical concept in immigration studies.
Finally, Chapter 9 provides the conclusions of the study. A summary of the research
and key findings are presented, followed by the perceived limitations and
methodological tensions of the study. The broader implications and
recommendations that arise from the research findings are also discussed.
10
11
Chapter 2 Literature Review 2.0 Introduction In a largely inductive study, the review of literature requires a specialised approach
so that researchers might have as few preconceived concepts and hypotheses as
possible (Strauss & Corbin, 1990, 1998). It is suggested that the literature review
should take place in two parts. A preliminary review is used to contextualise the
background, to identify a knowledge gap, and to provide a rationale for the study. In
this study, the preliminary review was conducted prior to data collection and is
detailed in this chapter. A secondary review was undertaken in conjunction with data
analysis and following the generation of theoretical understandings which allowed
for an examination of existing research and the study findings. This latter review
appears in Chapter 8.
As such, this chapter contextualises the phenomenon of nurse migration and broadly
reviews the literature relevant to the area of inquiry. The first section discusses the
driving forces, facilitating factors, and overall situation of international labour
migration. In the second section, the global and Australian situations of nurse
shortages and the strategies that seek to address these are examined. Following this
is a discussion of the range of issues related to nurse migration which serves to
situate and justify the proposed research.
2.1 Labour migration Driving forces and facilitating factors have contributed to a growth in international
labour migration. Some of the characteristics of this phenomenon are the growth in
total number of migrants, the increased proportion of women migrants, and the
growing migration from developing to developed countries.
2.1.1 Driving forces Early work on migration presumed that wage differential was the key reason for
people moving to other countries (Lewis, 1954). By the 1970s, as Mejia, Pizurki and
Royston (1979) pointed out, migration was better understood as a result of a range of
forces emanating from both source and receiving countries. These constituted
12
political, social, economic, legal, cultural, and educational factors (Mejia et al.,
1979). This complex range of factors has given rise to various theories on
international labour migration, none of which can claim to be dominant (Arango,
2000, 2004; Borjas, 1989; Brettell, 2000; Iredale, 2001; Lee, 1966; Massey et al.,
1993; Stark & Bloom, 1985; Zolberg, 1989). But very generally, these factors fit
within either “push” or “pull” categories.
In source countries, factors such as low pay, poor working conditions,
unemployment, and civil unrest push individuals to emigrate. Pull factors are those
that encourage people to relocate, such as demand for labour and a general higher
standard of living. From this perspective, for migration to occur, both forces must be
operating (Kline, 2003).
Economic differences between countries are widening, increasing the economic
motivation for migration. In 2000, the world’s gross domestic product was $30
trillion (USD), making the global average per capita income $5,000 (USD) a year
(Martin, 2005). Yet, per capita income ranged from $100 (USD) per person in
Ethiopia to $38,000 (USD) in Switzerland (Martin, 2005). The income gap between
poor and rich countries is thus sufficient reason for many people to make a
“rational” choice to migrate (Castles, 2002).
Economic disparities are important but this is by no means the only reason for
migration. In many instances, political and safety considerations are important
factors as is obvious where refugees and displaced persons leave a country to escape
political persecution (Martin, 2005). Violence, kidnappings, rapes, and other
manifestations of insecure societies induce still more people to migrate in search of
safety (Martin, 2005). Other factors which drive migration are a desire to improve
work conditions and standards of living, a search for professional development and a
desired social system or culture not present in home countries (Kingma, 2001).
2.1.2 Facilitating factors Facilitating factors are also significant because they increase the ease of migration.
13
Some key facilitating factors are globalisation, communication technology,
information technology, and transportation development.
In recent decades, globalisation and the increasing integration of labour markets
worldwide have increased the number of people with the desire and capacity to
move to other places. The growth in multinational corporations, for example, has put
pressure on governments to facilitate the international movement of executives,
managers, and other personnel (Martin, 2005). The increase in international and
regional trade regimes also permits freer movement of individuals within member
countries (Iredale, 2001; Martin, 2005).
Similarly, the rapid expansion of communication and information technology has
made information transmission faster and cheaper. The establishment of family and
personal migration networks (links between communities at home and in destination
countries) helps potential migrants learn about opportunities abroad and provides
financial assistance and facilitates employment and accommodation for new arrivals
(Fawcett, 1989; Martin, 2005; Stark & Bloom, 1985). Those without family and
friends abroad may be motivated to migrate through exposure to media outlets.
The development of transportation has also made long-distance travel much cheaper
(Martin, 2005). As a result, immigrants are able to more quickly recoup financial
outlays. Some employers offer incentives such as paid airfare/travel on the condition
that a working contract for a given period of time will be fulfilled. All these factors
facilitate the movement of people from one country to another.
Apart from the above, there are other intervening factors and constraints influencing
immigration (Arango, 2000; Hatton & Williamson, 2002; Lee, 1966; Zolberg, 1989).
As some have argued, the decision to immigrate is often made in a family context
with consideration to maximise expected incomes and minimise risks (Massey et al.,
1993; Stark & Bloom, 1985). In addition, personal health, personal wealth, potential
cultural and psychological costs to the migrating person also influence whether
immigration can and will take place. More importantly, immigration is not merely a
14
matter of choice. Immigration policies in the potential receiving country are
influential in determining immigration flow and the type of immigration that takes
place (Arango, 2004).
2.1.3 Global situation of labour migration As noted, the level of international migration has grown markedly. Data from the
United Nations highlight that there was an estimated 191 million international
migrants worldwide in 2005, an increase from 176 million in 2000 and 75 million in
1960 (United Nations, 2006). International migrants consist of nearly 3 per cent of
the global population, up from 2.9 per cent in 1990 (United Nations, 2006). Relative
to the total population, Oceania has the largest share of international migrants (15.2
per cent), followed by Northern America (13.5 per cent) (United Nations, 2006). The
US is the largest recipient of international migrants, having 38.4 million migrants in
2005 (United Nations, 2006).
A feature of this migration trend is the growing proportion of skilled migration from
developing to developed countries (also known as the “brain drain”). It is estimated
that, in 2001, nearly 1 in 10 tertiary educated adults born in the developing countries
resided in North America, Australia, or Western Europe (Lowell & Martin, 2005).
About 30 to 50 per cent of people in developing countries trained in science and
technology live in the developed world (Lowell & Martin, 2005). Taking Australia
as an example, its recent immigration policy has targeted the “skilled worker”
immigrant. Since 1997-1998, permanent arrivals through the Skill Stream of the
Migration Program have been consistently larger in number than through other
programs, accounting for 45 per cent of all permanent arrivals to Australia in 2005-
2006 (Australian Bureau of Statistics, 2007).
Although both men and women immigrate, the immigration of women has been
traditionally viewed as passive and secondary. One reason is that child-raising
responsibilities have severely restricted the career mobility of women. Today, by
contrast, women represent a growing share of immigrants, rising from 47 per cent in
1960 to 49.6 per cent in 2005 (United Nations, 2006) and the proportion has grown
15
to 51 per cent in more developed regions (Martin, 2005). In part this has occurred
because of the increasing demand for immigrant women to perform domestic work
and child and elder care services as more and more women in developed countries
have entered the labour force (Martin, 2005). The feminisation of immigration is
also significant in that many women are immigrating as primary wage earners, rather
than as accompanying family members.
2.2 Nurse migration Part of the phenomenon of expanding international labour migration is nurse
migration. This migration has several features: it is voluntary in nature (voluntary
migration instead of forced migration); it is skilled migration; and it involves women
as the primary migrants (instead of men).
Kingma (2001) has proposed several reasons for the global movement of nurses that
include both push and pull factors. First, nurses migrate in search of professional and
educational opportunities not available in their home countries. Second, nurses seek
better wages and living or working conditions than exist at home. The third reason is
that nurses seek work situations associated with less risk (biological, chemical,
physical, and social) to personal safety. Personal safety is an increasingly strong
contributing factor to nurse migration and “may be motivated by circumstances
within the health sector or the external environment” (Kingma, 2001, p. 207). This
factor is evident in African countries where there are high rates of HIV/AIDS and
other infectious diseases (Kline, 2003). It is argued that it is pull rather than push
factors that exert most influence on the size of nurse migration (Royal College of
Nursing, 2003). In moving beyond push and pull factors others have argued for a
broadening of analysis to incorporate distinctive historical and political contexts
such as post-colonialism (McNeil-Walsh, 2004). However, a shared element across
theoretical perspectives and in the current context is the extent of the global nursing
labour shortage, an examination of which follows.
2.2.1 Nurse shortage The impact and implications of nurse shortages is evident at both the global and
16
national levels. Policies adopted to address the shortages are somewhat similar
worldwide, with international recruitment becoming an increasingly prominent
approach.
2.2.1.1 The global situation There has been an unprecedented global shortage of nurses in recent years (Oulton,
2006). Both a decreased supply and an increased demand have contributed to the
shortage, making it more complex, serious, and enduring than previous shortages
(Hassmiller & Cozine, 2006). Quantifying the global nurse shortage is difficult
because of varying definitions of the shortage and problems of access, currency, and
quality of data (Oulton, 2006). However, the following statistics provide a general
picture of the extent of the shortage.
Research published by the Canadian Nursing Association predicted that Canada will
face a shortfall of 78,000 RNs by 2011 and the number may expand to 113,000 by
2016 (Nelson, 2004). In April 2006, officials from the US Health Resources and
Services Administration projected that the US nurse shortage would grow to more
than 1 million by the year 2020 and all 50 US states will be experiencing a shortage
of nurses to varying degrees by the year 2015 (HRSA, 2006). In Europe, Germany
and the Netherlands are both in need of 13,000 nurses and Switzerland is lacking
3,000 nurses (International Council of Nurses, 2003). In France, 18,000 nurses leave
public hospitals every year (International Council of Nurses, 2003). In 2025, the
small country of Denmark will face a projected shortage of 22,000 nurses
(International Council of Nurses, 2003) and it is estimated that New Zealand has a
shortfall of 2,000 nurses (Hulbert, 2005).
Shortages are also occurring in developing countries. The situation in Africa is
particularly serious. Across Africa, there are on average fewer than 50 nurses per
100,000 of the population, less than half the number required to deliver even basic
health care (Eastwood et al., 2005). Yet, these African countries face increased
demand for nurses as they struggle to provide anti-retroviral treatment and care to
HIV/AIDS patients (Eastwood et al., 2005). A report (Friedman, 2004) noted that in
17
Malawi only 28 per cent of nursing positions were filled in 2003 and in South Africa,
32,000 nursing positions were vacant in the same year. One hospital in Zambia was
reported to have only one-third of the 1,500 nurses required to function well
(Trossman, 2002). In the case of the Philippines, the country which supplies the
largest number of nurses to the US and the UK, the nurse shortage has reached 6 per
cent and is projected to increase to 29 per cent by 2020 (Marchal & Kegels, 2003).
2.2.1.2 The Australian situation Australia is no exception to the global nurse shortage situation. Unless remedial
measures are put in place, it is estimated that Australia will be faced with 40,000
nursing vacancies by 2010 (Karmel & Li, 2002). According to the Council of Deans
of Nursing and Midwifery data (Preston, 2006), in 2006 Australia as a whole had a
shortfall of 3,243 RNs (or 1.6 per cent of the RN workforce).
Where Australian states are concerned, the Australian Nursing Federation reported
that in Tasmania, nursing shortages had resulted in a large number of elective
surgery cancellations (Australian Nursing Federation, 2005a) and unacceptable
vacancy levels at major hospitals (Australian Nursing Federation, 2006b). An annual
increase of about 200 RNs will simply maintain the Tasmanian RN workforce at its
current level (Preston, 2006). In 2005, New South Wales figures indicated a shortage
of 1,750 nurses but this has not taken into account shortages in the private sector
(NSW Nurses’ Association, 2005). In Queensland, a shortage of 1,461 (3.8 per cent
of the workforce) nurses by 2010 is projected. If existing low staffing levels in
Queensland are progressively improved to a level equivalent to that of Australia as a
whole, then the projected shortage in this state almost doubles (to 2,849 or 7 per cent
of the workforce) (Preston, 2006). In Western Australia, if the staffing levels
improved to the national equivalent, it will have an approximate shortfall of 377
nurses by 2010 (Preston, 2006). In Victoria, it is estimated that 5,000 full time
equivalent or 6,050 additional RNs will be required by 2011 to 2012 (Department of
Human Services Victorian Government, 2004). In South Australia, between 650 and
1,350 new graduates per year are required to maintain the RN workforce at the
current size (Parliament of Australia Senate, 2002).
18
As a result of the growing evidence of a nursing labour crisis, the Australian
government in 1999 identified nursing as a national priority area (Heath, 2002) and
the Department of Immigration and Multicultural Affairs has since listed the RN on
the Migration Occupations in Demand List, which means that nurses receive bonus
points for migration (Department of Immigration and Multicultural and Indigenous
Affairs, 2005).1 All of these data reflect a serious problem of a growing shortage of
nurses in Australia.
2.2.1.3 Strategies to address the nurse shortage Strategies used to counter the shortage are similar across countries and include
increasing nursing education enrolment, seeking to recruit unemployed nurses,
improving retention and overseas recruitment. Each of these strategies is addressed
in turn.
Increasing nursing education enrolment
Increasing the number of people entering nursing education is identified as a
potential long-term solution to nurse shortage. Nursing education programs are
being provided to a broader range of recruits including mature age entrants, entrants
from ethnic minorities, and those with vocational qualifications or work-based
experience (Buchan & Sochalski, 2004). It is argued that special effort should focus
on attracting more young people, more men, and more members of minority ethnic
groups to the nursing profession to make the workforce more diverse and
representative of the population makeup (Goodin, 2003). A further position is that it
is essential to market a positive image of nursing to children at an early age because
they have decided by fifth grade on what are desirable and undesirable careers
(Cluskey, Jackson, Brubaker, Cram, & Awl, 2006). It should be noted that these are
not innovative ideas but have long been integral to campaigns to increase levels of
nurse enrolment.
1Since 1999, where the nominated occupation of an applicant is on the Migration Occupations in Demand List at the time an application is lodged or assessed, the applicant becomes eligible for “occupation in demand/job offer” points on the General Skilled Migration points test. An applicant receives extra points if he/she has a job offer from a suitable Australian employer.
19
Reaching unemployed nurses
Programs to encourage a return to the profession of licensed RNs who are
unemployed or working in non-nursing fields have been implemented in countries
such as the UK and Australia. Yet it is pointed out that the number of RNs interested
in returning to the profession is limited (McIntosh, Val Palumbo, & Rambur, 2006)
and the effectiveness of re-entry programs is questionable as they fail (much like the
marketing strategies suggested above) to address the underlying reasons why nurses
left the workforce (Cowin & Jacobsson, 2003).
Improving retention
The cost of turnover extends well beyond the fiscal cost of losing an individual. The
turnover of effective staff members leads to decreased morale and a sense of
rejection in those left behind (Manion, 2004). Hence how to nurture a culture of
retention is considered to be the key to easing the nurse shortage (Manion, 2004).
But as Buchan and Sochalski (2004) argued, the importance of retention is not
widely recognised and/or acknowledged.
Overseas recruitment
In the absence of alternative effective policies and as the demand for RNs continues
to grow and the RN workforce ages, the strategy of overseas recruitment is gaining
momentum (Buchan & Sochalski, 2004) and many developed countries are
increasingly relying on overseas RNs to fill vacancies. Although overseas
recruitment may not always be the most cost-effective solution, at a time of shortage,
it offers a relatively quick and sometimes the only solution. In the foreseeable future,
overseas recruitment will continue to play a significant part in supplementing
nursing numbers in many countries.
The UK recruits more nurses from developing countries than any other Western
nation. In 2002 alone, 16,155 foreign-trained nurses2 were recruited (Aiken, Buchan,
2 There is a range of terms used when referring to nurses from overseas in the literature such as foreign-trained nurses, foreign-educated nurses, and foreign-born nurses. This review adheres to the terms as used in the literature.
20
Sochalski, Nichols, & Powell, 2004). In the year to March 2005, a total of 11,477
overseas nurses were admitted to the UK from non-European countries and between
April 2005 and March 2006, another 8,673 were admitted (Aiken et al., 2004). This
recruitment strategy appears to have alleviated the UK nurse shortage to a great
degree and this, combined with a tightening of health funding, has meant that the
UK no longer recruits nurses in these numbers (Buchan & Seccombe, 2006). Yet the
aging population and an increasingly aging nursing workforce remains a challenge
to overcome. Overseas recruitment was initially presented as “a quick fix” to solve
acute nurse shortage in the UK but has now become an essential and recurrent
strategy in the overall nurse recruitment policy (Royal College of Nursing, 2003).
The number of foreign-educated nurses moving to the US more than tripled from
4,000 in 1998 to 15,000 in 2004 (Llana, 2006). This cohort now accounts for 14 per
cent of the current nursing workforce, up from less than 9 per cent in 1994
(Auerbach, Buerhaus, & Staiger, 2007). In fact, employment of foreign-born RNs
accounted for nearly one-third of the total growth of RN employment in the US
nursing labour market during 2002-2003 which means that the trend towards
increased reliance on foreign-born RNs has accelerated (Buerhaus, Staiger, &
Auerbach, 2004). As a result, some people have argued that the reliance on overseas
RNs to fill gaps is no longer a short-term solution but has become an entrenched
government strategy in some developed countries.
In response to the nurse shortage, the Australian government has introduced a
number of initiatives, one of which is attracting overseas RNs. Australia received
11,757 foreign nurses between the years 1995 and 2000 (Hawthorne, 2001). In
addition, the number of overseas RNs in Australia almost tripled from 1,188 in 2000
to 3,233 in 2004 (Jeon & Chenoweth, 2007). Almost 30 per cent (1,732) of nurses
obtaining initial registration with the Nurses Board of Victoria in 2004 were from
overseas (Australian Nursing Federation, 2005b). In Queensland alone, the number
of license applications from overseas nurses and midwives increased by 40 per cent
in 2006 (Queensland Nursing Council, 2006) and in New South Wales, aggressive
recruitment brought in over 1,000 overseas nurses in the same year (Lawson, 2005).
21
For the foreseeable future, international recruitment will continue to play a
significant part in boosting nursing numbers in Australia (Jeon & Chenoweth, 2007).
2.2.2 China as a source for nurse recruitment It appears that the dominant sources for nurse migration are developing countries
(Buchan & Sochalski, 2004) and with a 1.3 billion population, China represents one
of the world’s largest reservoirs of human resources. As Xu (2006, p. 131) argued, in
the context of the widening gap between the global demand for and supply of nurses,
it is not a question of “if” but “when” Chinese nurses will become a major
component of the global nurse market.
In 2004, the number of working RNs in China was 1.3 million, with just over one
nurse per thousand people (Jiang, Shen, & Yan, 2004). Yet, because of inadequate
government funding in health care, the level of unemployment and
underemployment of nurses in China is very high (Xu, Gutierrez, & Kim, 2008). As
a result, both the Chinese government and the Chinese Nursing Association openly
support the export of Chinese nurses (Xu, 2004; Xu & Zhang, 2005).
International migration of Chinese nurses began in the 1990s when the Chinese
government organised groups of nurses with good English skills to work in
Singapore and Saudi Arabia for determined periods of time. Most of those
employment contracts were arranged by government agencies (Fang, 2007). During
the last five years or so there has been a similar increase in the number of nurses
who have migrated to Australia and England, although most of these were arranged
by private companies rather than government agencies (Fang, 2007). However, the
exact number of Chinese nurses migrating overseas is unknown.
In a situation of increasing global demand for nurses and a shrinking of the
traditional supply markets such as the Philippines, commercial and government
recruiters have expressed a strong interest in the recruitment of nurses from China
(Fang, 2007). In 2006, the Australian Nursing and Midwifery Council met with three
Chinese delegations of officials and expressed an interest in further promoting
22
Chinese nurse migration to Australia (Australian Nursing and Midwifery Council,
2006). As Xu and Zhang (2005) argued, compared to those countries which are
opposed to the migration of their nurses, China is perceived to be a more ethical
source for recruitment. Several authors have assessed the potential for nurse
migration from China and have concluded that with its very large labour resource,
China will become an increasingly important supplier of nurses in the future
(Chatterjee, 2005; Fang, 2007; Kingma, 2001; Pittman et al., 2007; Xu, 2003; Xu &
Zhang, 2005).
2.3 Issues related to nurse migration Migration might be seen as an indication of greater freedom of choice and also as an
expected outcome of globalisation. Yet, as the scope of nurse migration has
increased, several related issues have received attention including the ethics of
overseas recruitment, safety and quality of nursing care, and the valuing of overseas
nurses.
2.3.1 The ethics of overseas recruitment As nurses migrate primarily from developing to developed countries (and many of
those developing countries are also facing nurse shortages) (Bach, 2003), people
have begun to question the ethics of some developed countries and have denounced
their recruiting strategies as “taking nurses away from where they are needed most”,
“poaching” or “stealing” (Muula, Mfutso-Bengo, Makoza, & Chatipwa, 2003; Singh,
Nkala, Amuah, Mehta, & Ahmad, 2003). The loss of skilled nurses (not only in
terms of absolute numbers but also in quality) and educational economic investment
constitute a “brain and skill drain” for many developing countries (Kline, 2003;
Muula et al., 2003; Singh et al., 2003). This is particularly a problem for some
African countries where nurses are “scarce and relatively expensive to train”
(Buchan, 2001, p. 204) and where the HIV/AIDS epidemic has greatly increased the
need for nurses (Kline, 2003). In addition and as noted, importing nurses to solve a
shortage does not address the underlying problems of those shortages (Mcelmurry et
al., 2006; Trossman, 2002).
23
The vulnerable status of immigrant nurses and the potential for exploitation or abuse
is also of great concern. In the UK, a case was reported where experienced nurses
from Pakistan and India were made to work in the laundries of nursing homes or as
care assistants (Harrison, 2004). In the US, a hospital was reported for employing
nurses from China and India as a cheap labour supply which it could “lock in” for
two years (Hwang, 2005). Cases of false promises of high salaries, wage deductions,
and probationary periods have also been frequently reported (Doult, 2005).
In response to issues such as the above, the International Council of Nurses (2001)
published a statement on ethical recruitment which recognises the right of an
individual nurse to migrate, but also acknowledges the possible adverse effect that
migration may have on health care quality in source countries. Ethical guidelines for
international nurse recruitment have also been published in some countries such as
the UK (Kline, 2003) and Australia (Australian Nursing and Midwifery Council,
2007) although these guidelines appear to have no impact on the private sector
(Kline, 2003).
Complex as they are, the ethical issues identified are not the only concern raised by
nurse migration. A further key concern is whether immigrant nurses have the
capacity to provide high quality nursing care to patients in host countries.
2.3.2 Safety and quality of nursing care Concern is raised about the quality of care provided by overseas nurses because it is
often assumed that their knowledge and skills are inferior. However, in reality little
is known about the effects of an increasing reliance on foreign-born nurses, the
effectiveness of their job performance, and whether their quality of nursing care
differs from domestic trained nurses (Gonda, Hussein, Gatson, & Blackman, 1995).
No studies to date have determined whether foreign nurses’ cultural orientation and
technical competence produce differences in patient outcomes when compared with
their domestic counterparts (Brush, Sochalski, & Berger, 2004).
An early study compared Philippine nurses who migrated to the US with domestic
24
US nurses from the view of directors of nursing (Miraflor, 1976). On academic
background, nursing knowledge, job performance, leadership ability, communication
skills, and interpersonal relationships, the study found that US nurses rated high on
average, but in the categories of job performance and interpersonal relationships
more Philippine nurses were rated as excellent (Miraflor, 1976). A decade on, a US
study using two different instruments found no difference when comparing the job
performance of 41 foreign nurse graduates with 199 domestic US nurses
(McCloskey & Aquino, 1988). A further study in the 1970s also found that foreign
nurses believed that their effectiveness was underestimated as a result of
communication problems (Davitz, Davitz, & Sameshima, 1976). Without solid
evidence of their effectiveness, the value of overseas nurses is often treated with
suspicion.
2.3.3 Valuing of overseas nurses The contribution of overseas nurses to the health care system is not well documented
(Gonda et al., 1995; Teschendorff, 1993b). A survey by Xu and Kwak (2005; 2007)
in the US found that internationally educated nurses tended to be younger, more
experienced, and better prepared educationally than domestic US nurses. These
nurses were more likely to work full time in nursing, work more hours per year, and
spend more time providing bedside care than their counterparts (Xu & Kwak, 2005).
Besides patient care and services, some have argued that overseas nurses contribute
valuable knowledge and skills to the receiving countries in providing care in an
increasingly multicultural and multilingual society (Gonda et al., 1995; Lowell &
Martin, 2005). According to Nickens (1990), the presence of minority health
professionals in health care settings increased the user friendliness experienced by
minority populations and hence accessibility. Thus, the experience and knowledge of
overseas nurses is seen to complement that of local nurses. All the issues addressed
above are closely related to overseas nurses and arguably will influence their
experiences of working in another country.
25
2.4 Experience of overseas nurses According to Murphy and McGuire (2005), internationally educated nurses are the
“forgotten nurses” in the health care system, largely because so little is known about
these people. Terms such as foreign nurse graduates (Yahes & Dunn, 1996), former
registered alien nurses (Lim, 2001), foreign-educated nurse (Bola et al., 2003; Davis
& Nichols, 2002), foreign-trained nurses (Polsky et al., 2007), overseas qualified
nurses (Hawthorne, 2001, 2002), and immigrant nurses (Hagey et al., 2001; Omeri
& Atkins, 2002) position these nurses as outsiders and set them apart as a
homogeneous group.
Despite the growing number of overseas nurses, little attention has been given to
understanding the experiences of those nurses working in another country. This is
unusual given their potentially profound impact on workforce cohesion and supply
(Hawthorne, 2001). Also, the fact that nurse shortages have made the global nurse
labour market increasingly competitive means that a better understanding of the
experiences of overseas nurses is important in both persuading them to come and
motivating them to stay for longer periods (Allan & Larsen, 2003).
The preliminary review of literature on the experience of overseas nurses was
undertaken in 2007 and constituted an extensive search of CINAHL, ProQuest,
Meditext, and Medline databases using various combinations of key words such as
international nurses, internationally educated (recruited) nurses, overseas (qualified)
nurses, foreign educated (trained/born) nurses, migrant nurses, immigrant nurses,
and experience. Three studies were identified from an Australian perspective
(Jackson, 1996; Omeri & Atkins, 2002; Teschendorff, 1993a), eight from the UK
(Alexis, Vydelingum, & Robbins, 2006; Allan & Larsen, 2003; Allan et al., 2004;
Daniel, Chamberlain, & Gordon, 2001; Hardill & MacDonald, 2000; Smith, 2004;
Taylor, 2005; Withers & Snowball, 2003), two from the US (DiCicco-Bloom, 2004;
Yi & Jezewski, 2000), two from Canada (Hagey et al., 2001; Turrittin, Hagey,
Guruge, Collins, & Mitchell, 2002), one from Iceland (Magnusdottir, 2005), and one
from Netherlands (de Veer, den Ouden, & Francke, 2004). The major methodology
adopted in these studies was qualitative, with only two survey studies identified.
26
A shared result from these studies is that most overseas nurses have a largely
negative experience of working in another country. Some of the contributing factors
include language barriers (Allan & Larsen, 2003; de Veer et al., 2004; Hardill &
MacDonald, 2000; Jackson, 1996; Magnusdottir, 2005; Menon, 1992; Omeri &
Atkins, 2002; Sarojini, Foong, Pin, Nge, & Hong, 2005; Smith, 2004; Taylor, 2005;
Teschendorff, 1993a, 1993b, 1994; Withers & Snowball, 2003; Yi & Jezewski, 2000),
cultural issues (Allan & Larsen, 2003; de Veer et al., 2004; DiCicco-Bloom, 2004;
Jackson, 1996; Magnusdottir, 2005; Menon, 1992; Omeri & Atkins, 2002; Smith,
2004; Teschendorff, 1993a, 1993b; Withers & Snowball, 2003; Yi & Jezewski, 2000)
and working relationship difficulties (Allan & Larsen, 2003; Jackson, 1996;
Magnusdottir, 2005; Yi & Jezewski, 2000). These problems are exacerbated by a
lack of support (Allan & Larsen, 2003; Magnusdottir, 2005; Omeri & Atkins, 2002),
a sense of isolation and alienation (Jackson, 1996; Magnusdottir, 2005; Omeri &
Atkins, 2002), experiencing racism and exploitation (Allan & Larsen, 2003; Allan et
al., 2004; DiCicco-Bloom, 2004; Hagey et al., 2001; Taylor, 2005; Turrittin et al.,
2002), adapting to new expectations of the RN role (Hardill & MacDonald, 2000;
Smith, 2004; Taylor, 2005; Teschendorff, 1993b; Withers & Snowball, 2003; Yi &
Jezewski, 2000) and unequal opportunities (Alexis et al., 2006; Allan et al., 2004;
Hardill & MacDonald, 2000; Taylor, 2005). The research on these factors is the
focus of the discussion below.
2.4.1 Language barriers Language is a major hurdle for most overseas nurses. An early 1990s study looked at
communication problems experienced by Philippine nurses working in Australia
(Teschendorff, 1993a, 1993b, 1994). The research found that although the
Philippines’ national nursing curriculum was based on the US model and English
was the language of instruction, the major hurdle identified by Philippine nurses in
adjusting to Australian nursing was language (Teschendorff, 1993a). As a particular
illustration of language difficulty, the study reported problems with idiom,
pronunciation, Australian accents, fast delivery of speech, slang, abbreviations, and
terminology in the clinical setting. Communication difficulties were also evident in
27
Menon’s (1992, p. 330) study that suggested Australian nurses soon tired of listening
to people whose pronunciation was difficult to understand. Other studies have also
produced similar findings (Allan & Larsen, 2003; de Veer et al., 2004; Hardill &
MacDonald, 2000; Jackson, 1996; Magnusdottir, 2005; Menon, 1992; Omeri &
Atkins, 2002; Sarojini et al., 2005; Smith, 2004; Taylor, 2005; Withers & Snowball,
2003; Yi & Jezewski, 2000).
In addition, language problems have been found to be particularly acute in telephone
communication because there are no gestures or expressions to convey added
meanings (Magnusdottir, 2005). As one Iceland study indicated, the fear of using the
telephone by foreign nurses lasted up to several years (Magnusdottir, 2005). Nurses
experienced high levels of anxiety when asked to come to the phone or during a
telephone conversation. Difficulty in transferring speech into writing was also
demonstrated as a more subtle and continuing problem for non-native speakers
(Omeri & Atkins, 2002).
Because of the frequently reported difficulties in communication, most countries
have adopted a requirement of a proficient level of English for overseas nurses. For
example, in Australia, nursing registration councils in all states require an
International English Language Testing System (IELTS) score of 7 on a band of 1-9
to achieve registration as an RN. There is suggestion of an even higher requirement
such as a score of 8 on English language to ensure sufficient language skills
(Australian Nursing Federation, 2006a). Yet, Arakelian (2003) was sceptical of the
value of the IELTS in the nursing context and suggested that communication skills
which focused on the needs of patients and the team needed to be measured and also
taught in context.
2.4.2 Cultural issues Issues of culture shock and conflicting values, beliefs, and culturally derived
behaviours have also been identified (Allan & Larsen, 2003; de Veer et al., 2004;
DiCicco-Bloom, 2004; Jackson, 1996; Magnusdottir, 2005; Menon, 1992; Omeri &
Atkins, 2002; Smith, 2004; Teschendorff, 1993a, 1993b; Withers & Snowball, 2003;
28
Yi & Jezewski, 2000). Not only do overseas nurses have to adapt to a new culture
when they come to another country, but they have to ensure that new colleagues do
not misunderstand their cultural beliefs and practices. For instance, the Chinese are
taught to value and respect older adults and to not talk back or question them
because with old age comes knowledge and wisdom (Chen, 2001). In Australia,
people may perceive this as passive behaviour. Furthermore, differences in
perceptions of nursing autonomy and decision making can mean a period of intense
readjustment for overseas nurses.
A qualitative study by Smith (2004) in the UK demonstrated that significant cultural
differences did exist between overseas nurses and domestic nurses. These included
differences in the areas of professional culture, organisational culture, and national
culture. The culture shock experienced by most overseas nurses was described as
overwhelming and this suggested a need for more effective preparation (Smith,
2004). However, there is no detailed analysis of this phenomenon and nor how such
cultural shock might be addressed.
Cultural conflict was also exemplified in DiCicco-Bloom’s study (2004) where 10
Indian nurses working in the US were interviewed. The findings indicated that many
experienced cultural displacement which was termed “a foot here” (US), “a foot
there” (India), and “a foot nowhere” (DiCicco-Bloom, 2004). This ambivalence
towards US norms and values was a constant in their daily lives. Yet it is unclear
whether cultural conflict was experienced by all immigrants or only those from quite
distinct cultures.
A survey study undertaken in the Netherlands of 987 nurses from European
countries indicated that one-third of these nurses experienced problems with Dutch
laws and the fiscal and social security systems (de Veer et al., 2004). A lack of
familiarity with the Dutch health care system also caused problems in seeking work.
These difficulties were exacerbated as a result of inadequate language skills. While
the impact of cultural differences was emphasised, the survey method limited in-
depth understanding of the issues.
29
2.4.3 Difficulties in working relationships The issues of language and culture may also affect the relationship between overseas
nurses and their colleagues and patients. The language problem labels overseas
nurses as different and difficult and this may provide domestic colleagues and
patients a reason for not trying to understand (Allan & Larsen, 2003; Jackson, 1996;
Magnusdottir, 2005). As Jackson’s (1996) study found, domestic nurses would rather
engage with colleagues who were “their own” student nurses or enrolled nurses and
did not trust foreign nurses.
Another large UK qualitative study by Allan and Larsen (2003) found that
internationally recruited nurses were often misunderstood by domestic nurses with
whom they work. Many thought that nurses had migrated only for economic reasons,
that they took jobs away from domestic nurses and at the same time also lowered the
overall salary standard. Moreover, some local patients lacked confidence in foreign
nurses and overtly expressed negative attitudes (Magnusdottir, 2005).
Difficult relationships with care assistants have also been reported (Allan & Larsen,
2003; Yi & Jezewski, 2000). Allan and Larsen (2003) found that some senior carers
tended to ignore internationally recruited nurses, telling them what to do and
assuming a position of authority. One US study concluded that on the one hand,
Korean nurses were not assertive and could not delegate work to the aids and thus
did most of the work themselves. On the other hand it was asserted that because of a
hierarchical interpersonal style, the Korean nurses tended to treat aids as inferiors
which made the relationship worse (Yi & Jezewski, 2000).
2.4.4 Lack of support Difficult relationships are compounded by inadequate support available to overseas
nurses (Allan & Larsen, 2003; Magnusdottir, 2005; Omeri & Atkins, 2002). As the
UK study pointed out when facing a problem colleagues often were, at best,
unprepared and indifferent in providing help (Allan & Larsen, 2003). In this study,
the support from managers in confronting bullying from care assistants was also
30
very limited (Allan & Larsen, 2003). A study by Omeri and Atkins (2002) found that
most participants did not know where to go and who to ask about almost all work
issues.
2.4.5 Isolation and alienation All of the above mentioned factors contribute to the loneliness experienced by
overseas nurses. An early phenomenological study by Jackson (1996) investigated
the experiences of nine nurses from diverse cultural backgrounds in New South
Wales, Australia. The results revealed that familiar and comfortable roles were
transformed and that migrant nurses suffered the experience of being a stranger and
being lonely in Australia (Jackson, 1996).
A further phenomenological study in New South Wales, Australia, by Omeri and
Atkins (2002) also showed that immigrant nurses’ experiences were mostly unhappy,
isolating, and lonely. Loneliness of immigrant nurses comes not only from having no
family and friends nearby but also from a lack of support in the workplace. This
sense of cultural separateness and loneliness was posed by the authors as “otherness”.
This study was limited in the areas of sample selection (the selection criteria
indicated that only immigrant nurses from non-English speaking countries would be
included, however, the actual five participants included one nurse from English
speaking background) and the choice of English as the interview language (which
may have limited the depth and understanding of interview data). Nonetheless, the
results shed some light on the experiences of immigrant nurses.
The Magnusdottir (2005) study in Iceland involving 11 RNs from 7 countries
produced similar findings. Foreign nurses felt unaccepted by the dominant group.
Interestingly, this was even the case for those with an Icelandic spouse. The need for
friendship with locals was often unmet and the feeling of wanting to be accepted was
paramount.
2.4.6 Racism and exploitation Studies have also referred to racism, discrimination, exploitation, and prejudices
31
faced by overseas nurses (Allan & Larsen, 2003; Allan et al., 2004; DiCicco-Bloom,
2004; Hagey et al., 2001; Taylor, 2005; Turrittin et al., 2002). Allan and Larsen
(2003) noted that some internationally recruited nurses felt that the language barriers
had become a vehicle for racism among UK nurses and carers. Brush (1999) found
that although legislation mandates equitable pay and working conditions, foreign
nurses have often been assigned sites, shifts, and days that are unattractive to other
nurses. Cases of discrimination against and exploitation of the internationally
recruited nurse continued to be registered (Allan & Larsen, 2003).
The large UK study by Allan and Larsen (2003) explored the experiences of 67
internationally recruited nurses from 18 different countries. The study found that
discrimination and racism were central to these nurses’ experience. The differences
in colour, culture, or language of internationally recruited nurses acted as social
markers which made them the objects of racial harassment (Allan et al., 2004). It
was also reported that racism and discrimination existed in various forms, such as
unfavourable treatment, the questioning of qualifications and competency, special
negative attention if mistakes were made, feelings of exclusion, and negative
stereotyping. In addition, expressions of racism and discrimination were often silent
(Allan et al., 2004).
Likewise, a US study explored the racial experiences of 10 Indian immigrant nurses
and a major emergent theme was racial experiences/alienation in the work place
(DiCicco-Bloom, 2004). A Canadian study also described the experiences of nine
immigrant nurses of colour from seven different countries who had filed formal
grievances or complaints of racism against their employers (Hagey et al., 2001). The
results showed that immigrant nurses were being marginalised and as a result
experiencing physical stress and emotional pain.
2.4.7 Assimilating Differences in the experiences that overseas nurses bring to their new role have also
been frequently noted. As Smith (2004) indicated, an RN in India followed
unquestioningly a doctor’s orders and did not expect to make autonomous decisions.
32
In contrast, RNs in the UK had more autonomy and greater responsibility for their
patients (Taylor, 2005). Interestingly, this is not the case with all overseas nurses. As
another UK study found, immigrant nurses from South Africa felt they were not
given sufficient responsibility given their experience and training and one participant
used the absence of physical assessments of patients to demonstrate the point
(Hardill & MacDonald, 2000).
Other studies have concluded that overseas nurses do not expect to take care of the
basic bedside needs of patients such as bathing and feeding because family members
take on this role in their own countries (Teschendorff, 1993b; Yi & Jezewski, 2000).
Yi and Jezewski (2000) found that Korean nurses thought that US nursing was too
focused on basic physical needs rather than the management of medical care. What
nurses were required to do was what family members do in Korea.
Research also showed that the experience of internationally recruited nurses was
shaped by expectations of the new work context (Allan & Larsen, 2003). The study
by Daniel et al. (2001) used focus groups to identify the initial expectations and
experiences of 24 newly recruited Filipino nurses at a London hospital and found
that career prospects and salaries were key factors influencing decisions to migrate.
Most Filipino nurses expected UK hospitals to be “high tech”, with a lighter
workload and a focus on technical nursing. However, as all the participants were
interviewed only shortly after arrival, whether their experiences would meet their
expectations was hard to determine.
Withers and Snowball’s study (2003) produces similar findings on Filipino nurses’
high expectations of the workplace in the UK. Two-thirds of the 120 participants
indicated that their expectations were unmet and that the information they received
prior to migration was inadequate (Withers & Snowball, 2003). Unmet expectations
may lead to dissatisfaction and ultimately resignation.
There is also a marked difference in the experiences of overseas nurses from an
English speaking background compared to those from a non-English speaking
33
background. It is speculated that a person entering Australia from a similar culture
such as New Zealand or England, with English as the native language, may
experience a lesser degree of shock than someone from a more dissimilar culture
(Pilette, 1989). In the Hawthorne’s (2001) study, non-English speaking background
nurses in Australia were reported to experience more challenges with the English
language, qualification accreditation, and career mobility. For a substantial number,
it took years to integrate into the Australian labour market (Hawthorne, 2001).
2.4.8 Unequal opportunities, deskilling, and undervaluing Finally, a sense of being deskilled and undervalued and experiencing unequal
opportunities is also obvious in the research (Alexis et al., 2006; Allan et al., 2004;
Hardill & MacDonald, 2000; Taylor, 2005). There is a perception that overseas
nurses are often not used to their full potential, their previous skills and experience
are not taken into account, and they experience deskilling (Alexis et al., 2006;
Hardill & MacDonald, 2000). Because of inadequate communication skills and a
lack of enculturation, some overseas nurses sense that they are simply a solution to a
labour shortage and may never reach their full potential as a professional nurse.
The study by Alexis et al. (2006) is a pertinent example of this point. Twelve
overseas black and minority ethnic nurses employed in National Health Service
(NHS) in the UK were interviewed. The results revealed a perception of a lack of
equal opportunity in career advancement for overseas nurses including limited
opportunities for skill development and training (Alexis et al., 2006). The NHS equal
opportunity policies appeared merely as a paper exercise which did not reflect
practice. Because of family commitments, however, many overseas nurses felt
compelled to tolerate this discrimination.
There are some limitations of existing research in the area of the experience of
overseas nurses. First, many studies treated overseas nurses as a homogeneous group
(Alexis et al., 2006; Allan & Larsen, 2003; Magnusdottir, 2005; Omeri & Atkins,
2002), overlooking variations in cultural and linguistic backgrounds. Second, most
researchers and participants in these studies were from English speaking
34
backgrounds and interviews were conducted in English (Alexis et al., 2006; Allan &
Larsen, 2003; DiCicco-Bloom, 2004; Hagey et al., 2001; Jackson, 1996; Menon,
1992; Smith, 2004; Taylor, 2005; Teschendorff, 1993a; Turrittin et al., 2002). Third,
on the few occasions where non-English speaking nurses did participate, the use of
English as the interview language greatly limited their levels of understanding
(Omeri & Atkins, 2002). Fourth, where a study focused on non-English speaking
background nurses, some large groups of overseas nurses, such as nurses from the
Philippines, were usually selected rather than other ethnic groups (Daniel et al., 2001;
Lopez, 1990; Parry & Lipp, 2006; Teschendorff, 1993a, 1993b, 1994; Withers &
Snowball, 2003). Finally, the studies were predominantly focused on producing a
description of overseas nurses’ experiences (de Veer et al., 2004; Gonda et al., 1995;
Hardill & MacDonald, 2000; Hawthorne, 2001) and some studies tended to be
impressionistic, anecdotal, and outdated (Jackson, 1996; Pilette, 1989; Teschendorff,
1993a; Yahes & Dunn, 1996).
In general, there have been relatively few studies undertaken on overseas nurses’
experiences of practicing in another country and even fewer from an Australian
perspective (Jeon & Chenoweth, 2007; Konno, 2006). The number of studies on
specific groups of overseas nurses is also very limited. A report of a study
undertaken in the US and directly related to this research area was located in 2009
during the analytical process and is addressed in the result chapters (Xu, Gutierrez &
Kim, 2008). This was the only publication found that focused on Chinese nurses.
Thus the above review gives support to an exploration of the experience of China-
educated nurses who work in Australia so that the meaning of their experience is
well understood and potential support services may be better constructed. It is also
suggested that the use native language of the participants in interview is preferable.
It also indicates the desirability of research in this area that incorporates a strong
analytical focus.
2.5 Summary The divergent social, economic, political, cultural, and educational differences
between countries are the driving force of labour migration. With developments in
35
transportation, communication, and information technology, migration has become
much easier (Arends-Kuenning, 2006) and has seen the number of international
labour migrants and particularly skilled and women migrants increase exponentially.
Nurse migration is part of this phenomenon. A key factor is the persistent nurse
shortage of recent years which has promoted international recruitment. As a result,
the number of overseas nurses entering Australia is increasing, notably from non-
English speaking Asian countries such as China and this trend can be expected to
expand in the future (Jeon & Chenoweth, 2007).
This chapter has addressed nurse labour migration related issues including the ethics
of overseas recruitment, the safety and quality of nursing care, the valuing of
overseas nurses, and the experiences of overseas nurses. Research has found that
overseas nurses in general have a negative experience of practicing in another
country and that there are a wide range of contributing factors (Konno, 2006). It is
understood that overseas nurses do not constitute a homogeneous group and it is
necessary to understand their experiences from an ethnic perspective in order to
meet their particular needs and to better support their practice in the Australian
health care system (Konno, 2006). The following chapter argues the theoretical
underpinnings of the study in drawing on some key concepts from the works of
Mead, Blumer, and Goffman all of whom are associated with the symbolic
interactionist perspective.
36
37
Chapter 3 Theoretical Perspective 3.0 Introduction This study was conceived within a SI framework with some attention to the
constructivist view. This chapter begins, therefore, with an introduction to SI and its
pragmatist origins. What follows is a brief discussion of some of the major
intellectual influences that ultimately saw George Herbert Mead engage with the key
SI concepts of mind, self, and society. This leads directly on to an overview of the
Chicago School of SI from the perspective of Herbert Blumer. The chapter
concludes with consideration of contemporary analytical SI interpretations and the
key concepts that form the theoretical framework of this research.
3.1 General introduction of SI With a focus on relationships between symbols (also known as social meanings) and
interaction (both verbal and non-verbal), SI is widely regarded as the most
sociological of all social psychological perspectives (Charon, 2007). It has its origins
in a critique of explanations of human behaviour as solely biologically and
physiologically determined and most obviously in a rejection of positivist
explanations of social phenomenon (Charon, 2007; Meltzer, Petras, & Reynolds,
1975). SI was derived largely from interpretations of the 1920s teachings of George
Herbert Mead (1863-1931) and was named by his student follower Herbert Blumer
(1900-1987) around 70 years ago.
Although many consider the SI perspective a homogeneous approach, at least four
variations have been identified: the Chicago School (George Herbert Mead and
Herbert Blumer), the Iowa School (Manford Kuhn and Carl Couch), the
Dramaturgical School (Erving Goffman), and the Ethnomethodological School
(Harold Garfinkel), each with its own intellectual roots and characteristics (Edgley,
2003; Katovich, Miller, & Stewart, 2003; Maynard & Clayman, 2003; Meltzer et al.,
1975; Musolf, 2003). The work emanating from the Chicago School at the
University of Chicago, which has continued the classical tradition of Mead and
Blumer, has been by far the most influential. It is this latter body of knowledge
combined with the work of Erving Goffman that is theoretically pertinent to this
38
research.
SI also reflects a range of intellectual influences which makes it problematic to
summarise concisely. Yet, regardless of the varying ways in which SI has been
interpreted, most of those identifying with this approach trace its principal origins to
pragmatism and related intellectual influences (Meltzer et al., 1975; Reynolds,
2003a, 2003b) each of which is now addressed in turn.
3.2 The pragmatist tradition It is generally accepted that, as an American philosophy, pragmatism exerted the
greatest influence on the development of SI (Reynolds, 2003b).3 The close
association between pragmatism and SI is evident in the fact that some refer to the
pragmatists as early interactionists (Musolf, 1989). The pragmatist influence
emerged largely from the writings of Charles Sanders Peirce (1839-1914), William
James (1842-1910), James Mark Baldwin (1861-1934), Charles Horton Cooley
(1864-1929), John Dewey (1859-1952), William Isaac Thomas (1863-1947), and
George Herbert Mead.
As the father of American semiotics (the study of signs), it was Charles Sanders
Peirce who first invented the term pragmatism (Page, 2000). In rejecting the idea
that mind and physical processes are separate, Peirce (1955) argues that mental
activities correlate with the underlying physiological activities of the brain.
According to Peirce (1955), consciousness and thinking are made possible through
signs (language) which represent reality. The existence of consciousness and the
ability of mind to manipulate signs is a result of evolution.
For Peirce (1955), the meaning of an object is embedded in the perceived effect of
an object on humans and in the response of humans to an object. More importantly,
as Peirce (1955) pointed out, signs were not neutral, but associated with sensations
(emotions). Signs and the associated sensations combined act as a means of guiding
3 The term pragmatism was first used in 1878 by Charles Sanders Pierce who argued that to understand the meaning of thought we need first to determine what action the thought will produce.
39
conduct.
Named as the father of American psychology, William James is a further noted
pragmatist. Three concepts of James proved to be central to the development of SI:
habit, instinct, and self. According to James, habits arose from past experiences
through repetition and served to modify and inhibit instincts (Meltzer et al., 1975).
Therefore, it is habits rather than instincts which function to maintain social order.
The view that human behaviour is not instinctive is even more obvious in James’s
conceptualisation of a social self distinct from the material and spiritual selves in
human beings. Social self is the desire to receive recognition from and to make an
impression on significant others (James, 1890). In James’ terms, an individual has
different social selves in different contexts and these selves function to influence
human behaviour. In addition, self and others are distinct but they do not exclude
each other (James, 1890). People and things in the environment belong to the self, as
far as they are felt as “mine” (James, 1890). In this sense, self is considered as a
product of interaction with others.
Furthermore, James was critical of the “reflex-arc” concept which reduced
behaviour to basically a nerve response and argued instead that interest and attention
affect human actions (James, 1890). This provided the beginning of a non-mechanic,
non-reductionistic view of human behaviour. It also meant that human beings were
perceived as distinct from the physical world in the sense that they can instil the
meanings of objects in their minds and thus render the social world subjective rather
than objective (James, 1890).
Named “the father of American social psychology”, James Mark Baldwin also
attacked biological determinism and advanced James’s concept of habit to make it
more social than psychological (Musolf, 1989).4 To Baldwin, habit is socially
learned and individuals cannot be separated from society (Noble, 1967). One can
only develop selves through imitation and interaction with others and thus society
4 James’ concept of habit was tied to his theory of instinct and was thus psychological.
40
influences the kind of person one becomes (Baldwin, 1894).
The importance of the relationship between the individual and society was pursued
further by Charles Horton Cooley who is well known for his concepts the primary
group, sympathetic introspection and looking-glass self (Cooley, 1983; Meltzer et al.,
1975; Reynolds, 2003a). The primary group is a small number of significant others,
such as family members and peer groups, with whom one has frequent face-to-face
interaction (Meltzer et al., 1975). Cooley argues that through one’s primary group,
basic behaviour is formed and the individual becomes a socialised member of
society (Meltzer et al., 1975).
The emphasis of the role of emotion and sentiment in human behaviour is reflected
in Cooley’s concept of sympathetic introspection (Cooley, 1983). As Cooley argues,
people use sympathetic introspection to imagine situations as perceived by others.
Individuals spend much of their lives living in the minds of others (without knowing
it) (Cooley, 1983, p. 208). This implies individuals are influenced by others (Cooley,
1983).
From here Cooley (1983) drew the concept of the looking-glass self to depict the
formation of the individual’s sense of self based on the perceived response of others
and particularly within the context of primary group. As Cooley (1983, pp. 182-185)
articulated, there are three components of the looking-glass self: the imagination of
our appearance to the other person; the imagination of his/her judgment of that
appearance, and some sort of self-feeling, such as pride or mortification. These
theoretical tenets added force to the proposition of the individual and society as
inseparable: there can be no individual apart from society; and society is a product of
the individual mind.
In considering the relationship between the individual and society (or social groups),
John Dewey returned to the concept of habit. However, in contrast to James, the
essence of habit for Dewey is not repetitious individual behaviour but “acquired
predispositions to ways or modes of responses” (Dewey, 1957, pp. 40-41). As such
41
and in echoing Baldwin, the conditions which constitute habit have their origins not
in the individual, but in the social order (Meltzer et al., 1975; Reynolds, 2003b).
Dewey also replaced the concept of instinct with impulse. In his view, instincts were
not the cause of social behaviour. Rather, it was impulse that gave new direction to
old habits and gave rise to new behaviours (Dewey, 1957).
Dewey moved on to argue that individuals always act based on deliberation. As
Dewey stated, “…Deliberation is a dramatic rehearsal (in the imagination) of various
competing possible lines of action…” (Dewey, 1957, p. 179). In other words, as
human beings attempt to complete a course of action, they go through a process of
deliberation whereby they respond to the environment selectively.
Dewey’s concept of mind as a function and minded activity as adaptive behaviour in
an ever-changing environment is also significant. According to Dewey, mind
occurred through the process of communication and specifically through the
employment of language (Meltzer et al., 1975). In his revolutionary article titled The
reflex arc concept in psychology, Dewey (1896) extended James’ critique of the
reflex arc conception of human behaviour5 and gave emphasis to the role of
interaction in explaining human and social behaviour. Mead wrote that:
For Dewey the distinction between the organism and the environment is only a
distinction in phases of the process, whether this process is called psychological or
biological…The organism determines its environment as genuinely as the
environment determines the organism (Mead, 1936, pp. 69-70).
Several contributions from Thomas are also of relevance in the evolution of an
interactionist perspective, the most notable being the definition of the situation
concept. In rejecting Watson’s radical behaviourist idea6 that humans simply respond
5 The stimulus-response conception of human behaviour as either purely physical or purely psychological “whichever being selected being an arbitrary matter of personal taste” (Dewey, 1896, p. 370). 6 This view, associated with Pavlov, emphasised physiology and the effect of external stimuli on human behaviour. Watson argued against the use of references to mental status and held that psychology should study observable (overt) behaviour (Watson, 1914).
42
to the objective features of a situation, Thomas argued that “if men (sic) define
situations as real, they are real in their consequences” (Thomas & Janowitz, 1966, p.
301). In other words, the importance of situational influence on behaviour is evident
in that our definition of a situation motivates us to act in a particular way consistent
with the definition (Musolf, 1989). As Thomas pointed out, definitions of the
situation preceded all behaviour:
Preliminary to any self-determined act of behaviour there is always a stage of
examination and deliberation which we may call the definition of the situation
(Thomas, 1931, p. 41).
The importance of understanding why others define situations in a way that leads to
a particular behaviour is that it allows us to understand the subjective meanings of
actions (Meltzer et al., 1975; Musolf, 1989). Definitions of situations may reflect
imbalances of power, but they also imply that one is not totally determined by the
social structure. Thus, some emphasis on subjectivity is needed to explain and
conceptualise the exclusively human behaviour (Meltzer et al., 1975; Musolf, 1989).
The varied theoretical arguments noted above provided a foundation for Mead who
was by far the most influential pragmatist. He is also widely regarded as the true
originator of the Chicago School of SI with his emphasis on linguistically mediated
knowing and acting.
3.3 Intellectual influence of Mead To understand the general positioning of the symbolic interactionist perspective, it is
necessary to address not only the pragmatist influence on Mead’s work but the
influence of Darwinism, German idealism, and behaviourism, all of which remain
central to SI (Charon, 2007).
That Mead was a pragmatist is evident in the key assumptions that underpin his
work. The first is that human beings are active and creative; they influence the world
they live in which, in turn, shapes their behaviour (Charon, 2007; Mead, 1934).
Second, for the human being, truth exists in its usefulness; that is we learn and
43
remember what is useful to us (Charon, 2007). Third, we are selective in what we
notice in every situation. Thus, we see and define objects in our environment
according to their usefulness (Charon, 2007, p. 32). Meaning, then, is not inherent to
objects (Mead, 1934), but lies in the effect they produce. Fourth, action and
interaction, rather than person or society, should be the focus when studying social
phenomenon (Charon, 2007; Mead, 1934; Weinberg, 1962).
In addition to pragmatism, Mead was inspired and influenced by the work of Charles
Darwin on the theory of evolution (Mead, 1934).7 Darwin was a naturalist and
argued that we must understand the world we live in without appeal to a supernatural
explanation (Charon, 2007, p. 33). All behaviour then is considered a constant
adjustment or adaptation to the natural environment. Mead too argued that human
beings must be understood in natural terms (Charon, 2007; Mead, 1934). Thus,
Darwin influenced Mead in thinking of social life as a process, in the state of
becoming, unfolding, and emerging (Charon, 2007).
But Mead went further than Darwin in some key aspects. In Darwinian terms,
evolution in animals is a passive process. Yet, Mead stated that once humans were
formed, language and the ability to reason resulted in human beings becoming active
participants in their environments (Charon, 2007; Mead, 1934). In other words,
echoing Dewey, organisms and environments mutually determine each other (Mead,
1934). Further to this, Mead argued that the ways in which humans act in relation to
a particular situation were learnt through social interaction (Blumer, 1969; Mead,
1934).
An additional influence was German idealism which informed Mead’s theorising in
several ways. One doctrine of German idealism is that the world we live in is self-
created and human beings respond not to the world per se but to their own working
definitions of that self-created environment (Reynolds, 2003b). This notion is crucial
7 Darwinism (evolution through adaptation) differs from Social Darwinism where social inequality was considered the result of natural selection and philanthropic or state interventionism to help the less fit would only do more damage to society than good. Mead was a strong critic of Social Darwinism.
44
to SI. The Darwinian premise that the world evolves and that reality is in a process
of evolution was also reinforced by the German idealists (Mead, 1936). In addition,
Willhelm Wundt, a direct descendant of German idealist thought, influenced Mead
through his writing on gestures and language (Miller, 1973).
Scientifically, Mead was a social behaviourist (Mead, 1934). He argued that as social
beings, humans must be understood in terms of what they do rather than who they
are (Charon, 2007; Mead, 1934). Mead’s (1934) thoughts were indeed always
concerned with action or behaviour. Behaviours from Mead’s (1934) perspective are
social acts that include not only physical behaviour, but also behaviour that takes
place internally and is not directly observable. What we then draw from Mead is that
to understand human overt action, we must comprehend human action as it involves
understanding, definition, interpretation, and meaning (Mead, 1934). We also
recognise these processes as explicitly social.
3.4 Mead and mind, self, and society In 1894, Mead joined the faculty of the University of Chicago where he taught for
his remaining 37 years. Interestingly, Mead never authored a book in his lifetime.
Following his death, his students compiled and edited his lecture notes, unpublished
papers, and manuscripts into a series of four books: The philosophy of the present
(Mead, 1980), Mind, self, and society: From the standpoint of a social behaviorist
(Mead, 1934), Movements of thought in the nineteenth century (Mead, 1936), and
The philosophy of the act (Mead, 1938). Among them, Mind, self and society was the
most influential and contains the most complete exposition of SI.
In this latter work, Mead considered that mind, self, and society were closely
interrelated and social interaction (via language/symbols) accounted for the
development of mind and the presence of self (Mead, 1934). Two forms of human
social interaction are identified by Mead: the conversation of gestures and the use of
significant symbols. For Mead, gestures do not carry ideas with them and thus the
conversation of gestures is a simple stimulus-response and non-significant (Mead,
1934). In contrast, the use of significant symbols involves interpretation of the action
45
(Mead, 1934). This means that human beings engage frequently in the conversation
of gestures as animals do, but their distinctive mode of interaction is at the symbolic
level (Blumer, 1969).
Gestures become significant symbols when individuals who make gestures respond
in a way that is the same as they seek to elicit from the respondents (Mead, 1934). In
other words, the meanings of significant symbols are shared (Mead, 1934). True
communication is thus realised among humans through the use of significant
symbols.
In much the same way, the vocal gesture is significant because “it affects the
individual who makes it just as much as it affects the individual to whom it is
directed” (Mead & Strauss, 1964, p. 36). We respond to our own speech as others do;
its meaning is the same for us as it is for others (Musolf, 1989, p. 383). An extension
of this concept is that the vocal gesture allows us to take into account the attitude of
the person to whom we are addressing our gestures (Musolf, 1989).
Mind, which Mead calls the “reflective intelligence of humans” (Mead, 1934, p. 118)
arises out of the process of social interaction where, as noted above, language plays
a crucial role in its development (Mead, 1934). In Mead’s words:
Mind arises through communication by a conversation of gestures in a social
process or context of experience--not communication through mind (Mead, 1934, p.
50).
The brain and mind are thus not identical. The brain is a human organism while the
mind is a process which is essentially social (Mead, 1934). Mind allows for self-
indication, internally organising our act, and making a delayed response. That is to
say, it is an internalised symbolic covert interaction towards oneself (Mead, 1934).
Following directly from the above and as an object of one’s own awareness, self, too,
is a social construct that does not exist or develop apart from society (Mead, 1934).
The self is distinctively different from the body as self is not there when we are born
46
but appears as a part of social experience (Mead, 1934).
In Mead’s terms, the self consists of I and me. The I is the response of the actor to
the attitudes of others, a more impulsive, psychological and acting part of ourselves;
and the me is the organised set of attitudes of others which one assumes from the
outside world and from others, and is the more reflective and socially aware side of
our selves (Mead, 1934). Put differently, the I represents a selected line of action and
the me represents one’s awareness of social expectations (Charon, 2007; Mead,
1934). What appears in consciousness is always the self as an object, as a me (Mead,
1934). A self exists when one takes on the attitudes of others and can act towards
oneself as others might act (Charon, 2007; Mead, 1934). This is the point at which
we are “aware of another self as a self” (Mead, 1913, p. 377).
Thus, becoming aware of the role of others is an essential mechanism in the
development of self. According to Mead, a child first learns to pretend to be certain
individuals around him/her, deliberately taking on their roles, imitating their
behaviours, seeing him/her self from the perspective of them, and acting towards
him/her self as they do (Mead, 1934). As the child develops, he/she takes the roles of
many others with whom he/she associates and develops a generalised other
(society’s attitudes, viewpoints and expectations) that incorporates the common
responses of those around him (Mead, 1934). To Mead, it is from this perspective,
from the generalised other, that a person develops a complete self.
Self and society are made only possible because of communication (Mead, 1934). To
communicate requires one to see things, including oneself, from the other’s
perspective. Here again the theorising draws on the inseparability of the individual
and society. Humans live in groups, groups of individuals form society, and it is
within a social process that an individual’s mind and self emerges (Blumer, 1969;
Mead, 1934). In other words, individuals act with one another in the mind, take
account of one another as they act, symbolically communicate, and interpret one
another’s acts (Charon, 2007; Mead, 1934).
47
The significance of this theorising is in explaining social order which requires
cooperative actions based on shared meanings, common understandings, and
expectations (Charon, 2007; Mead, 1934). Over time, this cooperative symbolic
interaction necessarily creates a shared symbolic representation of the generalised
other among its members or what we call a culture (Mead, 1934). Culture means the
consensus of the group and the pattern of what people do. Within a culture (or
group), individuals see their actions through the perspectives of generalised others
and use this consensus to guide their own behaviour and also to judge the behaviour
of others (Charon, 2007).
By virtue of ongoing symbolic interaction, society is thus not to be considered as a
set of fixed institutions or structure. Instead, it is a formative process through which
society is constantly constructed and reconstructed (Blumer, 1969; Mead, 1934).
This view of society as continuous action is of paramount importance to SI.
3.5 Blumer and SI Following Mead, the three premises of SI were set down by Blumer. The first is that
human beings act towards things, whether physical objects, other people, social
institutions, ideas, activities, and situations, on the basis of the meanings that those
things have for them (Blumer, 1969, p. 2). That is to say, we assign meanings for
things and those meanings determine how we will act in regard to those things.
Human behaviours are thus not products of various factors such as motives, attitudes,
personality, or role requirements that play upon human beings. Instead, meanings
that things have for human beings are central in the formation of people’s behaviour
and attitudes (Blumer, 1969). This meaning establishes the way a person interprets
something, the way an individual comes to act towards it, and the way he or she is
prepared to talk about it (Colomy & Brown, 1995, p. 22). For instance, if I define a
chair as something to sit on, I will act towards a chair as such and use it as an object
upon which to sit. Someone else may define a chair as a kind of weapon and respond
to it by throwing it towards others.
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The second premise concerns the source of meaning. It is argued that meaning arises
in the process of interaction (communication, broadly understood) with other people
(Blumer, 1969). That is to say and reminiscent of Dewey, our meaning for a thing is
not intrinsic or inherent in the thing itself, nor is it merely an expression of
psychological elements. Instead, our meaning comes from our interactions with
others. As people interact, they use their own meanings for things in the interactions
with others. As the interaction continues, however, the meaning of the thing may
remain constant, may change, or may alter in some way.
Blumer insisted that social interaction is of vital importance in its own right. It is a
process that forms human conduct instead of merely a means or a setting for the
expression of human conduct (Blumer, 1969). The meaning of a thing for a person
grows out of the ways in which other persons act towards the person with regard to
the thing (Blumer, 1969). Thus, I was not born knowing that a chair is something to
sit on. Someone had to show me or tell me its function. If I had to determine its use
on my own, it could only be through an internal conversation I had with myself.
Last, these meanings are handled in, and modified through, an interpretive process
used by the person in dealing with the things one encounters (Blumer, 1969, p. 2).
As we experience things we adapt and modify our understanding of the things. This
process involves communicating with oneself and indicating to oneself the meaning
of the thing towards which one is acting via symbols. At first, I defined a chair as a
sitting object. However, later I saw someone throwing a chair at another which
caused me to re-evaluate my understanding of the possible use of a chair.
Blumer’s other major contribution to SI was the development of a naturalistic
research methodology. According to Blumer (1969), traditional methodology and
their methods and techniques (such as the survey) did not put enough emphasis on
the importance of the meaning that things had for a person in shaping behaviour.
Instead, meaning was viewed as innate to the object itself and thus a dismissible
factor. Although Blumer (1969) believed that an object had an independent empirical
existence, he proposed that sociologists should seek to understand, rather than
49
predict or control, human behaviour.
In understanding, Blumer (1969) started with an interpretive approach to human
nature. Humans do not simply react to another human’s actions; they interpret and
define actions and respond based on the meaning of those actions. A research
methodology must therefore be able to capture information on the meanings and
interpretations held by the individual. This, according to Blumer (1969), can only be
achieved through direct examination of the empirical world.
In summary, from a symbolic interactionist perspective, objects do not have inherent
meanings but assume meanings as people act towards them and these meanings are
then constructed and reconstructed through ongoing social interaction. Realities are
thus the product of processes of interpretation and negotiation. The study of minded
behaviour involves the study of active, interpreting, and interacting individuals. Thus,
in understanding human behaviour, James’ (1890) social self, Cooley’s (1983)
sympathetic introspection and looking-glass self, Dewey’s (1957) notion of
deliberation, Thomas’s (1931) definition of the situation, Mead’s (1934) awareness
of the role or attitude of others, and Blumer’s (1969) human action based on
meaning all suggest that it is fundamental to understand, as best as we can, the
subjective meanings of the actor.
3.6 Critics and contemporary development of SI SI is a perspective. Like all perspectives it is limited because it must focus on some
aspects of the world while ignoring or deemphasising others (Charon, 2007). And as
with all theoretical propositions, SI has been subjected to criticism from both within
and outside the knowledge area (Meltzer et al., 1975). Criticism of SI is directed
primarily at the capacity, or lack thereof, of SI to acknowledge and address social
structures and culture, give consideration to human emotions and unconscious
elements, and to locate any interpretations of society within the macro world of
power, organisations, and history (Fine, 1993; Gusfield, 2003; Kemper, 1978;
Lichtman, 1970; Meltzer et al., 1975; Reynolds & Reynolds, 1973; Reynolds, 1969).
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As we have seen, the perspective of SI puts an explicit emphasis on social process
and the emergent nature of interaction, meaning, and self. In so doing, it stands
accused of marginalising the role of structural factors in shaping human life (Meltzer
et al., 1975). As Stryker argues, the micro focus of SI serves:
…to minimize or deny the facts of social structure and the impact of the macro-
organizational features of society on behaviour (Stryker, 1980, p. 146).
These criticisms are not entirely without foundation. However, it is worth returning
to some early symbolic interactionists’ works where acknowledgement of both the
micro and macro contexts in which action is constructed appears even if not fully
explained. For Mead (1934), role taking is a major means of socialisation . The me
part of self represents the influence of the generalised other which is society and
hence it allows for the influence of the social structure upon self (Mead, 1934). As
Mead (1934) wrote:
It determines the sort of expression which can take place, sets the stage, and give
the cue…Social control is the expression of the “me” over against the expression of
the “I” (p. 210).
The structural influence on social behaviour is also shown in Blumer’s work. He
wrote that:
…action is formed or constructed by interpreting the situation. The acting unit
necessarily has to identify the things which it has to take into account-tasks,
opportunities, obstacles, means, demands, discomforts, dangers, and the like; it has
to assess them in some fashion and it has to make decisions on the basis of the
assessment (Blumer, 1969, p. 85).
And further:
…concerns with organization on one hand and with acting units on the other hand
set the essential difference between conventional views of human society and the
view of it implied in SI. The latter view recognizes the presence of organization to
51
human society and respects its importance (Blumer, 1969, p. 87).
The concept of acting unit as used here may refer to any structure or entity capable
of action. Macro-historical processes and structures not only appear in Blumerian
thought, but Blumer offers an explicit advocacy of their study and significance.
Furthermore, Blumer’s substantive research focused on macrosocial phenomena
such as relations between labour and management and addressed such relations in
terms of a macroanalysis (Blumer, 1958). Blumer, therefore, clearly recognises and
stresses the existence of a broader social and physical environment. He nonetheless
rejects the notion that the broader environment, or some elements of it, is the sole
explanation of human behaviour.
In recent years, the perceived astructural inadequacy of SI has seen an expansion of
SI research focused on the study of social structures (Dennis & Martin, 2005;
Denzin, 1977, 1992; Goffman, 1983; Hall, 1972, 1987; Hochschild, 1979; Maines,
1977; Mills & Kleinman, 1988; Scheff, 1988). Indeed, as Maines (1977) argues,
there is nothing inherent in the SI perspective that precludes the analysis of social
structure and social organisation. In addressing the argued analytical gap, some
symbolic interactionists have used concepts such as negotiated order (Strauss, 1982;
Strauss, Schatzman, Ehrlich, Bucher, & Sabshin, 1963) and structural processes
(Maines, 1977) to indicate recognition of structure in shaping human behaviour. Hall
(1987), for example, argued for an interactionist approach to the study of social
organisations but one which connected the action with structure and history. In
seeking to make this link, Hall drew on the notion of embeddedness where the action
context is facilitated and constrained by its location within, and its relationship to,
another and perhaps larger context (structural context) and its past (historical
context).
The more overt appearance of social structures in SI research is probably the most
significant contemporary development in the area. Nonetheless, for symbolic
interactionists, the emphasis is always on agency no matter how imposing a structure
52
may appear. History and social structure may shape and give meaning to behaviour
but do not determine that behaviour. Actions are, in the first instance, about agency.
From the SI perspective, it is argued that human beings act on the basis of symbols
and thus upon definitions and meanings made possible by symbols. Here, in
emphasising thinking and reflexivity, SI is also criticised for its neglect of the
influence of human emotions and unconscious elements in human conduct (Brittan,
1973; Meltzer, 1959, 1972). As Meltzer et al. (1975) acknowledged, it is true that SI
was incapable of effectively addressing the unconscious and thus ignored this
element. However, some early symbolic interactionists did deal with a wide range of
emotions. For instance, as James (1890) proposed, symbols were associated with
sensations and the sensations associated with symbols, in turn influenced cognition
and conduct. In a similar vein, Cooley (1983) presented a picture of an active
individual influencing the perceptions of others in the process of being influenced by
their perception. If we take Cooley’s (1983) concept of the looking-glass self, it
means that individuals are able to visualise how they appear before others and
experience pride or shame accordingly. The concept of the primary group (Cooley,
1983), which serves as a normative group, becomes the internalised standard against
which the individual judges himself or herself.
More importantly, following Cooley’s looking-glass self, Goffman (1959) depicted
how individuals make shared awareness explicit through self presentation. This,
according to Scheff (2005), implies a fourth step beyond Cooley’s three: the
management of embarrassment or shame. In Goffman’s terms (1959), individuals are
social actors who make a conscious effort to convey an impression that they wish
others to see. Impression management is for the purpose of presenting the best
aspects of an individual or ensuring that one is accurately perceived by others
(Goffman, Lemert, & Branaman, 1997). Indeed, each of us is taught to “act” or “not
to act” in certain ways in front of others through socialisation to avoid shame and
embarrassment (Page, 2000). Here, emotions are attached to the particular image
presented and the actor may feel good or bad dependent upon how an encounter
unfolds.
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In relation to emotion management, Goffman (1959) further conceptualised face as a
desired social image of the self supported by others and one which could be lost,
maintained, or enhanced through social interaction. Individuals experience
embarrassment when face is lost during a particular encounter (Goffman, 1955). In
addition, when the competence or moral standards of individuals are questioned,
those individuals work hard to re-establish positive impressions (Goffman, 1955). A
concern of face motivates people to act in ways which meet group expectations and
as such it acts as a mechanism to maintain social order (Goffman, 1955; Goffman et
al., 1997).
Although some emotions such as love, hate, anger, joy, and sorrow have received
little attention from interactionists, other emotions such as embarrassment and
shame have been widely studied (Cooley, 1983; Goffman, 1959; Meltzer et al., 1975;
Scheff, 1988). SI views emotion as the way in which a person perceives the self and
it represents a reaction to the world surrounding the individual. Many contemporary
interactionists recognise the importance of emotion in shaping human behaviour and
many studies focusing on emotions have been carried out (Charmaz, 1980;
Hochschild, 1979; Mills & Kleinman, 1988; Scheff, 1988; Shott, 1979).
In summary, the view of SI in this study draws not only on the tenets of the classic
Chicago School of SI but also on structural and emotional factors as informed by the
more recent theorising on SI. Finally, the key concepts applied in this research are
addressed below.
3.7 Key concepts drawn from SI This study was informed by the following symbolic interactionist “way of seeing”
and “way of thinking”. The human being is considered an active actor in the
environment, with a self. To understand a social phenomenon, it is necessary to
focus on human action and interaction. These are ongoing dynamic processes
wherein situations are defined and meanings are interpreted. The meanings of
objects, in turn, are made possible by symbols. The emotions associated with
54
symbols and the concerns of impression and face are sources of motivation of
human behaviour. During interpretation, actors take into account structural factors
such as power, organisations, and culture. The interpretation is also based on the past
experiences of actors and their anticipation of the possible consequences in the
future.
The key concepts applied in the theoretical framework underpinning the research are
humans as actors, self, meaning, symbols, emotions, interpretation, action and
interaction, process, situation, social structures, and history.
From the SI perspective, human beings are actors with selves and thus are able to be
symbolic objects of their own actions and to act towards themselves as they might
act towards others (Colomy & Brown, 1995). This capacity of self-interaction
(through defining the situation) gives human action a reflective character and also
considerable autonomy. Thus, the human being is not a passive, conforming object
of socialisation, but an active, creative organism who constructs his or her social
world (Mead, 1934). In other words, human beings construct actions on the basis of
what is taken into account and not simply as a response to external factors (Blumer,
1969; Mead, 1934). From this perspective, action is understood from the position of
whoever is forming the action and the researcher needs to see the situation as it is
seen by the actor. In this study, China-educated nurses were considered actors who
actively constructed the meaning of their experiences and acted upon the basis of
those meanings. A researcher studying the experience must, as much as possible, see
it from the perspective of the actors rather than others.
The self of the human being is a social product (Mead, 1934). It emerges not just
from the individual, but how others perceive the person, and how the person
responds to this perception (Mead, 1934). In other words, self is not fixed, but
constructed and reconstructed through social interaction with others (Mead, 1934).
In this study, the researcher paid attention to how the selves of the China-educated
nurses were constructed and reconstructed and how their identities were negotiated
in the Australian context.
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In acting, humans act on the basis of the perceived meaning of objects, events, other
people, self, and ideas (Blumer, 1969). Meaning is, therefore, not fixed and intrinsic
to the object but rather socially created (Blumer, 1969). This must mean, indeed, that
events, objects, and situations have a multiplicity of possible meanings (Gusfield,
2003) and these meanings change over time and vary from group to group. Thus, a
researcher cannot simply assume the meaning an object or a situation has for the
participant (Gusfield, 2003). To explore the experience of the China-educated nurses,
it was necessary to understand the meanings that they gave to events and situations
and how they were constructed, maintained, and negotiated over time.
This is also true of the human environment. The nature of one’s environment is not
so much determined by its objects,8 but the meanings those objects have for
individuals (Blumer, 1969). People assign different meanings to the same objects
and thus individuals who live in the same area (physical world) may have, indeed,
quite different environments. As Blumer (1969, p. 11) noted, “people may be living
side by side yet be living in different worlds”. We see from this point that in order to
understand the experience of the participants, it is necessary for the researcher to
understand the world of socially defined objects upon which the action is based.
Although working in the same physical context as their Australian colleagues, the
China-educated nurses may exist in a different world of mental objects. To grasp this
world, we need to identify the underlying meanings that are assigned to objects in
the Australian health care system by the nurses.
The meanings of things, other people, the self, and various ideas are made possible
through symbols which arise in the social interaction process and are shared among
social groups (Blumer, 1969; Mead, 1934). The important significant symbols of
human beings are language. As a meaning-making entity, human beings use
language as the dominant medium for communication and meaning construction
(Mead, 1934). Through the use of language, an individual might see him or herself
8 Blumer defines an object as “anything that can be indicated or referred to” (Blumer, 1969, p. 11).
56
as an object, imagine how the self is perceived by others, and regulate his or her
conduct accordingly (Mead, 1934). Symbols and their meanings allow individuals to
carry out distinctively human action and interaction. To study human action,
researchers must pay attention to the symbols participants use and the meanings they
stand for. In this study, the researcher focused on the words (through in-depth
interviews) and their meanings (by interpretation) expressed by China-educated
nurses when describing their experiences.
Every symbol has an emotional component and emotion is increasingly recognised
as no less important than symbols in guiding human conduct (Franks, 2003). As
Shott (1979) argued, “role taking emotions”, such as embarrassment and shame,
motivated people to avoid deviant behaviour. From the SI perspective, emotions are
socially constructed with certain normative standards (Franks, 2003). In this study, it
is acknowledged that human action is based on the meaning of symbols and
associated emotions. Some attention was given to emotion when interpreting how
China-educated nurses made sense of their experience, how they presented themself
when interacting with others and how they were motivated to act in a particular way.
Instead of a conventional stimulus-response sequence (in Darwinian terms), Mead
(1934) argued that human action is a stimulus-interpretation-response sequence.
Human action is not caused by certain factors such as motives, attitudes, role
requirements but rather it is built up and constructed by the individual based on
meaning (Blumer, 1969). The meanings of things, other people, self, and various
ideas are formed through an ongoing interpretive process that occurs during
interaction with others, self, and objects (Blumer, 1969). Thus, meanings are
negotiated and constructed over time and are subject to change. It is the
interpretation process that is unique to human beings and it is the interpretation
process that this research seeks to explore. This means getting inside the defining
process of the actors in order to observe what they take into account and how they
interpret what is taken into account in order to understand their actions. In this study,
to understand why China-educated nurses act as they did, the researcher sought to
explore how they interpreted the objects and events they encountered.
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It has been argued here that human society consists of people engaging in action
(Blumer, 1969). This means that the life of any human society consists of an
essential and ongoing process of fitting together the activities of its members
(Blumer, 1969). Joint actions are characteristic of social interaction and rest on the
ability of actors to take on a role, to grasp the other’s perspective, and to see what
their actions might mean to the other actors with whom they interact (Blumer, 1969).
In other words, actors constantly adjust their behaviour to the actions of others.
Fundamentally, human groups (or society) exist in action and must be seen in terms
of action (Blumer, 1969). This view contrasts with a more dominant perspective
which considers society composed of cultural or social structures. Yet, the
determinism of the structural position leaves little room to conceptualise the active
person who shapes society. In studying the empirical social world, therefore, a
researcher needs to trace the ways in which actions are formed. In this study, the
processes that underpin the experiences of China-educated nurses are the focus of
the inquiry and it is through an understanding of actions that these processes are
revealed.
This requires an understanding of human activity as an ongoing stream of action
whereby humans engage in covert and overt forms of actions (Blumer, 1969; Charon,
2007) and where decision making is constantly influenced by our interaction with
others and with the self (Charon, 2007). Through socialisation, individuals learn to
think and interact with others based on symbols and shared meanings (Mead, 1934).
This points to the fundamental tenet of this study which is that human beings
construct their realities in a process of interaction with others. To understand human
behaviour, it is important to understand how the process of definition and
interpretation of the situation redirects and transforms behaviour (Benzies & Allen,
2001). The actions of China-educated nurses are constantly influenced by social
interaction. To understand these actions, we need to understand that process of social
interaction.
Action is paramount but it also takes place in a context. An individual forms action
58
based on the interpretation of persons, places, and events (Blumer, 1969). Action
thus is the here (context) and now (present) (Gusfield, 2003) and so it is situational.
To understand human action, researchers must know the situation of the actor and
the actor’s definition of that situation (Gusfield, 2003). In this study, it is necessary
for the researcher to understand the situation of the participants and how they define
that situation.
When we interpret the context, we take into account social structures such as power,
gender, race, ethnicity, organisations, and culture. As Blumer (1969) has argued, it is
undeniable that human behaviour occurs within structural (such as power and
organisations) and cultural (such as social expectation, norms, and values)
constraints. Macro-like structures continually affect how individuals define a
situation and actors draw upon their understandings of these structures to develop
their respective lines of actions (Blumer, 1969). We acknowledge, therefore, the
place of structural conditions in providing a social context for interaction. Yet, social
structure, while effectual, is never strictly considered as causal. It does not determine
the action but rather, influences meaning construction (Blumer, 1969). In this study,
it is assumed that social structures shape the actions and experiences of China-
educated nurses through meaning construction and definition of situation.
In the same sense, every action has a history and must be seen within a historical
context. During the interpretation process, actors draw upon their past experiences in
defining the present situation. Although the past is used to guide action in the present,
our histories do not cause what we do in the present (Charon, 2007). The future is
also very important in our definition of a situation because what we do in the present
depends in part on our consideration of the consequences for the future (Charon,
2007; Mead, 1934). We understand from this premise that the actions of China-
educated nurses are caused by their definitions of the here and now. Yet, both past
experience and future anticipation may influence those definitions and thus actions.
In summary, SI provides a persuasive theoretical perspective for studying how
individuals interpret objects and people in their lives and how this process of
59
interpretation leads to action in specific situations (Benzies & Allen, 2001). SI
emphasises the importance of defining the situation through symbols; the centrality
of meaning to human interaction; the necessity of understanding the subjectivity and
human agency of the actor; and a focus on interactive indeterminacy, contingency,
and emergence in human behaviour (Blumer, 1969; Mead, 1934). In addition, the
criticisms of SI were given due consideration in relation to this study. On the issue of
structure and agency, this study tended to focus more on China-educated nurses as
agents who interpreted and thereby constructed their experience. But it was also
concerned with explaining how social structures (such as power, history, social
organisation, culture, and gender) and emotions shaped individual behaviour. It is
the combination of these tenets that situate the study theoretically.
3.8 Summary This chapter has constructed and justified the theoretical framework to be applied in
this research. As background, the chapter provides insight into the range of
intellectual ideas that ultimately shaped the Chicago School of SI. Of these traditions,
pragmatism and the works of Mead have been by far the most influential. Blumer
followed, not only to name SI, but also to extend Mead’s theoretical perspective and
develop it into a distinctive research methodology. This study draws predominantly
on the theoretical tenets of Mead, Blumer, and Goffman. However, the theoretical
perspective also acknowledges criticisms surrounding SI because of its astructural
bias and neglect of emotions. Thus, the key concepts that underpin this study are
humans as actors, self, meaning, symbols, emotions, interpretation, action and
interaction, process, situation, social structures, and history. We turn now to a
detailed exposition of the study methods which is the focus of Chapter 4.
60
61
Chapter 4 Methods 4.0 Introduction While theory refers to a way of thinking about and studying social phenomenon,
method is a set of procedures and techniques for gathering and analysing data
(Strauss & Corbin, 1998). The purpose of this chapter is to describe and justify the
GT methods employed in this study. Although a concurrent process of sampling,
data generation, and data analysis is characteristic of the GT approach, for ease of
description, each method is considered sequentially. In addition, the relevant ethical
issues are addressed and issues of rigour examined.
4.1 Justification of GT methods The value of a qualitative study is that it delves in-depth into complexities and
process (Marshall & Rossman, 1995) whereas quantitative approaches may
oversimplify the complex nature of real-world experiences (Patton, 1990). The
nature of the research question (how and why China-educated nurses give meanings
to the experience of working in Australia) and the fact that the area of research
interest has not been adequately addressed previously calls for a qualitative
exploration.
The methods of GT were chosen for this study because it is generally acknowledged
that the philosophical underpinnings of GT are informed by SI (Charmaz, 2006;
Strauss & Corbin, 1990, 1998). The SI emphasis on language, meaning, self,
interaction, and process complement a GT study (Charmaz, 2006).
A further reason for selecting an inductive approach is that theory building in this
area of knowledge has been largely absent. GT methods allow for an uncovering of
the underlying social processes that are grounded in empirical data (Glaser, 1998).
The main purpose was to generate a theoretical understanding rather than simply
describe the study phenomenon (Glaser & Strauss, 1967). The use of GT methods is
more likely to offer insight, enhance understanding, and provide a meaningful guide
to action (Strauss & Corbin, 1998).
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4.2 GT methods As its name implies, GT moves from data to the development of theory; it is both an
interpretive and an inductive process (Glaser & Strauss, 1967). In this study, GT
provides a constant comparative method for the generation of a theoretical
understanding of the experiences of China-educated nurses working in Australia.
4.2.1 Background of GT GT was first developed in the 1960s by Barney Glaser and Anselm Strauss as a
systematic method of research designed to generate rather than test theory (Glaser &
Strauss, 1967). At that time, grand theory (logic-deductive theorising) and theory
testing (verification) were the predominant approaches to knowledge development
(Glaser & Strauss, 1967). The intention of Glaser and Strauss was to close (what
they argued was) an existing gap between theory and empirical research by turning
the focus to the discovery of concepts and hypotheses relevant to a study area
(Glaser & Strauss, 1967).
Following the initial publication on GT9, Glaser and Strauss parted in their
methodological approaches (Glaser, 1992).10 Glaser remained consistent in his
vision of GT as an objective method of discovery (Charmaz, 2006). This objectivist
approach is founded in the belief that researchers should remain impartial and
objective during data collection and analysis (Charmaz, 2000, 2006). For objectivists,
categories emerge from the data and hold explanatory and predictive power across
different times, spaces, and individuals. Strauss (1987) and his subsequent co-author
Corbin (Strauss & Corbin, 1990, 1994, 1997, 1998) moved the method towards
verification with an emphasis on technical procedures. Yet, just as significantly, the
Strauss and Corbin (1990, 1994, 1998) approach extended the focus of the classic
micro-social processes of GT to include the macro-social dimensions and their effect
on people’s actions.
9 The discovery of grounded Theory: Strategies for qualitative research was published in 1967 (Glaser & Strauss, 1967). 10 There has been much debate surrounding this parting of the approaches, but a discussion of this area is beyond the scope of this chapter (see Duchscher & Morgan, 2004; Corbin, 1998; Glaser, 1992; Heath & Cowley, 2004; Kendall, 1999; Locke, 1996; Melia, 1996; Rennie, 1998a, 1998b; Walker & Myrick, 2006).
63
In recent years, a growing number of scholars have moved GT away from the
objectivist and towards the constructivist position (Annells, 1996; Bryant, 2003;
Charmaz, 2000, 2006). According to Charmaz (2000, 2006), a constructivist view
places emphasis on how data are interpreted. This latter perspective acknowledges
that a neutral position is impossible and hence that data collection and analysis are
influenced by the researcher’s theoretical beliefs and interactions with participants
(Charmaz, 2000, 2006). For constructivists, meaning is the centre of inquiry and the
results are contextualised. In other words, the theoretical concepts serve as
interpretive frameworks and offer an abstract understanding rather than a tidy theory
for explanation and prediction.
4.2.2 Modified constructivist GT The methods applied in this study depict a modified constructivist GT approach
informed by a combination of the Glaserian and constructivist positions (Charmaz,
2000, 2006; Glaser, 1978, 1992, 1998, 2001; Glaser & Kaplan, 1996; Glaser &
Strauss, 1967). This choice was made partly because GT was used as a set of
analytic tools rather than a methodology in this study. The work of Glaser provides a
flexible yet rigorous guideline of analysis which minimise forcing of data into
preconceived concepts. The choice is also to acknowledge that although the
philosophical starting points of Glaser and Charmaz are quite different, their
technical coding steps are similar. Indeed, Charmaz (2000, 2006) cites extensively
from Glaser on coding techniques in her works. The Strauss and Corbin (1990, 1998)
coding approach is largely disregarded in this study because it diverts attention from
analysis of data towards techniques and procedures and thus might inhibit the
important function of creativity (Glaser, 1992). Finally, Charmaz’s constructivist
view fits well with pragmatism and SI where research outcomes are the result of
interpretation rather than the discovery of something that is given and out there
(Charmaz, 2006).
A continuum can be identified between objectivist and constructivist GT (Charmaz,
2000). Many agree that the positions of Mead, Blumer, and Glaser are of the critical
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realist position (Kirkham, 1995; Lomborg & Kirkevold, 2003) and that of Strauss
and Corbin is much closer to a relativist, subjectivist position. Constructivism is
discernible in Strauss and Corbin’s work in their insistence that a developed GT is a
rendition of “a reality that cannot actually be known, but is always interpreted”
(Strauss & Corbin, 1990, p. 22) and in their claims that knowledge per se is linked
closely with time and place and that truth is enacted (Strauss & Corbin, 1994).
Nonetheless, Charmaz (2000) is probably the first to overtly advocate a
constructivist GT which she defines in terms of the relativist assumption of multiple
realities and the recognition of the mutual creation of knowledge by the researcher
and the researched. Charmaz emphasises the distinction between reality and truth as
follows:
A constructivist grounded theory distinguishes between the real and the true. The
constructivist approach does not seek truth--single, universal, and lasting. Still, it
remains realist because it addresses human realities and assumes the existence of
real worlds (2000, p. 523).
In criticising many grounded theorists for writing as if data has an objective status,
Charmaz (2000) argued that events took place and were reported to others as
representations. Researchers are dealing with their own constructions and
interpretations of the research participants’ construction and interpretations. Thus,
the product of the research does not constitute the reality of the participants as such,
but builds an insightful framework that is relevant and useful. In other words, the
research product is influenced by the world view of the researcher and the
definitions of the situation that the researcher relies upon. As such, in the words of
Charmaz (2000, p. 523), “a grounded theorist constructs an image of a reality, not
the reality--that is, objective, true, and external”.
In shifting somewhat from the position of Charmaz, the methods in this study
conform to a realistic ontology that assumes that there is a real world out there, but
that the world is known through subjective interpretation and thus is incomplete and
evolving. In other words, our subjective interpretations are not all that exist because
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there is a reality that is independent of our descriptions (Searle, 1995). This explains
the modified position taken here which sits in direct contrast to the relativist premise
that reality is multiple and there exist as many such constructions as there are
individuals (Guba & Lincoln, 1989; Kwan & Tsang, 2001). Indeed, the relativist
view becomes problematic if it moves us to an absolute position where all views of
the same situation are considered equally valid (Fox, 2001; Olssen, 1996) and thus
where anything goes.
The position of this study, therefore, lies somewhere between Strauss and Corbin
and Charmaz. It accepts Charmaz’s distinction between reality and truth. It also
acknowledges a constructivisitic epistemological premise that the researcher and the
researched influence each other during interaction (Charmaz, 2000, 2006).
Knowledge is therefore created and constructed during the research process among
the researcher and participants. As a result, research inquiry is necessarily value-
bound and a certain degree of bias and subjectivity is unavoidable (Charmaz, 2000,
2006). My personal experience, in combination with my cultural background, gender,
racial and social affiliation, impact upon the way I make sense of the world.
But importantly the study also adheres to the view that although we may not entirely
know reality, we must presuppose reality for otherwise we drift into solipsism (Fox,
2001; Olssen, 1996). We therefore accept the assumptions of a constructivist GT
apart from the relativist ontology of some constructivist works. In adopting a
modified constructivist GT approach, the researcher can move GT methods further
into the realm of interpretive social science consistent with a Blumerian emphasis on
meaning and the existence of a real world (Charmaz, 2000).
The following outlines the research process and engages with key concepts critical
to the GT methods. While the sampling and data generation process as articulated
here appears linear, it was recursive in its application. Also, it is worthy of note that
in a GT study this process evolves in accordance with the data generated and the
proceeding analysis.
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4.3 Recruitment procedure This research was conducted in two major cities in Australia: Brisbane and Adelaide.
The study participants were recruited using the same approaches in both regions: a
call for participation and snowballing.
First, a call for participation was advertised in the publications of the Queensland
Nursing Union (see Appendix A) and the Australia Nursing Federation (see
Appendix B). The initial notice included the possibility of a focus group. Focus
groups were ultimately not used as a data generation strategy. Furthermore, nurses
born and educated in Taiwan were included in the recruitment advertisement but it
was subsequently decided to confine the sample to Mainland China due to social and
economic differences. Interested participants were asked to contact the researcher.
Appointments for the interviews were negotiated with potential participants
following initial contact. Second, snowball sampling was undertaken to recruit
further participants. This was done by requesting participants to refer people they
know who might be interested in participating to the researcher.
Gaining trust from potential participants is essential in the recruiting process. On
most occasions, initial contact with potential participants was via email or telephone.
Detail matters in gaining trust and thus much attention was paid to factors such as,
how participants would be approached, how I presented myself as a researcher, and
how the research project was explained.
Snowball sampling proved to be successful and 15 out of 28 participants were
recruited through this strategy. To further develop the categories, 18 of the initial
participants were invited and agreed to undertake second interviews. Recruitment of
study participants took place over a 13 month time frame, resulting in 22 interviews
with 13 participants in Adelaide and 24 interviews with 15 participants in Brisbane.
4.4 Ethical considerations Ethical approval for the study was granted by the Human Research Ethics
Committee of the Queensland University of Technology. When a potential
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participant demonstrated interest in participation by contacting the researcher, he/she
was screened for inclusion criteria and then given the information sheet (see
Appendix C) and consent form (see Appendix D). Prospective participants were
given time to read and think about the study before making a final decision to
participate.
Prior to the interview, the study was explained to the participant, including the
purpose, the procedures for data collection, potential risks and benefits, time
commitment, the rights of the participant, and strategies to protect privacy and
anonymity. Also, an opportunity to ask questions was given prior to signing consent
form to ensure the participant was fully informed.
Participation in this study was voluntary and participants were free to withdraw at
any time without penalty. A decision to participate or not would in no way impact
upon the work situation of a participant. No coercive or deceptive tactics were used
to encourage participation. Participants were recruited through their professional
organisations and personal contacts rather than their employers.
In the snowball sampling the researcher asked the initial participants, on the basis of
their own experience of being interviewed, to consider if they could recommend the
research to others who might be interested in participating. If agreed to, the
participants were requested to give the information sheet about the research to the
potential participants. The researcher did not seek any information about the
potential new participants but waited until they made contact in relation to the
research.
Privacy and anonymity of participants were ensured by the development of a master
list that identified participants by an assigned code. This list was kept separately in a
locked filing cabinet away from the transcripts and audio-records. Only the
researcher had access to the key and the list. The master list and electronic
recordings will be destroyed at the completion of the research. No names or other
identifiers such as place of employment or geographic region appeared in the
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transcripts, field notes, reflexive journal, memos, or presented data. All electronic
transcripts, field notes, reflexive journal, and memos were stored in a password
protected computer accessible only to the researcher. The researcher was responsible
for transcribing all interviews.
No physical risk to the participants was anticipated. It was possible that participants
might feel emotional or psychological discomfort in reflecting upon their
experiences during or following interviews. A plan for risk management included
continuous assessment of a participant’s level of comfort and anxiety throughout the
interview, terminating the interview, rescheduling it for a later time if discomfort or
anxiety occurred, and a referral of participants to a free counselling service at the
Queensland University of Technology if they so desired. In addition, participants
were informed that they could refuse to answer any question at any point in the
interview. None of the participants experienced emotional distress and no referrals
were required in this study.
4.5 Sampling strategy A GT sample is not entirely pre-determined as is the situation in quantitative
research where participants are ideally statistically representative of a broader
population. The sampling strategies applied in this study were purposive sampling
and theoretical sampling.
Purposive sampling was used at the start of the research to select participants who
met the following inclusion criteria. Each participant had:
• been born in Mainland China;
• studied nursing in Mainland China, registered as a nurse and had work
experience in Mainland China; and
• migrated to Australia and worked in the Australian health care system as an
RN for at least six months.
For the purposes of this study, only nurses from Mainland China were included in
acknowledging that the health care systems of Taiwan and Hong Kong are
69
significantly different and warrant separate examination. The six month time frame
specified in the inclusion criteria was to ensure that the participants had a reasonable
amount of exposure to the study phenomenon. Diversity of demographic
backgrounds for participants was preferred to maximise variation and thus enhance
transferability of the study findings.
For ease of organisation, the first few interviews were conducted in Brisbane where
the researcher was studying. Those China-educated nurses who worked in Brisbane
and contacted the researcher after seeing the advertisement were the first few invited
to participate.
As the analysis proceeded, theoretical sampling11 was employed based on the
emerging analysis. Theoretical sampling is a distinctively GT method. It is a process
whereby concepts, categories, and conceptual ideas are elicited from raw data
through constant comparison and used to direct further data generation (Glaser,
1978). In other words, it is the means by which a researcher develops categories and
builds theories. Unlike other sampling techniques, the researcher who uses
theoretical sampling cannot know in advance precisely what to sample for and where
the sampling will lead because of the emergent nature of this method (Glaser, 1978).
Strauss and Corbin (1990) make the important point that theoretical sampling is not
only about the selection of participants, but also about the selection of incidents by
way of altering the interview questions. This form of sampling is thus based on
incidents and not on individuals per se (Strauss & Corbin, 1990). Alteration of the
interview questions to meet the needs of the ongoing theory development was
widely used in this study.
In addition, the researcher also used theoretical sampling to select participants with
particular experiences or characteristics to meet specific needs identified through
data analysis and relevant to the theory development. One example was the
11 Theoretical sampling considers what is theoretically relevant, what is absent (Strauss, 1987), analytic sampling of incidents and maximisation sampling to elaborate the theory (Glaser & Strauss, 1967).
70
revelation, after the initial analysis of the first eight interviews, that marital status
had a considerable influence on participant experience. As such, the researcher
sought China-educated nurses who were married and with their partners living in
Australia, to further refine the theory.
A further point to consider was that theoretical sampling may include sampling
within and outside a substantive research area. In this study, the sampling was
limited to the substantive area because the researcher intended to develop a focused
theory applicable to one substantive group only (Glaser & Strauss, 1967). Indeed,
the extent to which it is necessary for a researcher to go outside the substantive area
is debatable (Glaser, 1978, p. 51). As Glaser (1978) has argued, sampling outside the
substantive area before an emergent theoretical framework is stabilised may
undermine theory relevance.
For Glaser and Strauss the process of theoretical sampling continues until the point
of theoretical saturation is reached. Saturation means that no additional data are
being found whereby the researcher can develop properties of the category (Glaser
& Strauss, 1967). Yet, making a theoretically sensitive judgment about saturation is
always subjective and never precise (Glaser & Strauss, 1967, p. 64). Rather, the
decision is “a matter of degree” in that:
It is more a matter of reaching the point in the research where collecting additional
data seems counterproductive; the “new” that is uncovered does not add that much
more to the explanation at this time (Strauss & Corbin, 1998, p. 136).
Although the point of saturation is open to interpretation and criticism,12 the concept
was used to guide this study. After 39 in-depth interviews, a reasonable degree of
theoretical sufficiency had been achieved and there was no new information
emerging in the form of category, sub-category and property. Aware that saturation is
always provisional and tentative and that enough data is needed in order to be
persuasive, participant interviews were continued to strengthen the abstract
12 See for example Morse (1995) and Suddaby (2006).
71
connections between categories. This resulted in a total of 46 interviews with 28
China-educated nurses who work in Australia.
4.6 Participant demographics Basic demographic information was collected from each participant using a pre-
designed questionnaire (see Appendix E). The demographic data acquired for the 28
participants in the study is as follows. Although gender was not specified as an
inclusion criterion, all participants were female. The age distribution was 20-30
years (16 participants); 31-40 years (10 participants); and 41-50 years (2
participants). Among the 28 participants who were interviewed, 4 held a three-year
diploma in nursing, 18 held a baccalaureate degree in nursing, and 6 had a
postgraduate qualification. As to marital status, 15 were single, 11 married, 1
divorced, and 1 separated.
Participants in this study came from nine provinces and three municipalities in both
the northern and southern parts of China: Beijing city, Shanghai city, Chongqing city,
Liaoning Province, Henan province, Jiangsu province, Hubei province, Anhui
province, Hunan province, Zhejiang province, Fujian province, and Guangdong
province. They had a range of 1-20 years nursing experience in China before
immigrating to Australia. More specifically, 10 had 1-5 years; 13 had 6-10 years; and
5 had 11-20 years experience. Of all the participants, 24 had worked as RNs and 2 as
nurse managers and 2 had been lecturers in nursing schools in China.
Participants were employed in a variety of health care settings in Australia, including
public hospitals (21 participants); private hospitals (7 participants); and nursing
homes (1 participant).13 The employment status of participants was full time (26
participants); part time (1 participant); and part time/casual (1 participant).
Participants also worked in different departments of health care facilities, including
medical/surgical (11 participants); intensive care/cardiac care/high dependency (9
participants); oncology (2 participants); aged care (1 participant); theatre (1
13 Note: one participant worked at both a public and private hospital.
72
participant); dialysis unit (2 participants); and rehabilitation (2 participants). The
employment positions of the participants ranged from graduate nurse program (level
1 year 1) to level 2 year 1, with 14 participants employed at level 1 year 1 to level 1
year 5 and 14 participants above level 1 year 5.
The work experience of the China-educated nurses in Australia ranged from six
months to four years. For 9 participants this experience was less than 1 year, for 11
participants 1-2 years, and for 8 participants more than 2 years. Furthermore, eight
participants had work experience in countries other than China and Australia: one in
Oman and seven in Singapore. Finally, only 8 of the participants lived with their
nuclear family in Australia and another 20 resided without family members.
4.7 Data generation strategies and sources The choice of data generation method is determined by the nature of the research
question. Interviews are particularly suited for studying people’s experiences and
elaborating their perspective on the world (Kvale, 1996). In this study, in-depth
interviews allowed the researcher and participants to move back and forth in time, to
reconstruct the past, interpret the present, and predict the future (Rubin & Rubin,
2005). It was used as the major means of data generation to capture the information
on the experiences of China-educated nurses. The interview methods implemented
are described below.
4.7.1 In-depth interview An interview is a conversation that has a structure and a purpose (Kvale, 1996). It is
flexible and dynamic and directed towards understanding participants’ perspectives
on their experiences as expressed in their own words (Taylor & Bogdan, 1998). The
format of the first three interviews in this study was largely unstructured which
provided the freedom to explore the study phenomenon. Along with the analysis, the
interview became more focused gradually.
The interviews in this study were conducted face to face. Although a telephone
interview may have been more convenient, it was rejected in this study because of
73
the loss of non-verbal cues which was important in interpreting meaning (Berg,
2009). Two practice interviews were conducted prior to the formal study interview to
refine skills and increase the researcher’s confidence.
Interviews were conducted at locations that were convenient to the participants and
which would offer the most privacy. Most chose to be interviewed in their own home
(35 participants) and others were interviewed in the workplace (5 participants) and a
meeting room in the researcher’s university (5 participants). A further interview took
place in a coffee shop.
An interview checklist including all the material needed for the interview was
developed (see Appendix F). Prior to the interview, the checklist was used to ensure
that all supplies needed were at hand (such as a notebook, a pen, a digital recorder,
and some water) and functioning to avoid disruptions.
Each interview started with some casual conversation to put the participant at ease
and for the purpose of explaining the study. The voluntary nature of the research was
emphasised. After the consent form was signed and permission for interview
recording secured, the participants were asked to fill in a demographic form. The
interview then proceeded.
In this study a few questions were prepared to provide direction if needed. The initial
interview question, broadly posed and designed to encourage a conversation, was
along the lines of: Tell me of your experiences of working as an RN in the Australian
health care system. This broad question was consistent with the principles of GT and
allowed the participants to direct the focus of the conversation that followed. In
addition, follow-up questions were used to encourage elaboration of responses when
necessary. Probing questions were used to ensure clarity. Some examples of probes
were as follows: Can you give me an example of that? Could you tell me a little
more on that? What happened next? Aware of the importance of solid data in theory
construction, the researcher sought to ask meaningful questions and in a sensible
way.
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The interview questions in this study evolved across the interviews as part of
theoretical sampling described above. Following some initial analysis of the data of
the first six interviews, the interview questions were refined, added or deleted to
meet the needs of the ongoing theory development. One example was the
appearance of the concept of invisible loss during early analysis. In exploring this
further, the next few participants were asked: In my previous interviews, some people
mentioned an invisible loss caused by immigration. Have you experienced something
like this? These types of questions guided discussion and were eventually discarded
when categories became saturated. The researcher kept in mind that pre-established
questions acted as a guide only and it was important to remain open to the flow of
the participants, as new ideas arose during the interviews. One example of the
interview questions used for the seventh interview is shown in Appendix G.
The quality of interview data is influenced by the nature of the relationship between
researcher and participants (Popay, Rogers & Williams, 1998). Rapport building
with participants was thus essential to increase the researcher’s chances of hearing
the “true story” (Berg, 2009). In this study, rapport was established over time and
through the use of several strategies. First, the format of the interview was one of
conversation rather than pursuing questions one by one in rapid succession. Second,
active listening was deemed important in showing respect to the participants. The
researcher’s role was to facilitate articulation of the experience. Third, the researcher
used quite neutral non-verbal cues such as nodding to support the participant during
interview. Finally, participants were reminded that there was no right or wrong
answer and that any experience that they chose to share was of interest.
After 28 interviews with 28 participants, the theoretical categories for this study
were tentatively established and data generation became more deliberate with the
intent of expanding and refining certain conceptual categories. The same participant
pool was invited for a second interview. There were many advantages in undertaking
second interviews. First, by that time, the researcher was familiar with participants
and had a better sense of who would be a rich source of data following initial
75
analysis. Second, a trusting relationship between researcher and participant was
established. Third, compared to the first in-depth interview, the second was far more
focused which for new participants may have appeared quite rigid and prescriptive.
Undertaking a second interview with the same participants eliminated any issues as
they had been given an opportunity to talk freely on the previous occasion. Of the 28
participants, 18 were invited to engage in a second interview. This decision was
made on the bases of addressing specific conceptual gaps and the knowledge that the
invited participants would be a rich source of data.
Chinese was the interview language and data were collected through the eyes and
ears of a Chinese nurse. Interviewing in the first language helped maximise the
quality of data (Twinn, 1998). The researcher’s familiarity with the culture and
language of the participants was an advantage in facilitating an in-depth
understanding and interpretation of verbal and non-verbal clues (Barnes, 1996).
The interviews were audio-recorded digitally. Although Glaser (1998) does not
recommend recording, it has the advantage of capturing data more faithfully than
hurriedly written notes. It also means that the researcher’s attention was on the
conversations with participants and not note taking.
The pace of interviews was adjusted to suit individual participants. Interviews in this
study lasted from 40 minutes to 158 minutes, with a mean of 72 minutes. In addition
to formal audio-recorded interviews, there was follow up telephone and email
contact with some participants for data clarification.
4.7.2 Other data sources Outlined in the following section are the additional methods of field notes and
reflexive journaling which supplemented data gathered in interviews. In accordance
with GT, the literature was also used as an additional source of data to expand
understanding of concepts and to fill conceptual gaps. To reduce redundancy, these
data appear in the result chapters.
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Field notes were taken by the researcher in English immediately following an
interview to record details of the observations, interactions, environment, and body
language of the participants. Specifically, the notes addressed the following:
• information shared by participants before and after the formal interview;
• description of the interview setting, the participant’s nonverbal behaviours,
activity of other persons present during the interview, distractions,
interruptions, and the researcher’s response to the interview;
• an overall impression of each interview and the quality of the data collected;
and
• an evaluation of the performance of the interviewer and areas for
improvement;
As Glaser (2001) proposed, in GT, all is data whatever the source. It is not just what
is being told, how it is being told, but the conditions under which it is told (Glaser,
2001). The interactive dynamics in the interview situation served as additional data
and were used to inform subsequent interviews.
Since the researcher was the data generation and analysis instrument, there was
some imperative to consider how researcher subjectivity could influence the research
findings (Gasson, 2003; Mays & Pope, 2000). For that purpose, a reflexive journal
was written in English by the researcher at least weekly to record the subjective
feelings, thoughts, decisions, and problems generated during the research process.
Reflexive strategies included remaining aware of personal values and the influence
of the researcher’s role in the interview process; attending to emotional reactions and
thought processes in response to the data; examining the self in the process of
theoretical interpretation of the data; and documenting these processes to objectify
the subjective influence. Some examples of reflexive journaling are shown in
Appendix H.
The journal was included as a data source and as a contribution to theoretical
sensitivity during analysis. It was also used as one strategy to achieve transparency
77
and to ensure rigour in the research process.
4.8 Data analysis After the completion of an interview, the audio-recorded data were transcribed
verbatim by the researcher into a Microsoft Word document with numbered pages
and lines and an extra-wide right-sided margin. The transcription was undertaken in
Chinese in order to ensure that meaning was not lost and that the information
provided by the participants was not taken out of context.
Following transcription, the recordings and transcripts were reviewed for accuracy.
The length of sentences was reproduced from the original speaker. In addition,
emphasis, pauses, and significant non-verbal language from field notes were added
to the transcripts where appropriate. All identifying information was removed and
replaced with numbers and/or generic terms to represent that information.
In accordance with GT methods, data analysis started after the first interview. First,
field notes of the interview were reviewed. Second, the researcher listened to the
interview recording several times. Special attention was paid to the nuances of
meaning carried by voice inflection and voice tone which were not readily available
in the transcription. The transcription was also read several times to allow additional
immersion in the data and to get a sense of the whole picture.
The constant comparative method is a core component of GT analysis which
requires the researcher to move back and forth between data generation and data
analysis. It is used primarily for generating concepts and conceptual growth (Glaser
& Strauss, 1967). It is also indispensable for theoretical sampling wherein data
collection, sampling, and analysis take place simultaneously (Glaser & Strauss,
1967).
Through constant comparison, incoming data were constantly compared with
previous data and concepts or categories emerging from one stage of data analysis
were compared with concepts or categories emerging from the next stage of data
78
analysis. In other words, old data were constantly revisited and re-analysed as new
concepts appeared that had not been coded in the earlier analysis. This constant
comparative method provides a verification of developing categories by constantly
redesigning and reintegrating theoretical concepts as new data enter (Glaser &
Strauss, 1967). This process of constant comparison continued during the whole
research process through a series of reiterative coding steps: initial coding, focused
coding, and theoretical coding (Charmaz, 2006).
4.8.1 Initial coding Initial coding involves breaking down the data to conceptualise them (Charmaz,
2006). In this study, incident by incident coding was employed which allowed the
researcher to remain open to possible theoretical directions (Charmaz, 2006). It is
important to note that while the data were fractured, the meanings of incidents were
examined in context.
Initial coding was conducted in Chinese. In accordance with SI, the researcher was
particularly interested in preserving the meaning and actions of the participants. As
such, in vivo codes (direct words or phrases used by participants) were used
wherever possible. On other occasions, codes were constructed by the researcher to
represent the meaning elicited from the incident (Charmaz, 2006).
All data in this study were subject to initial coding and the resultant codes adhere
closely to the data. All constructed codes were also provisional at this stage
(Charmaz, 2006). Using constant comparison as described above, modifications
were made over the period of analysis. Although a lengthy and labour intensive
process, initial coding was necessary to make the theory grounded. Some examples
of initial coding (translated from the Chinese version) are shown in Appendix I.
4.8.2 Focused coding The second phase of analysis was focused coding which occurred after some strong
analytic directions were established through initial coding. At this stage, the
researcher began to use the most significant and/or frequent earlier codes to sift
79
through larger segments of data and the codes were more directed, selective, and
conceptual (Charmaz, 2006). However, attention was also paid to the possibility of
any significant new codes that appeared in the data.
Chinese was used for focused coding and codes were then translated into English for
further comparison. The researcher attempted to use words that reflected action and
process wherever possible in the English version of codes (Charmaz, 2006). Some
examples of focused coding are shown in Appendix J.
The researcher compared data to data to develop focused codes and also compared
data to these codes in order to refine them further (Charmaz, 2006). The codes were
then compared with each other and grouped according to shared meanings. Concepts
were then condensed or collapsed, gradually developing into more abstract tentative
categories and sub-categories which reduced the number of units for ongoing
analysis (Charmaz, 2006).
4.8.3 Theoretical coding Following focused coding, theoretical coding was employed to conceptualise
possible links between categories and to move the analysis beyond description
(Charmaz, 2006). Theoretical codes are integrative and bring together the fractured
data in such a way that the result is a coherent analytic story (Charmaz, 2006). The
important point here was to remain open and to let the relationships appear rather
than being forced (Charmaz, 2006).
Theoretical codes were produced from hand sorting of theoretical ideas written in
memos. Memos were spread out on a large table and systematically reviewed.
Constant comparison was done to see how one category theoretically related to its
sub-categories and properties and also other categories. Diagrams were used to
enable visual representation of the relationships among the categories and facilitate
thinking at an abstract level. Resorting of the memos occurred when they fitted
somewhat differently. The researcher kept on sorting, comparing, and resorting until
the integration of categories, that is a basic social psychological process, was
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produced.
During the coding process, a core category was selected to explain the process
underlying the experience of the participants. The core category accounts for most
variations of the central phenomenon around which all the other categories are
integrated (Strauss & Corbin, 1990). Although it appears straightforward, identifying
a core category was complex and problematic. For example, it was unclear at which
moment the categories should be integrated into a whole. In contrast to Glaser’s
view that this can occur early on in the analysis, given the importance of the core
category in directing the focus of the entire study, to do so seemed premature and
inappropriate. There was also an awareness of the risk of being guided by pre-
conceptions if the core category had been decided upon too soon. An additional
concern was whether the links between categories should be determined first or the
core category which connects all the categories together. Furthermore, although the
participants’ concerns may emerge, the name of such an abstract concept has to be
constructed by the researcher.
After the analysis of 28 interviews, an initial core category for this study was
identified as reconciling the unexpected. The term reconciling was not literally used
by participants to describe what they did or how they experienced immigration.
Rather, it was derived from multiple descriptions, comments and ideas expressed by
the participants about changing realities, the process of making congruent and letting
go and reframing unpleasant experiences after immigration. The core category was
changed to reconciling different realities later on to better reflect the extent to which
even what was expected required reconciling on the part of participants. The core
category then became a guide for further data collection and theoretical sampling.
The coding was also delimited to those categories that related to the core category in
sufficiently significant ways.
It is important to re-emphasise that coding is not a precise data reduction technique
but an interpretation of meaning (Mintzberg, 1979). Categories do not suddenly
emerge from data as if by magic, but have to interpreted and pulled from the data. A
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concept was raised to a category level because of its theoretical reach, incisiveness,
and relation to other categories. Additional data were gathered to check and further
refine these tentative categories analytically and to relate conceptually between a
category and its sub-categories and properties. These categories serve as interpretive
frames and offer an abstract understanding of the study phenomenon.
Indeed, the identification of categories has much to do with a researcher’s intuition
and tacit understanding (Mintzberg, 1979). In other words, the GT methods are
inadequate if only grounded. As Glaser (1999) argued, the GT method requires the
researcher to display creativity, insight, and openness. Similarly, Charmaz (2006)
makes the point that although tools may help, constructing theory is not a
mechanical process.
In this study, there was a diligent effort to ensure technique and procedures did not
impede the creative and intuitive component of analysis. One pertinent example was
the choice of approach for the management of data analysis. Manual coding of the
first two interviews produced a large number of codes. For the purposes of keeping
track of the data and codes, a data analysis software program, Nvivo 7, was tried.
However, the software was discarded after a few days’ effort because the researcher
found the focus on technology a distraction from thinking about the data and thus a
constraint on the analytic work. This may in part be attributed to a lack of familiarity
with the computer program. Nonetheless, on leaving the software behind, a filing
system was created to manually organise the analysis.
At some stage of the analysis, the researcher moved from the data to engage with the
literature and to allow theoretical reflection and speculation to influence the
emerging theoretical understanding. As a result, the findings of this study, while
grounded in data, often go beyond the words (Cutcliffe & McKenna, 2004).
4.8.4 Memos In addition to coding, memos were written in English throughout the analytic
process to record the researcher’s analytic ideas, conceptual insights, questions, and
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directions for further data collection (Strauss & Corbin, 1998). Memo writing not
only provides a record of the researcher’s thinking about coding, but also keeps the
researcher involved in the analysis (Charmaz, 2006; Strauss & Corbin, 1998).
The goal of a memo is to get an idea down on paper at the moment it occurs. No
mechanical rule was applied for memo writing in this study and the language tended
to be informal. Each memo was dated and contained a heading denoting the concepts
or categories to which it pertained. The memo was also used extensively in
preparing the first written draft of the thesis. Some examples of memos are shown in
Appendix K.
4.8.5 Translation As previously noted, Chinese was the language used in the initial and focused
coding processes. It was important that data analysis was carried out in the language
of the interview rather than that of the translated data to avoid compromising the
quality of data obtained from a non-English speaking population (Twinn, 1998).
Nonetheless, some translation of the material was necessary to facilitate supervision
of this thesis. The requirements of an Australian degree and the research committee
meant some translation was obligatory.
There are no existing formalised guidelines for translation in interpretive research. In
this study, the first few interview transcripts were translated fully into English to
facilitate the intensive supervision of the coding process. A further few interview
transcripts were translated after a major change in coding directions for the same
reason. However, the English versions of coding for these transcripts were
supplementary and only the Chinese versions of coding were included in ongoing
analysis.
As indicated previously, English translation of analysed data occurred following
focused coding. The focused codes were translated to facilitate discussion with
supervisors on groupings and naming of the focused codes into categories and sub-
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categories. The key quotations from participants were also translated before insertion
into the dissertation.
The translation was carried out only by the researcher to maximise consistency and
reliability. The researcher is a native Chinese speaker and also competent in English.
In this study, meaning translation instead of literal translation was used to reflect the
theoretical perspective of SI. On some occasions nuances were untranslatable and
the researcher had to interpret in order to make the meaning clear and approximate
the original as much as possible.
4.8.6 Theoretical sensitivity As implied earlier, the generation of theory is a result of emergence, integration, and
interpretation of concepts representing the study phenomena. The researcher is the
“tool” through which meaning is interpreted and elaborated. It is therefore essential
for the researcher to possess theoretical sensitivity. Theoretical sensitivity refers to a
researcher’s awareness of the subtleties of meaning of data and an ability to “see”
with analytic depth what is there (Strauss & Corbin, 1990). Depending on previous
reading and experience within an area, one comes to the research situation with
varying degrees of sensitivity and this can also develop further during the research
process (Strauss & Corbin, 1990, pp. 41-42).
According to Glaser (1978), the first step in gaining theoretical sensitivity is to enter
the research setting with as few preconceived ideas as possible and to be open and
receptive to what is actually happening and emerging. While agreeing with this
principle, Strauss and Corbin (1990, 1998) argued that there needs to be a balance
between objectivity and sensitivity so that the researcher can recognise and respond
to the meanings in the data. In this study, the focus of the research was purposely
kept broad at the start to allow what was significant to appear. In addition, the
interview questions were posed broadly at the outset to ensure that any part of the
conversation was not prematurely closed.
Theoretical sensitivity is further developed during analysis as the researcher interacts
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with data (Strauss & Corbin, 1990). It was important to remain open and reflective
during the data analysis and to maintain an attitude of scepticism. All categories,
sub-categories and properties that arose early in the research were regarded as
provisional. They were constantly checked out against the actual data and never
accepted as fact (Strauss & Corbin, 1990). Also, the focus was on exploring the
phenomenon from the perspective of participants and listening to the voices of the
participants.
Other sources of theoretical sensitivity were literature such as selective readings on
theory and various kinds of research and documents which provide sensitising
concepts (Strauss & Corbin, 1990). The treatment of literature is detailed in the
following discussion.
4.8.7 Treatment of the literature Glaser (1978) warned that grounded theorists should not read theoretically related
literature prior to data collection due to the risk that prior knowledge would bias
collection and interpretation of data. However, this realistically cannot be fully
achieved as researchers come to a study with various forms of experience and
knowledge (Suddaby, 2006). Indeed, Glaser’s advice to not read the related literature
is impractical for dissertation research.
Strauss and Corbin (1998) on the other hand purported that a preliminary literature
review at the beginning of a study is useful to identify gaps and to assist in
sensitising the researcher. As a study progresses, literature also becomes an effective
analytic tool to stimulate thinking and analysis (Strauss & Corbin, 1998).
Thus, it is apparent that a fine line exists between not doing a literature review and
being adequately informed so that a study is appropriately focused even if the
specific problem is unknown in the early stages of a research project (McCallin,
2003). Dey (1993) aptly argued that there is a difference between an open mind and
an empty mind and the issue is not whether to use existing literature, but how.
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In this study, a preliminary literature review was conducted prior to determining the
research method. The review indicated very little theory building in this area which
pointed to GT as an appropriate research method. Most of the literature reviewed
was not theoretically related. My presumption about this area was that most overseas
nurses had negative experiences while working in another country. In addition, an
implicit agenda in undertaking this research was to provide information on how to
improve the support service for immigrant nurses. However, I was aware of these
preconceived ideas and remained open to the research process. Reading the literature
also encouraged thinking about the phenomenon from multiple perspectives and
increased my sensitivity to what was occurring in the data.
Before the framework of analysis was settled upon, only SI literature, technical
literature in the area of research, and theoretical literature outside the substantive
area were consulted to increase theoretical sensitivity. After the categories stabilised,
theoretical literature was sought on issues such as ambiguous loss, identity, the other,
invisible loss, and ambivalence. This body of literature was used as an additional
source of questions and comparisons to expand and clarify the categories and to
inform theoretical sampling and analysis. Finally, a detailed literature review on
reconciling, theorising on migration, and the experience of immigrant nurses
working in another country was undertaken to relate existing research to the findings
of the study.
4.9 Rigour Although science is always a “best guess” based on the evidence available, rigour is
still essential for all research. Without rigour, research cannot be used to inform
policies or develop programs. However, in interpretive research, rigour is a complex
issue and one surrounded by debate (Cutcliffe & McKenna, 2004). Terminology on
rigour varies including terms such as trustworthiness (Lincoln & Guba, 1985), truth
value (Lincoln & Guba, 1985), authenticity (Guba & Lincoln, 1989), credibility
(Lincoln & Guba, 1985), validity and reliability (Morse, Barrett, Mayan, Olson, &
Spiers, 2002; Whittemore, Chase, & Mandle, 2001), validation (Angen, 2000), and
goodness (Arminio & Hultgren, 2002). The criteria by which we judge rigour also
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differs (Bailey, White, & Pain, 1999; Chiovitti & Piran, 2003; Cutcliffe & McKenna,
2004; Gasson, 2003; Guba & Lincoln, 1989; Hall & Callery, 2001; Koch &
Harrington, 1998; Rolfe, 2006; Sandelowski, 1986a, 1993; Tobin & Begley, 2004;
Whittemore et al., 2001).
Generally speaking, researchers have adopted one of three approaches to rigour in
qualitative research: some seek to emulate the criteria of quantitative research; some
use a different set of criteria to quantitative research; and still others prefer
individual judgments without any predetermined criteria (Rolfe, 2006). As
qualitative research is not a single paradigm and there are a variety of approaches,
most researchers agree that there is no “one size fits all” solution for rigour.
One criticism of the concept of rigour, as applied in qualitative research, is that it is
used to evaluate the product of research rather than the process of research (Charmaz,
2006; Glaser & Strauss, 1967; Strauss & Corbin, 1990, 1998). It is thus important
that rigour is built into the qualitative research process rather than imposed
retrospectively upon it (Morse et al., 2002). As Glaser and Strauss (1967, p. 5) have
asserted, “the adequacy of a theory…cannot be divorced from the process by which
it is generated”.
A further criticism is that rigour is viewed as largely a technical issue. While the
systematic and standardised research procedures (science) are designed to give the
analytical process precision and rigour, creative flexibility (art) is a vital component
(Bailey et al., 1999). Addressing outcomes and issues of technique will achieve little
unless they are embedded in a broader understanding of the rationale and
assumptions behind the methods (Barbour, 2001). As some scholars claim, adhering
to the techniques and procedures of methods alone is insufficient to ensure rigour
and may even impede the artfulness and sensitivity that are essential to quality
(Cutcliffe & McKenna, 2004; Sandelowski, 1993). Yet nor can creativity in and of
itself result in sound science (Whittemore et al., 2001). It is therefore important for
researchers to strike a balance between demonstrating rigour and displaying
creativity (Patton, 1990).
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It is also important to note that rigour or validity in interpretive research does not
equate with a claim for truth. No matter how rigorous the analysis, interpretive
research will not meet the objectivity criteria of positivism (Sandelowski, 1993).
In taking the above points into account, it is acknowledged that the quality of
interpretive research lies more with theory and process and is judged by its ability to
provide reasonable and plausible insight into a phenomenon so that a deeper
understanding of the phenomenon is achieved (Shah & Corley, 2006). Two strategies
were used to ensure rigour in this study: theoretical rigour and procedural rigour
(Burns & Grove, 2001; Chiovitti & Piran, 2003; Sandelowski, 1986a, 1986b).
Theoretical rigour is required in pursuit of best research practice (Maggs-Rapport,
2001). Since all forms of inquiry involve perspectives (Rennie, 2000), a study
should be firmly grounded in a theoretical perspective. One weakness of GT is its
philosophical naiveté and confusion (Bryant, 2002). This weakness extends to
inconsistencies which suggest that GT is sometimes used as an excuse for evading
theoretical issues (Bryant, 2002).
In this study, theoretical rigour was sustained by ensuring congruence between the
research question and research methodology; between the researcher’s ontological,
epistemological, and theoretical stance (Morse et al., 2002). The research question
and aims of the research were clearly stated as proposed by Meyrick (2006).
Although acknowledging that GT need not be tied to a single epistemology, the
theoretical perspective of SI informed all aspects of the research process, such as
data generation and analysis, to ensure the logic and consistency in research
approach.
Procedural rigour means rigorous data collection procedures and self-criticism in
order to reduce distortion and incorrect interpretation (Burns & Grove, 2001). This
was achieved by providing sufficient detail about all aspects of the research process.
This includes the selection of participants and sampling techniques, data generation
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methods, acknowledging my prior understanding and the influence of literature
sources on the analysis, and memo writing to track the development of categories
and sub-categories.
Both theoretical and procedural rigour was further enhanced through the use of a
detailed reflexive journal to maintain the transparency of the research process (Koch
& Harrington, 1998; Mays & Pope, 2000; Meyrick, 2006; Sandelowski, 1986a,
1986b). This journal critically reflected upon the entire research process, decisions
made at each stage of the research, the rationale underlying such decisions and
personal reflections on the study. The use of a reflexive journal is also compatible
with the SI view of the social construction of knowledge (Hall & Callery, 2001).
Being reflexive means being sensitive to the ways in which the researcher influences
the research process (Gasson, 2003) and to the effects of interactions between
researcher and participants on meaning construction (Hall & Callery, 2001).
However, it is worthwhile to point out that the purpose of reflexivity is not to claim
objectivity as embraced in quantitative research. As Gadamer (1994) emphasised,
prejudices are the conditions by which we encounter the world as we experience
something. It is impossible to separate ourselves from what we know and thus our
subjectivity is an integral part of our understanding (Angen, 2000).
Although member checking is a popular way to establish rigour, it is disregarded in
this study for the following reasons. First, the fact that the interview was audio-
recorded and transcribed verbatim provides a guarantee of at least verbal accuracy
(Koch & Harrington, 1998). Second, after the researcher’s interpretation/theorising,
the categories have moved beyond the descriptive level and we should not expect
participants to arrive at the same categories as the researcher (Sandelowski, 1993).
Third, the fact that actions are categorised rather than people will make it extremely
difficult for a participant to identify his or her contribution (Koch & Harrington,
1998). Finally, some have argued that member checking is actually more often a
threat to validity because it disregards a researcher’s interpretations of data and
accepts participants’ views of themselves as the heart of the research (Meyrick, 2006;
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Morse et al., 2002).
4.10 Summary A modified constructivist GT method was applied in this study and has been outlined
in this chapter. The chapter addressed some basic tenets of GT including theoretical
sampling, data generation strategies and sources, constant comparative
analysis/coding steps, memo writing, theoretical sensitivity, and treatment of the
literature. Recruitment procedures and ethical considerations were detailed.
Justification was provided for the use of the interview, language of the interview and
coding. Translation issues were also explored. Finally, detailed consideration was
given to the concept of rigour and its relevance to this research. In the following
chapter the first of the categories and related sub-categories as produced in the
analytical process are examined and theoretically developed.
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Chapter 5 Realising 5.0 Introduction While the focus of many studies is on the economic effects of immigration and its
impact on host societies, this study is primarily concerned with the social
implications of immigration. More specifically, its intent is to understand
theoretically the experience of working in Australia from the perspective of China-
educated nurses.
Reconciling conceptualises a set of covert and overt actions engaged in by China-
educated nurses while responding to different realities. The phases of reconciling are
realising, struggling, and reflecting. Realising is the starting point of reconciling and
it refers to an awareness of the discrepancies between different realities. This chapter
begins by explaining the process of realising, the first major category of the study. It
consists of the following three sub-categories: it is indeed different, this is the
Western way, and you are you and I am I (Figure 1). Each of these will be addressed
in turn.
Figure 1. The category and sub-categories of realising
5.1 It is indeed different It appears that the participants lacked appropriate information before immigrating.
The information available in China was generally confined to work conditions and
salaries for nurses in Australia and there was little input on what might be expected
socially and culturally. The participants also indicated that they did not and could not
reflect greatly on what lay ahead in Australia. The very act of immigrating was the
fulfilment of a long held dream and there was a willingness to take risks to fulfil that
dream.
The result was a disparity between what the participants understood about nursing
from their education and past experience and what they encountered in the “real”
world. Nursing work was perceived to be indeed different in many ways in Australia.
The major differences, explored below, related to the following four aspects: more
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decision making, more basic nursing care, less technical nursing, and no need to
consider the cost.
5.1.1 More decision making In Australia, nursing is considered an independent profession and nurses are not
overtly subservient to doctors. In addition, the organisation of nursing work in
Australia allows some degree of individualised care and nurse managers generally
are not pre-occupied with direct governance of nurses. As a result, the participants
noted that nurses in Australia were required to think and make independent decisions.
The participants pointed to the contrasting situation for nurses in China where there
was far less opportunity for autonomous decision making. In China, nursing as a
profession is largely dependent on medicine and nurses remain under the control of
doctors. As one participant stated:
I feel nurses here are more independent than in China. You need to think a lot. In
China, the situation is basically like this: you call the doctor when a patient
complains to you and you do whatever doctors tell you. (Participant 5, Interview 5)
Several factors contribute to the medical dominance of nursing in China. To begin
with, Chinese society has traditionally placed a high social value on medical
diagnosis and medical treatment (Haley, Zhao, Nolin, Dunning, & Qiang, 2008). It is
also assumed that medical knowledge is superior and more socially prestigious
which undermines the importance and legitimacy of nursing knowledge. Of course it
can also be argued that this is true of nursing in the West. Nonetheless, the nursing
system in mainland China is still struggling to develop the political and educational
institutions to underpin nursing professional development (Xu, 2003; Xu, Xu, Sun,
& Zhang, 2001)
The inferior image of nursing in Chinese society reinforces medical dominance. The
predominant social view is that nurses are not highly educated, a view captured in a
popular Chinese saying that: “one can at least become a nurse if she is good for
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nothing else” (Xu, Xu, & Zhang, 2000). As a result, nurses are seen as those who
express the care prescribed by doctors.
As such, nurses in China have limited autonomy. The power disparity and the related
assumption that doctors are more knowledgeable render decision making firmly a
doctor’s responsibility (Bucknall & Thomas, 1997).
The situation in China is like this. After working for many years, many nurses feel
that they just do what doctors ask them to do. Even if they have their own ideas, it
is the doctor who makes the final decision. (Participant 1, Interview1)
However, it is also important to note that nurses in China, if in a somewhat invisible
role, are decision-makers. Nurses observe patient conditions, draw upon various
forms of knowledge and experiences to inform doctors and shape their decisions.
This universal dilemma of the invisibility of the nurse has been subject to much
theorising. In the 1960s, Stein (1968) used the concept of the doctor-nurse game to
explain a complex relationship whereby nurses provide information for and pose
recommendations to doctors in such a way that does not challenge the existing
power structure. For the game to be successful, nurses must adopt a passive position
in presenting information so that it appears doctors fully own decisions (Manias &
Street, 2001). For Stein (1968), the authority of doctors was reproduced and
sustained through such interactions. Some decades later, Manias and Street (2001)
argued that this strategy had a positive dimension in enabling nurses to contest the
dominant practices that marginalised nursing knowledge. Nonetheless, where the
input of nurses was invisible, the outcomes of their decisions remained hidden
(Manias & Street, 2001; Porter, 1991). For the participants, the work of Australian
nurses conformed far less to the doctor-nurse game.
Generally speaking, nurses here are more independent. They don’t rely on doctors
totally. They can have their own thoughts and make decisions on the caring of
patients. (Participant 4, Interview 4)
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Here doctors and nurses each have their own administrative hierarchy. They don’t
interfere with each other’s business. Doctors do not have power over nurses just
because of their education. (Participant 7, Interview 7)
This perception of autonomy is related to the extent of the professionalisation of
nursing. The notion of a “profession” initially appeared as a demarcation issue; that
is, drawing a boundary between “special” and “ordinary” occupations (Lamont &
Moln´ar, 2002). From this view, professions are those occupations that have
successfully claimed and received special advantages and rewards (Shaffir &
Pawluch, 2003). In China, nursing is distinguished more so as an occupation than a
profession.
Nonetheless it is the case that boundary building between nursing and medicine is, at
its root, a process of social interaction (Abbott, 1988). Occupational boundaries are
not self-evident but have to be negotiated constantly within a system of work. While
the status of nurses is stronger in Australia, status differential still exists as the
following quote suggests:
I feel that the status between nurses and doctors here still differs…I feel the respect
is not so much about nursing as a profession, but nurses as human beings
generally…Not that the medical system in Australia considers nurses as someone
high in status, not so from my point of view. (Participant 1, Interview 1)
While nurses are increasingly recognised, there is still a discrepancy between the
image of nursing in rhetoric (as an independent profession) and the realities of
nursing practice. In the 1970s, Hughes (1971, p. 308) made the point that “ the
[nurses’] place in the division of labour is essentially that of doing in a responsible
way whatever necessary things are in danger of not being done at all”. More than
four decades later, the point remains relevant.
May and Fleming (1997) further allude to this point in arguing that the profession of
nursing has been more concerned to construct occupational differences than to
compete on the same terms with medicine. While the emphasis of medicine is on
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scientific treatment, the argument is that nurses care about patients (May & Fleming,
1997). Hence, the nursing profession has grounded its jurisdictional claims in the
language of care in order to establish professional autonomy (Allen, 2001). Yet, the
difficulty with the May and Fleming (1997) argument is that the
“professionalization” discourse (and not nurses) dictates the grounds on which this
struggle is played out. This is equally the case in China and Australia. It appears that
nurses in Australia and even globally, are still struggling to improve their image and
status.
Apart from medical dominance, the organisation of nursing work is a further factor
that constrains nurses’ decision making in China. To maximise efficiency and to
cope with the level of work, nursing work in China is often routinised.
Nursing work in China is basically routine, task by task. Nurses are not caring for
the patient, but fulfilling tasks. (Participant 12, Interview 12)
In contrast, the delivery of nursing care is perceived to be more individualised in
Australia indicating a different philosophy of care and better staffing resources. The
participants thus perceived that they had more freedom in decision making
concerning care delivery in Australia.
Health care organisations in China are also strictly hierarchical. Hospitals set down
rigid rules and regulations to which nurses are required to adhere. Nurse managers
implement surveillance strategies and constantly scrutinise the work of individual
nurses. As one participant said:
In China, nurse managers spend all day looking at you and checking your
work…Have you done this? Have you done that?…You should not sit there and
chat. You should not sit there and drink, and so forth. (Participant 3, Interview 3)
In contrast, the role of nursing management in Australia is one of overall
coordination.
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That is to say, unlike in China, nurse managers here coordinate and manage the
ward comprehensively, and not just spend time looking at you as an individual.
(Participant 3, Interview 3)
It should also be noted that nursing in China is not a unified entity. Nurses are as
much subordinated by management groups in nursing as they are by medicine. In
that context, the authority of individual nurses determines the level of involvement
in decision making. In a ward hierarchy, what we might refer to as thinking is the
responsibility of top level nurses, while doing is the role of bedside nurses. Where
the rules are laid down and there are superiors who make decisions, bedside nurses
are expected to follow the rules and listen to nurse managers. Constrained by a
system that gives priority to rules and routine, Chinese nurses have little decision
making power and are seldom required to think independently. Indeed, their capacity
to think becomes invisible or obscured over time.
In Australia, judgments made by nurses are well respected. Along with increased
autonomy comes additional responsibility. Yet, although decision making implies
greater power and higher status, the participants were uncomfortable with being held
accountable for their decisions.
The prn order is here, but whether to give the medicine or not, how much to
give? …To a large extent, you as a nurse need to assess the patient’s condition and
decide on that. The doctor’s order is like that, it gives you a right, but when you
execute the right, you need to think a lot...At the beginning, I was scared. Why I
should take this responsibility? It should be a doctor’s responsibility. (Participant
6, Interview 6)
Without doctors available in the ward, the administration of pro re nata (prn) drugs is
often the sole responsibility of nurses in Australia. While this reflects autonomy of
practice (Usher, Baker, Holmes, & Stocks, 2009), the participants were not fully
confident in clinical judgment. They thought that their nursing knowledge might be
inadequate and they needed to know more in order to better execute that autonomy.
It is probable that this is a perceived rather than actual knowledge deficit (Bucknall
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& Thomas, 1997). The nurses may also have reverted to the novice role in a new
context and thus looked to rules in decision making. A further reason is related to the
foreign status of the participants. They were reluctant to make decisions as they
feared that there would be no protection in the case of a wrong judgment.
The level of decision making involved in nursing work is shaped by many factors
such as the practice context, type of knowledge, and power. Clinical judgement is
considered to be a largely intuitive skill, honed and refined through adopting
strategies that work and avoiding those that do not (Usher et al., 2009). Over time
the participants gained more experience in decision-making and became increasingly
confident. A further concern of difference related to what was described as basic
nursing care.
5.1.2 More basic nursing care The China-educated nurses perceived that basic nursing care constituted a great deal
of the daily work of nurses in Australia. From their perspective, nurses undertook
too much of this form of care.
Nursing here is different from in China, such as we don’t have much basic nursing
care. As to the basic nursing care, in China, we only learn its theory, not practice;
here the basic nursing care is (widely practiced). (Participant 9, Interview 9)
It is very different...Nurses here are required to do basic nursing care whereas in
China we are usually not. The family does that. (Participant 14, Interview 14)
From the SI perspective, each task has its meaning for those who perform the task
(Shaffir & Pawluch, 2003). The meaning of basic nursing care for the China-
educated nurses differed from that of the local nurses. In China, RNs typically do not
provide direct care (Xu et al., 2008). Rather, families or personal carers accompany
patients in the ward and provide all the required basic care (Lee, 2001).
Several factors contribute to this constructed reality. First, direct care is often of an
intimate and private nature. Patients in China, therefore, prefer to retain some
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privacy in hospital and are reluctant to be cared for by a nurse. Second, a moral
obligation to look after a sick family member is embedded in Chinese culture.
Meeting basic needs through the provision of direct care is seen as a way of
demonstrating care and affection (Haley et al., 2008).
In addition, nursing in China is often understaffed because of lack of recognition and
funding (Haley et al., 2008). During a day shift, a nurse may care for an average of
15-20 patients and this number increases on public holidays (Ma, 2005). Thus
realistically, nurses are often too busy to meet the direct care needs of patients. In an
effort to redress the nursing labour issue and to contain health care costs, the
boundaries between waged and unwaged care are necessarily blurred.
It is also the case that in China nursing is considered a semi-skilled job and nurses
are of low social status. The media portrayal of nurses gives people an impression
that nurses do little other than the “hard and dirty work” (Pang, Arthur, & Wong,
2000). Consequently, nurses in China are concerned to set down a boundary between
nursing work and the work of a servant (Pang et al., 2000). A distancing from basic
nursing care is one way to protect professional integrity and gain social respect for
nurses in China (Pang et al., 2000).
Even where nurses embrace the caring aspect of the profession they do not want to
be solely acknowledged for that attribute, particularly when their knowledge and
expertise are overlooked (Dombeck, 2003). This constructed meaning shapes how
China-educated nurses react to basic nursing care. As nurses ascend the professional
ladder, they distance themselves further from “dirty” work.
Although the participants accepted the concept of patient centred care, they found it
hard to accept the washing, toileting, and feeding of a patient as part of the role of
the RN in Australia. As one participant indicated:
Here, nurses need to do the bathing and toileting. I feel that is very hard for me. I
swore that I would never work there again after the 6 weeks clinic practice in the
medical unit. That is too much. I have never done anything that dirty and that tiring
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in my nursing life...Although I have heard of this situation before (I came), it was
still very hard for me to face it in real life. (Participant 22, Interview 22)
Goffman’s theorising on stigma has relevance for this analysis. If basic nursing care
carries stigma, it is a social process constructed from the experience, perceptions,
and anticipation of negative social acceptance and judgements about such work
(Goffman, 1963). People who carry out such stigmatised work are envisaged as
undesirable in the view of others and are devalued by society (Goffman, 1963).
Work that is, or that people think is, stigmatised is held in secret. As one participant
demonstrated:
I feel it is not good if people in China know that I am doing this kind of work here
since we seldom do it (basic nursing care) in China. However, we have had to do it
after we came to Australia. (Participant 14, Interview 14)
Another participant put it this way:
I feel too embarrassed to tell people (the fact)…If I tell my family that a nurse in
Australia needs to shower the patient, I think even my family would find it very
hard to accept. (Participant 16, Interview 16)
Goffman (1963) contends that it is a constant effort for those who are stigmatised to
manage and control social information about themselves. They actively engage in
what he refers to as impression management to shape how they are seen by others
(Goffman, 1959). Where fear of disclosure might have brought embarrassment and
loss of face, participants chose not to inform families and friends at home that they
were undertaking such work in Australia. The stigma connotes a mark of disapproval
and disgrace and has significant psychological consequences for those stigmatised
(Goffman, 1963). One participant purposefully chose not to work in hospital settings
in Australia in order to avoid such stigma.
Because I feel that if I choose to work in a nursing home, I don’t need to do that
(body care). There are carers there to take care of that. If I work at a hospital, I
feel (I cannot get away from that). (Participant 16, Interview 16)
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The tension here was between being a professional and yet doing what was
considered “unprofessional”. The relocation of nursing education from hospital-
based to higher education institutions upgraded the image of nurses and improved
the professional status of nursing. However, the historical “service” version of
nursing remains (Allen, 2001).
To cope with basic nursing care, the nurses tended to distance themselves from the
identity that accompanied that work (that is, low status worker). As Goffman (1961)
points out, one is not “just the role” in which one has been cast. The role is not
playing the individual, but the individual is “playing with the role” (Goffman, 1961).
Through this role distancing, the participants were able to effectively separate
themselves from what the work implied of them.
A further coping strategy was the use of methods to neutralise stigma and to
rationalise or justify actions to others as well as to themselves. Indeed, during the
interviews, the participants spent much time explaining how they made sense of
basic nursing care. It appears that they were making sense of this work more for
themselves than the researcher. The fact that the nurses were so clear in their
articulation of the issue also indicates a high level of reflection.
The rationalisation is evident in the detailed accounts provided by participants about
why basic nursing care was better performed by RNs. To begin with, there was some
professional knowledge involved in basic nursing care to perform it safely. Health
care assistants were not educated to observe and interpret patients’ conditions. The
day-to-day realities of health care in hospital settings also afforded RNs very little
opportunity to supervise the work of care assistants. And basic nursing care provided
nurses an opportunity to assess the patient completely and also in context.
Part of the rationalising strategy was recreating the meaning of basic nursing care.
The reality that local nurses did basic nursing care willingly helped the participants
gradually reconstruct their perceptions of basic nursing care. The appreciation and
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positive feedback from patients further reinforced the legitimacy of the new meaning.
Using the reactions of others (their looks, their words, and their emotions), the
participants reshaped their views of basic nursing care.
The nursing concept here is very good…It is not a wrong thing for nurses to
provide basic nursing care as nursing should be human centred. (Participant 7,
Interview 42)
A closely associated difference was, as termed by the participants, technical nursing.
5.1.3 Less technical nursing In combination with the focus on fulfilling the basic care needs of patients, nursing
in Australia is perceived to be less technical. Overall, the participants were
unimpressed with the technical skills of local colleagues.
But what do nurses here actually do? They do not even do the IV, the cannulation
and so forth. All these are doctor’s job. What do nurses here do? After I think
carefully, I find the only specialised skill for most nurses in medical/surgical wards
is medicine administration. (Participant 1, Interview 1)
I want to mention the advantage of nursing in China, which is we are more solid in
technical skills. Here I feel generally nursing care has no large component of
technical skills. (Participant 7, Interview 7)
The importance the participants attached to technical nursing skills can be
understood historically. The traditional skills hierarchy in China accords the highest
status to medically derived technical work. The commercialisation of health care
also means that technical nursing attracts greater monetary return. Nurses in China
prefer to perform technical work because it symbolises professionalism and is more
socially prestigious.
However, the participants were prevented from using some technical skills acquired
in China and which they were perfectly capable of performing. They had to prove
their competence within the Australian system by attending courses and proving
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competence. This was considered a process of deskilling although far less so in
technically oriented departments such as intensive care units than others such as
rehabilitation wards. However, since many participants found it difficult to secure a
job in the highly technical areas, they considered their skills and expertise were
wasted or underutilised.
The perception that nursing care in Australia is less technical may create a sense of
loss since they could not demonstrate their superior technical skills which may have
engendered greater respect. This situation also created a form of moral dilemma for
the nurses where patients had to wait for procedures or where they received “sub-
standard” care. A common observation was of a doctor failing to successfully insert
an intravenous cannula into a patient with “poor veins” and the obvious pain it
caused to the patient. The nurses were of the view that they were better skilled and
yet were frustrated because they were not permitted to apply those skills.
5.1.4 No need to consider the cost Nursing care in Australia is also perceived to be far better resourced. It appeared that
Australian nurses could use resources at will. Yet in China, budgeting is a serious
concern where nurses must count equipment and material each shift and charge the
patient who is the recipient of those resources.
Because of the medical service here is paid by the government, you don’t need to
consider the money issue. You only need to consider…the patient’s conditions and
what care you need to provide. (Participant3, Interview 3)
In China, if you work in a big hospital, you need to consider the bonus…When you
use something for a patient, you need to think of how to save more and how to
achieve the best value. (Participant 9, Interview 9)
Since the early 1980s, China’s heath care system has undergone massive
restructuring (Haley et al., 2008) and the government’s share of national health
spending has steadily decreased (Lague, 2005). This has meant that hospitals have
been forced to introduce fee-for-service systems (Browne, 2005). As part of the
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market economy, hospitals also link the staff bonuses to the amount of income they
generate (French, 2006). This bonus scheme provides a strong incentive for nurses to
offer cost effective care. Indeed, one of the major tasks for nurse managers in China
is to be creative in saving. The priority given to nursing care quality is thus reduced.
Faced with the dilemma of sustaining organisational profits and patient health,
nursing care in China is complex.
The focus on cost containment also creates potential conflict in nurse-patient
relationships since patients and families tend to oversee nursing work closely (and it
may be easier to oversee nursing work than medical work). This not only
undermined the fulfilment that nurses drew from their work but also contributed to
high levels of occupational stress and consequent “burn-out”. This is evident in the
following reference to the nursing situation in China:
Because many patients pay for the medical services themselves, they pay a lot of
attention to that. Some even to the degree…to record everything nurses do for them
each day, such as how many times you take their temperature…It is very detailed.
It brings you lots of invisible pressure. (Participant 3, Interview 3)
Many Chinese find themselves without access to any type of comprehensive health
insurance. In China, around 56 percent of health care costs are paid for directly by
patients (Powell, 2005). Low income families find it difficult if not impossible to
afford health care (Wang, Xu, & Xu, 2007). Mostly because of the issue of cost,
Chinese patients and their families will look for faults in health care which
contributes to further stress for nurses.
Nurses are under constant psychological stress. They are not getting paid much,
because patients always make trouble, big or small. They know that they can get a
refund from the hospital if they can make some noise. (Participant 6, Interview 6)
In the Chinese context of a nascent market economy, nurses are now encouraged to
view their patients as “consumers” or “clients”. The “buying” of a service by health
care users implies increased consumer expectations. The frequent media portrayal
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about inadequate service also challenges nurses’ authority and increases tension
between nurses and patients. As one participant stated:
In China, it is rare that patients say “thank you” to nurses. Rather, it is common
that patients get angry with you. (Participant 7, Interview7)
Australia has a national health insurance scheme and patients either enjoy largely
free health care or have private health insurance. There appears to be less conflict of
interest between nurses and patients. In this respect, the participants perceived
patients in Australia as pleasant and nursing work in Australia as more rewarding.
In China, nurses need to consider a lot the money issue. I feel working as a nurse
in Australia is a big improvement in quality for me. I can feel the essence of
nursing more from my daily work. (Participant 22, Interview 22)
More decision making, more basic nursing care, less technical nursing, and no need
to consider the cost are characteristic of nursing work in Australia. The work
environment and the organisation of nursing work differ to China from the
perspective of participants.
Most importantly, the system is different! The whole system cannot compare, they
are totally different. (Participant 1, Interview 1)
In migrating to Australia, the China-educated nurses brought certain meanings and
perspectives about what nursing is and how nursing care should be undertaken.
When confronted with nursing in Australia, the participants sought to make sense of
the new experience and did so by perceiving it as different from nursing in China.
While acknowledging the difference, it is important to note that the difference
reflects the perceptions and interpretations of the reality from the perspective of
participants rather than a matter of objective truth. In addition, the participants’
comments on nursing in China were historical rather than contemporary.
It is also the case that health care organisations are not rigid, fixed entities, but
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dynamic arrangements of intricate social relationships (Charmaz & Olesen, 2003).
The organisation of nursing work is different in Australia and China but both are
what Allen (1997) refers to as negotiated orders. On one hand, the participants may
be motivated to immigrate because of the difference; on the other hand, these
perceived discrepancies might also mean that they are not clinically well prepared
for the realities of the nursing world in Australia. This point is further illustrated in
the next sub-category this is the Western way.
5.2 This is the Western way This is the Western way points to the discrepancies between China-educated nurses
and their colleagues in perceptions on what was real nursing work and how one
should engage with others. The participants’ emphasis on harmonious relationships
and respect for elders also made delegating tasks to enrolled nurses and carers
problematic.
After immigration, the participants found not only a change in the nature of nursing
work in Australia, but also the ways nursing care was delivered. It appeared that the
local nurses concentrated more on communication through talking and yet the
participants were more concerned about “real nursing work” through doing.
I don’t know what they (local colleagues) are doing, chatting with doctors-- a
waste of time from my perspective. (Participant 26, Interview 40)
The concept of real nursing work is constructed in a particular social context and
thus is not static. In China, the implementation of the market economy delineates
nursing care as a commodity with a price tag. Physical labour is the most visible
aspect of nursing care in the sense of paid work because one is doing something. In
contrast, the invisible nature of soft nursing work (emotional labour of caring)
renders its cost imperceptible and economic compensation difficult (Reverby, 1987).
The staffing shortage also prevents the provision of thorough social and
psychological care in the Chinese context. The nurses are encouraged to appear busy
in terms of observable, physical work. The talking domain of nursing care thus
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remains largely unrecognised and undervalued.
The cultural definition of what constitutes real nursing work shaped the
communication between the nurses and patients, which was usually brief,
predominantly task-oriented, and concerned with physical care.
Our communication with patients is limited to the functional level. There are few
in-depth communications between us. (Participant 7, Interview 42)
Apart from less emphasis on talking as nursing work, it is also possible that the
participants talked less because they were less capable of doing so. They consciously
played down the talking component.
Chinese nurses are very diligent and hardworking. But they don’t talk much with
others and they don’t like to talk due to inadequate language skills. (Participant 14,
Interview 14)
There was not only less communication but different communication. For example,
due to a lack of understanding about English expression, requests tended to be
articulated through direct Chinese translations which were often perceived as rude
and impolite by local colleagues.
Although she (a Chinese nurse) did a lot of physical work, she talked to colleagues
like this: I do this and you do that. Colleagues perceived this as an order…and not
being given a chance to express their opinions…They felt annoyed being told by a
newcomer. (Participant14, Interview 14)
Many Chinese are not used to saying “thank you”. It sounds as though one regards
others as outsiders. However from a local’s viewpoint, you are very rude by not
saying “thank you” or “please”. (Participant 10, Interview 10)
Language is the symbol used for communication which stands for shared meaning
within a given community (Mead, 1934). The expression of politeness is socially
constructed and not a self-existing entity with an intrinsic nature (Blumer, 1969).
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Once the consensus of politeness has been agreed upon, it is taken for granted as a
routine by members of a community to sustain some social order. People who
conform are considered polite while those who breach the rules are seen as acting
impolitely.
The participants acted on the basis of their previous definitions of politeness and
encountered resistance in the interaction. This further reflects the view that the
meaning of politeness does not reside in the intentions of the actor, but depends on
the response of others (Blumer, 1969). Problematic situations required the nurses to
reflect on the definition of the situation and construct new actions instead of
responding in pre-established ways. One such example is that the nurses found it
necessary to appear warmer, softer and more suggestive in posing requests.
When communicating with others, I tried to learn how to be polite so as to be more
acceptable by others. Sometimes, my words sound too formal and impolite, but I
found others can put it in a softer and more acceptable way. (Participant 12,
Interview 31)
Interestingly, the participants also perceived the more direct style of Western
communication as rude and impolite. They were easily hurt because of the
insensitive and sometimes even aggressive words of local colleagues.
When working with each other, local colleagues tend to be very direct. They do
what they want and they point out what they dislike about you directly, not being
concerned whether it would hurt you or not. (Participant 1, Interview 43)
As noted earlier, the rules of communication are socially situated. The Western style
of communication tends to be direct and straightforward, not giving people “face”.
The Chinese form of communication, by contrast, is more indirect and implicit in
order to maintain harmony. It is not uncommon for a Chinese to dwell on thoughts
for a long time before speaking out for fear of hurting others or causing conflict.
These social norms of communication are culturally embedded and dictate how one
presents oneself in a particular situation.
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Here you need to ask for what you want directly, let alone being polite in saying no
when being asked…If they didn’t tell you to take a break, you needed speak out
yourself: it is time for me to have a break. (Participant 1, Interview 43)
With the passage of time, the participants learned not to take a colleague’s comments
personally and to accept what was said as simply the “Australian” way.
As a senior nurse, I was in charge sometimes. I found local colleagues wouldn’t
mind being told by a senior on how to appropriately undertake a task. They would
accept your suggestion happily and would not remember the incidence afterwards
or give you a hard time in return. Vice versa, when you are being told, you should
not take it personally either. (Participant 12, Interview 31)
Differences in communication were also reflected in the way nurses addressed a
patient in Australia.
Here every nurse calls everyone sweetie, love, things like that. It is totally different
from us. We call everyone by name… I have never thought of addressing a patient
so intimately. It is hard for us because we don’t feel this way. (Participant 20,
Interview 41)
Such norms of addressing are also socially constructed. The symbolic action of
addressing a patient becomes a ritual through ongoing professional socialisation. In
the Chinese context, nurses are encouraged to address a patient in a way similar to
addressing a neighbour or friend. The “Australian” form of addressing a patient as
love or sweetheart was alien to the participants.
In Chinese culture, words such as sweetheart and love are used only when people
address someone who is very close and usually in private (Gao & Liu, 1998).
Intimate relationships are demonstrated by doing things for each other or by hints
and little gestures. Verbal expressions are less important (Gao & Liu, 1998). To be
explicit with someone not close sounds not only unnecessary but also disingenuous
(Gao & Liu, 1998). It is difficult emotionally for the participants to adopt the
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practice of addressing a patient intimately. However, the nurses saw a need to do so
in order to conform to the normative expectations of the work setting.
…but I think gradually we need to learn from local nurses. Anyway, do in Rome as
the Romans do...As an Asian, local people will regard you with special respect
when they hear you speak good English and see you behave like an Australian.
(Participant 20, Interview 41)
Some participants also attributed the superficial nurse-patient relationship to their
failure to address patients in a “proper” way.
What impressed me most is that local colleagues can easily treat patients as their
own relatives. I was moved that they can address patients so warmly and intimately.
I feel I lack this ability. There is a certain distance between patients which I feel
hard to close. (Participant18, Interview 18)
Goffman’s notion of life as a dramatic performance provides a useful frame for
interpreting this situation. From patients’ reactions, the participants perceived a need
to be sensitive to the expressive dimension of their behaviour. The nurses learned to
be “on” to perform for patients. The performance functions to create and sustain a
“projected self” and a show of normality in order to be viewed as legitimate
(Goffman, 1959). While not comfortable in doing so, the participants started to call
patients love and sweetheart gradually in order to give the impression that they were
not much different from local nurses.
It should also be noted that although the endearing form of address appeared an
accepted ritualised practice in the clinical areas, it is not without dispute in Western
countries (Oakley, 2005; Willey, 2008). It is argued that this form of address reflects
the association of caring with “mothering” in which the patient is “childlike” and the
nurse the “parent” figure (Hewison, 1995). This patriarchal relation of institutional
care reinforces the diminished power of the patient (Oakley, 2005).
A further difference in communication related to the delegation of work to enrolled
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nurses and carers which was a source of stress for the participants.
She (a local enrolled nurse) doesn’t listen to you sometimes, which makes it hard to
finish work on time...Local nurses will definitely bring this issue out, but as a
Chinese, I dare not offend her. (Participant 12, Interview 12)
Sometimes they won’t listen to you if you are too soft…In addition, one carer
reports to you that another carer is not good. Meanwhile, the latter complains to
you that the former is lazy. I feel it is difficult to deal with this kind of situation.
Also if you are too tough with them, they will unite and complain to the manager
about you. (Participant16, Interview 16)
The difficulties in work delegation appeared to be a shared issue among the
participants. Due to foreigner status, the nurses found it hard to manage local
enrolled nurses and carers who would not listen and were uncooperative. The
situation was exacerbated where enrolled nurses and carers were senior to the
participants in both practice experience and age. Coming from a Chinese culture
where harmony in the workplace and a deep respect for the elders is valued, the
participants were discouraged from confronting these staff and from reporting
interpersonal issues with co-workers. Indeed, the relationships with enrolled nurses
and carers were consumed with negotiations over status and authority.
Chinese are taught to be humble and modest in their interactions because people
think that if one speaks out loudly for oneself, one does not have much inside. While
modesty is a primary virtue in Chinese relationships (Gao & Liu, 1998), in Australia,
one needs to promote oneself.
If you are too gentle and modest here, people will look down on you…You should
show your capabilities wherever you go, be courageous, show initiative and be
active. Here people will only have belief in you if you can talk a lot. People will
only appreciate you if you are knowledgeable. (Participant 1, Interview 1)
Presumably, a strong desire to impress people entices one to brag about one’s
accomplishments (Schueler, 1999). Modest people underestimate self worth to some
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extent to avoid provoking an envy response in others (Schueler, 1999). In a
collectivist culture such as China, it is necessary to be humble and modest to
maintain group harmony. There is also a negative association between the amount of
words one speaks and how trustworthy others consider one is, with those who speak
less viewed as more trustworthy (Lebra, 1987).
The interpretation of the concept of hard work further situated the China-educated
nurses differently.
They are clear on work and breaks. You should take a break when it is time to
break…They feel it is inappropriate for you to sacrifice your time…They won’t
consider this as hard work. Indeed, they feel you are being irresponsible.
(Participant 2, Interview 2)
In China, nurses are expected to sacrifice their break times for patients when
necessary. A strong work ethic is considered a source of great pride. To the
participants, working longer hours and assuming heavier workloads were
compensating strategies for their perceived inadequacies. Dedication and hard work
would reduce complaints from patients and colleagues. The nurses assumed that
local colleagues would share the same definitions of the situation (not taking a break
demonstrates dedication) and act accordingly. However, the nurses were
unappreciative of this practice.
Learning to act appropriately is a process of ongoing socialisation. It is about “taking
over specific standards, beliefs and moral concerns” (Fine, 2003, p. 76) and involves
more of what is not said than what is stated (Clausen, 1968). Socialisation thus
represents a ubiquitous feature in all interactions: the apprehension of another’s
perspective so that joint action can occur (Denzin, 1969). As newcomers, it is
necessary for the participants to display these implicit, often “taken for granted”
qualities to be accepted.
Perceptions on how to nurse also differed between the participants and local
colleagues.
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We have different ideas on what is the right way. But as a newcomer, locals
wouldn’t accept my view…The baby was agitated and crying. They gave the baby
no sedation but a pacifier. Actually the use of a pacifier could even inhibit
breathing…From a Chinese viewpoint, we thought the baby needed comfort…We
emphasised that therapeutic touch could comfort the baby. I tried to touch the baby
but they thought I was wrong in disturbing the baby. (Participant 26, Interview 40)
There is a tacit understanding about how nursing care should be carried out in a
given context. The participants who attempted to act based on pre-established
Chinese understandings failed. Using Blumer’s (1969) words, the structural and
cultural conditions of Australian nursing was an “obdurate” reality capable of
“talking back”. Problematic situations required the nurses to construct new meanings
dependent upon the response of others and to act differently.
The point here, as Xu et al. (2002) have argued, is that nursing education and
practice are never value free. Rather, they are deeply embedded, either explicitly or
implicitly, in the cultural values and norms of a given community. This may, in part,
explain why even some very experienced China-educated nurses had significant
problems at the outset. Nervous and tentative, the participants were eager to conform
to the Australian way and to live up to the attitudes and behaviours expected of them.
You live in Australia and take care of patients in Australia under the Australian
health care system. You cannot work at all if you still retain your Chinese way and
it won’t fit. (Participant 7, Interview 42)
The differences in work are demonstrated in the different emphases on nursing work
and how to deliver care. What China-educated nurses take lightly, local nurses
consider more seriously and that which China-educated nurses feel strongly about,
local colleagues consider of no consequence.
Some locals pay a lot of attention to those details, such as our work manners. Since
we do our work quickly, we may overlook some minor details and they consider us
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rude or impolite…Actually we are only concentrating on how to do our work,
looking after our patient. (Participant 26, Interview 26)
Coming from diverse social and cultural backgrounds, it is realistic to assume that
the participants would work differently, particularly during the initial period.
Difference is a means of describing and recognising, but the shared negative
evaluation of human differences become social markers and bring stigma to people
(Ainlay & Crosby, 1986). The undesired divergence from normal creates challenges
and dilemmas for the nurses and renders them deviants in Australia.
Labelling theory is useful here in understanding the negative meanings attributed to
human difference. According to this theory, deviant behaviour does not simply
violate norms, it is the behaviour that others successfully define or label as deviant
(Becker, 1973). That is to say, an act itself is not inherently deviant but rather it is
others’ negative reactions to the act that makes it and the person who performs it,
deviant. As Goffman (1963) put it, the “normal” and the “deviant” are not about
persons but perspectives.
Conceiving deviance as a “reaction process” leads to a perception that the boundary
between normal and deviant is disputable and ambiguous (Herman-Kinney, 2003).
Social inequality may directly or indirectly relate to labelling which takes the
meaning of dominant group as legitimate (Becker & Arnold, 1986). The view that
deviance is a social definition makes it necessary to understand the behaviour from
the subjective points of view of the deviants, by sharing their “definition of the
situation” and “constructions of reality” (Berger & Luckmann, 1967).
The workplace exposed the participants to a different approach to work. However,
defining the Australian way of nursing as the norm rendered the Chinese way
abnormal and unacceptable. The process of social labelling is also a process of what
Roth (1972) termed “negotiating for social worth”. Aware of the difference and the
negative consequences it implied, the participants accommodated themselves to the
social norms of the work setting. The understanding of how one should behave
arises, unfolds, and is passed on during interaction with others (Reynolds, 2003a).
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Over time, the nurses learned how to act appropriately in a range of social situations.
Apart from differences in nursing work, there were also perceived discrepancies in
collegial relationships. The following sub-category you are you and I am I captured
the superficial collegial relationships experienced by the China-educated nurses
while working in Australia.
5.3 You are you and I am I In migrating to Australia, the participants relinquished previous social ties in China.
In seeking to build new relationships in Australia, the nurses encountered many
barriers. To begin with, participation in social activities required one to embrace the
cultural norms. The disparity in values and interests made the nurses realise that we
cannot live a life like that. In addition, without a common experience, meaning is not
shared when communicating with local colleagues and this resulted in a sense of we
are among but not in. Furthermore, the ideology of individualism in Australia
implies a preoccupation with self and loose human connections. The comparison of
human relationships in Australia and China exacerbates a perception of it is
courteous but not close. Although a simple relationship has its advantages, the
participants perceived loneliness as the price paid. All these aspects shape a social
reality of you are you and I am I from the perspective of the China-educated nurses.
The following is a depiction of the sub-category you are you and I am I and its three
properties: we cannot live a life like that, we are among but not in, and it is
courteous but not close.
5.3.1 We cannot live a life like that Having no family or friends nearby, the participants experienced loneliness to
various degrees during the initial settling down period following immigration to
Australia. Longing for new relationships in the new community, the nurses were
disappointed.
Since you are in a new environment, you want to fit in very much. But people in
that environment resist you to some extent. It was obvious that no one talked to you
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when you took a break. You felt the place was very cold and everyone was serious.
(Participant 26, Interview 40)
Loneliness is related to both a lack of quantity of social interaction (social) and a
lack of quality in relationships (emotional) (Weiss, 1973). It is a response to a
discrepancy between desired and achieved levels of social contact (Blazer, 2002, p.
315). The need to talk during work breaks is really a need to relate, not in the sense
of telling or narrating, but in the sense of having relationships and connections with
other people.
Participation in informal social activities is critical to relationship building. Yet, the
nurses felt removed from local colleagues. Apart from a few colleagues interested in
China and Chinese culture, the participants felt that they had to initiate conversations
if there was to be any interaction. There was little involvement among colleagues
after work and thus few opportunities to get to know and understand each other.
Unlike colleagues who paid more attention to leisure and to enjoying life, the
participants were concerned more about work.
The concept of Australians differs from us. They pay more attention to life quality.
They can work for two days and then play for five days, things like that. Chinese
are different…We may also spend time travelling, but we still are concerned more
about work. (Participant 20, Interview 20)
Work and study occupied much time for the participants. They were also concerned
about the financial costs involved in social activities. Unlike Australians, who
appear to be able to spend at will, the nurses were accustomed to saving money.
We don’t like local people, they only think about today, not even care about
tomorrow. Chinese think about the future and plan for it. We need to save money
all the time to feel secure while they (local people) want to enjoy life all the time.
(Participant 1, Interview 43)
Chinese in general are pragmatic about life. The participants perceived a strong need
to restrain from over spending. In addition, one’s life is very much bounded by the
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family in China. As a result, the nurses perceived a higher level of family
commitment and concern than local colleagues.
There is no way (for us) to live a life like that. After all we need to consider the
family, but they (local colleagues) only need to consider themselves. (Participant 2,
Interview 2)
The different interests and forms of recreation also created disconnection between
the participants and local colleagues.
We have got different interests. Local people like to drink in a pub. This is their
way to relax and socialise with others. However, our life is not like that. We don’t
like to go there and sit, spending hours of chat over a cup of drink. (Participant 18,
Interview 36)
Social activities can mean different things to different people. Culture is an
“interpretive framework” through which the individual views the activities. While
most local colleagues considered drinking and partying culturally appropriate and
relaxing, the participants found these activities boring and meaningless. Also on
occasions of drinking and partying, local colleagues tended to be causal about
matters such as male-female relationships.
Colleagues of my age would like to look for short term relationships. However…I
am still quite Chinese in this respect…I cannot do the same thing as my colleagues
such as clubbing and spending the night with a boy. (Participant 22, Interview 44)
The social environment in which one was born and raised exerts a tremendous
influence on a perception of what is moral or immoral. According to Goffman,
Lemert and Branaman (1997), as social beings, individuals are concerned with
emulating the moral standards of the society. In the Chinese context, a casual
relationship is considered immoral and thus unacceptable.
Communication with local colleagues was also mentally difficult and the
participants experienced less personal control in conversation. Any conversational
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topic was usually unfamiliar and held no interest. Unable to make oneself
understood brought frustration to whoever was the speaker. Taking into account the
effort needed on both sides, it is understandable why some participants eventually
ceased trying to socialise with local colleagues.
The type of social activities one engages in influences one’s language acquisition
(Miller, 2000). However, during social interaction, we tend to see ourselves as we
think others see us and we also see others as we see ourselves (Hewitt, 2007). This
culturally embedded sense-making makes it difficult if not impossible for the
participants to find common ground, to see local colleague’s viewpoints, or even to
really hear one another (Chayko, 2002).
Indeed, acquisition of a non-native language by an immigrant is not just a practical
skill that one can acquire value-free (Gao & Liu, 1998). Learners have to adopt what
they see as alien values first before engaging with locals. The more one is ready to
embrace a culture, the more one will mingle with locals in social activities and as a
result the more one will be tuned to the language of that culture.
Only when you embrace their culture, can your language be improved…If you want
to fit in with locals, you need to embrace their culture first. Then this would help
you to step into their group and facilitate your interaction with locals. (Participant
7, Interview 42)
However, adjusting the meaning system takes great effort, for in doing so one must
break with a deeply internalised, seemingly natural perspective on how the world
works (Chayko, 2002). Most participants had the intention of settling down in
Australia when immigrating and were ready to embrace “the Australian way of life”.
However, they became conscious of differences rather than similarities as life in
Australia underlined the incongruities between personal and social values. The time
away from home, combined with exposure to the experiences of local colleagues,
allowed the participants to re-examine their own beliefs and practices. This
seemingly insurmountable difference gave rise to a moment of we cannot live a life
like that.
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Human beings create their own social world (Blumer, 1969) and different meaning
systems function as invisible walls in separating people into groups. The
separateness leads one to consider “the other” as immature, bizarre, crazy, and
difficult or impossible to live with (Manning, 1992). This in turn generates a dislike
of difference. These separate worlds of the participants and colleagues disrupted the
meaning making and constrained social interaction in many ways.
5.3.2 We are among but not in Social interaction does not guarantee that a true social connection will emerge when
people spend time together. Building close relationships with local colleagues is
difficult if not impossible for various reasons. Language is the medium through
which many relationship activities are conducted (Duck, 2007). Using English to
forge close ties at work was difficult for the participants.
How to communicate with your boss, how to effectively express your ideas, these
are problems for us. For example, we can only have work relations with doctors. It
is hard for us to reach the level of friendship. However, many local nurses are
good at small talk and they are very close with doctors. I think our language is still
inadequate for developing and sustaining good collegial relationships. (Participant
7, Interview 42)
Language also inhibits the formation of meaningful relationships with colleagues
outside work. Although the participants can function at work, there is little
opportunity to use English in interpersonal communication after work. Just repeating
the same sentence in routine communication does not reach far for one’s utterances
(Miller, 2000).
Local people may have lived here for 30 years and you have only 2 years. The
experience is like a 30 year-old talking to a two year-old...To me, the
communication is almost one way. The 30 year-old plays with the two-year old.
(Participant 12, Interview 31)
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In conversation with colleagues, there was little of shared interest. The effort
involved in being seen to be interested was tiring.
I know I should try my best to communicate more with others. But sometimes I am
too tired to talk with them. I always feel I don’t have much to talk about.
(Participant 2, Interview 2)
As Mead (1934) argues, during social interaction one attempts to fit one’s action
with others through the process of role taking. Role taking or assuming the
perspective of others was more problematic when interacting with local colleagues
who acted in unexpected ways. The nurses sought to present a self appropriate to the
situation even though inwardly alienated from this presented self. An authentic
expression of self was usually lost as it was necessary to pretend to understand at all
times.
Without a common experience, conversation with colleagues became awkward.
There was always risk of embarrassment due to the inadequacy of engaging with the
focus of conversation. This is reflected in the following quote:
When they talk about food… How can we know if we have never taste it before?
Like they have all kinds of salads here and we know nothing since we have never
seen them before. (Participant 6, Interview 28)
We see that social interaction is mediated by symbols and meanings, which are
socially constructed and subject to modification (Blumer, 1969). Shared experiences
enable someone to interpret a given symbol with similar meaning (Mead, 1934) and
thus facilitate joint action. Participants saw different meaning systems with
colleagues and could not create a shared understanding of reality. The symbols
colleagues used in talking are “just another thing” (Chayko, 2002) for the nurses and
they could not mentally “go there” and thus were at least temporarily excluded from
the conversation. The symbolic meaning systems which connect people can create
and maintain social distance and separate people into groups of “you” and “I”.
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Although cherishing the chance to get to know people, social activities can lose the
intended meaning for the participants.
I also attend some social activities among colleagues. But in this atmosphere, you
are not truly there to relax and… enjoy that atmosphere. You go for the sake of
going. It becomes a task to be done. (Participant 17, Interview 34)
Uneasiness and lack of reward in relating to colleagues discouraged further
interaction. The participants were uncomfortable because they were unsure of the
expectations of others and of how they should best respond. For example, they could
not do what Becker (2005, p. 119) refers to as framing “the appropriate verbal
context for sustaining the action or the ceremonial”. They did not “hear cues
familiar” to them nor could they “easily give those that make for smooth transitions
in conversation” (Becker, 2005, p. 119).
In the age of migration, many people are living and working in countries very
different from their own. In order to locate a sense of connectedness, they must
either overcome differences or relate with others who are similar in some aspects
(Hewitt, 2007). Migration overcomes the physical boundaries, but the invisible wall
of social-psychological distance remains. In failing to develop friendships with local
colleagues, the participants turned to their own people for a sense of connectedness.
The families in China were still connected somehow through technologies. Fellow
Chinese who are not part of the social mainstream provided the needed
companionship and comfort.
People might argue that the participants chose not to use English after work and thus
chose a self-imposed alienation from local colleagues. This view coincides well with
the stereotype of Chinese as withdrawn, quiet, and resistant to integration (Miller,
2000). Such a view places any language and social problems with the individual,
ignoring any deeper social structural cause. What is difficult to resolve is whether
the participants separated themselves from colleagues through choice or as a
response to an inability to do otherwise. What is known is that where confrontation
with difference became uncomfortable, they distanced themselves further from
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colleagues. Difficulties in facilitating social connections are further illustrated in a
perception that local colleagues are courteous but not close.
5.3.3 It is courteous but not close It was not long before there appeared an invisible gulf between the participants and
colleagues. It was hard to enter into colleagues’ groups and share feelings such as
joy and sadness. This sense of being left out is evident in the following excerpt:
Things they find interesting, you don’t always find appealing. And, things you feel
are funny, they do not always understand. This is psychologically stressful. You feel
you cannot share with local colleagues many happy moments and you cannot enter
into their group… It is not that they keep a distance from you intentionally, but it
was there when you first arrived. (Participant 23, Interview 23)
Although longing for connection and community, the participants were disengaged
in the workplace. Apart from casual conversation, there were no colleagues the
nurses could talk to seriously about life and no one to be called a friend. The
participants perceived the collegial relationships in Australia as superficial and
existing only at the level of the working relationship. This is reflected in the ritual
greeting in daily interactions. Indeed, relationships with local colleagues did not go
beyond the ritual greeting. The greeting itself was evidence of the relationship and
was the relationship itself.
The view of a superficial relationship is also embedded in the perception that it is
courteous but not close in Australia. Local colleagues were gentle and polite to the
nurses, but apart from this, there was no closeness. It seemed that they talked to the
nurses out of courtesy rather than genuine interest and this courtesy sustained the
disconnection experienced by the participants.
They (local colleagues) don’t really care about you in the heart, but they talk to
you out of courtesy…That is to say, the relationship is superficial. It is like
Englishmen talk about the weather when they meet each other. They usually ask
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you where you come from and why you have come to Australia ...After that, there is
nothing else to talk about. (Participant 12, Interview 12)
The perception that it is courteous but not close is also shaped by the ideology of
individualism that prevails in Australia. An individualistic society means a social
reality of preoccupation with self and loose personal relationships (Hay, 2000).
There is a sense from the nurses that even relationships among family members in
Australia are not as close as in China. In Australia, it appeared that each person
entered into his or her private life world, doing his or her own things, attending to
the self, and seemingly acting exclusively on the basis of self-interest. Not
accustomed to this structure and related sentiments, the nurses perceived there was a
lack of the human touch in Australia.
Chinese are very dedicated…When we give we give all…However much the
“foreigner” give, he/she is still him/herself. They want to be independent first,
everything else comes after that. (Participant 1, Interview 1)
The participants yearned for someone to talk to and to share experiences with;
someone who could be counted on and would always be there; and someone who
could resonate rather than passively attend. How to reconcile the separateness and
togetherness, to be both independent from and connected to each other, was a
struggle.
The very meaning of friendship differed. In the Australian society, a friend may be a
non-intimate acquaintance while in collectivist cultures such as China, friendship
implies a long term intimate relationship, with many obligations (Triandis,
Bontempo, Villareal, Asai, & Lucca, 1988). The participants wanted and needed
more from friendships than local colleagues could give. However, the sentiment of
psychological and emotional distance may also have been the creation of a nostalgic
comparison with China, as shown in the following quotes:
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Unlike in China, colleagues are usually familiar with each other, here the collegial
relationship is working relations and they have no relations after work.
(Participant 2, Interview 2)
Anyway, they (local colleagues) come when they are on duty and they leave when
they finish the shift. In China, we are colleagues even after the work. We go out
together, and then we become very good friends. (Participant 1, Interview 1)
In China, work, play, and friendship are more often blended and colleagues are
expected to engage socially with each other after work, sharing thoughts and
experiences and helping each other when necessary. The Chinese culture emphasises
the sense of the group and personal relatedness. In a close-knit community such as
China, there is a sense of intense and meaningful connections with others.
Another thing is a sense of belonging and attachment, the collective attachment;
here it is far from as good as in China. You do not feel like a home here. In China,
if we are colleagues, then they know everything about you, and you tell them
everything… Here people never say anything about themselves, and they never ask
you. (Participant 1, Interview 1)
In China, nurses do not change jobs very often and the community of colleagues
exists as an “extended family”. In contrast, the turnover rate for nurses in Australia is
much higher and people flow easily from one place to another. The nursing
workforce is one characterised by casualisation and mobility (Peerson, Aitken,
Manias, Parker, & Wong, 2002). This unstable pool of colleagues may to some
extent dilute relationships. All of the above leads some participants to conclude that
inwardly they are not as happy as they were in China.
Like my uncle and elder brother at home…They lead an easy and comfortable life
in China and they go out and have fun together every weekend…The social life
here is not as good as in China. And you don’t have friends…That is why
sometimes I feel I am not as happy as I was in China. (Participant 1, Interview 1)
Lonely and detached, it is “a world of others” to the participants. Longing for a
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sense of connectedness and to be one of them, the nurses were frustrated by a
“failure” to develop close friends in the new place. An inability to form friendships
with colleagues signals that one is still an outsider to the group.
Interestingly, some participants also considered the superficial relationships in
Australia an advantage. The complex human relationships experienced in China can
be a burden. One has to constantly watch his/her behaviour in dealing with people
and particularly superiors. In Australia, one is relatively free to do whatever one
wants. The lack of complicated human relationships is welcomed but the price is
loneliness.
A sense of you are you and I am I means that people are different. It implies a social
and emotional separateness and a lack of connectedness between each other.
Friendship is “we”; what we have created mutually (Josselson, 1996). The use of the
pronoun we is an indication of the communal connectedness between the
participants and other Chinese, people like them. In contrast, the participants felt
unconnected with local colleagues. They referred to them, specifically the Anglo-
Saxons, as “鬼佬” (Chinese colloquial, means foreigners): people not of their kind,
while they themselves were the ones living in a foreign land.
No shared experience leads to no shared meaning which in turn makes
communication problematic and community building difficult. Relationships with
colleagues are superficial and it is hard to build strong, meaningful connections.
There was an invisible distance between the participants and their local colleagues
which language itself could not bridge.
5.4 Summary After immigration, the participants not only faced the challenges of understanding
Australian nursing but also of delivering nursing in the Australian way. Based on
past experiences in China, nursing work in Australia was perceived to be different in
many aspects. For the nurses, past experience both enabled and constrained
interpretations of nursing work and practice in Australia.
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The participants also perceived collegial relationships in Australia as you are you
and I am I. The differences in interests and values posed barriers for interaction in
everyday life between the nurses and colleagues. Lack of common experience also
inhibited communication and relationship building. The collegial relationships were
superficial and colleagues are courteous but not close.
From the SI perspective, social interaction requires a shared system of symbols and
meanings among actors (Lamertz, Martens, & Heugens, 2003). A discrepancy in
meaning systems leads to the breakdown of sense making and a collapse of joint
action (Blumer, 1969). The meaning system connects human beings together but
once established, it becomes highly resistant to change (Clark, 2002). Along with the
experience of being different the participants gradually realised the presence of
symbolic boundaries between themselves and local colleagues.
It is indeed different, this is the Western way and you are you and I am I create the
need and context for reconciling on the part of China-educated nurses. The
participants regarded differences as learning opportunities and took responsibility for
the learning. All these factors may have contributed to their late struggling
experience while in Australia. The category of struggling and its sub-categories are
the focus of the next chapter.
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Chapter 6 Struggling 6.0 Introduction The category of struggling reflects the dilemma of the “middle position” of the
participants and how being situated as “the other” was experienced. There are a
number of key elements of this experience. First, in living between China and
Australia, the nurses were often caught between two worlds and faced the dilemma
of whether to be “Chinese” or to be “Australian”. Second, a sense of not knowing
underpinned the differences in nursing practices between China and Australia.
Indeed, the change in environment inevitably exacerbated a sense of the unfamiliar.
Third, being “the other” in Australia, the participants had to prove themselves to be
accepted and recognised. A desire to present a good self-image in public and to
ensure no loss of face meant that the participants felt compelled to equip themselves
totally. Finally, there was so much to learn to compensate for perceived inadequacies
that learning became a central part of life and as “the other” it was considered this is
your own business. To meet social expectations and not to present oneself as needy
or weak requires a high level of self-reliance. Thus the learning process was isolated
and difficult for the China-educated nurses. This chapter explicates the category of
struggling which consists of the following three sub-categories: caught between two
worlds, you have a lot to learn, and this is your own business (Figure 2).
Struggling
Caught between two worlds
You have a lot to learn
This is your own business
Living between two cultures
Not knowing
Coming to be recognised
To be Chinese or to be Australian
To save face or to ask
Becoming self-reliant
Figure 2. The category and sub-categories of struggling
6.1 Caught between two worlds According to Berger (2004), immigration is inevitably an experience of being caught
between two worlds. For the China-educated nurses, a clear tension emerged
between a “here” and a “there”, between traditional ideas and modern values,
between a desire to hold on to the old self and a need to conform to the new society.
This duality characteristically defines the existential condition of the immigrants as
“a state of in between-ness” (Lawson, 2000). That is to say, being an immigrant
means being in a “middle position” or in between two cultures and systems of
reference (Bagnoli, 2004). The main properties of the sub-category caught between
two worlds are living between two cultures and to be Chinese or to be Australian.
Each of these will be addressed in turn. What follows is an explication of the
consequences of being caught between two worlds: not belonging in either place or
Chinese still form communities with Chinese.
6.1.1 Living between two cultures As Cox (1987) has argued, no person at any point of time can or does start as an
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empty vessel. China-educated nurses therefore, bring with them considerable
“cultural baggage”. Since they have been raised in China, they cannot simply discard
the Chinese element. After all, it is deeply embedded in their minds and is part of
who they are. Yet for those relocated to Australia, the host society exerts some
degree of pressure to conform, whether subtly or explicitly. As one participant
indicated:
Sometimes I struggle over whether I should act Chinese or Australian. For example,
when my colleagues invite me to go clubbing with them, I am always hesitant. I
think I should go because it is a good chance for me to communicate with them in
private. However, as a Chinese, I don’t like clubbing and I don’t have the habit as
well. Even if I go, I know I won’t fit into that environment. (Participant 7, Interview
42)
According to SI, culture refers to the “consensus” of the group (Blumer, 1969).
Individuals who become part of a group agree to some extent to control their own
behaviours through adherence to a consensus. Living in Australia, the China-
educated nurses saw a clear need to fit in and become part of the community. On one
hand, adjustment is necessary because it indicates respect for the local culture (Lee,
1994). It would be neither reasonable nor practical to expect any significant change
of the host culture to accommodate immigrants’ needs within a short period of time
(Lee, 1994). Thus, one needs to modify one’s attitudes, belief system, and life
following immigrating.
We are the ones who came here to their country, therefore we have to change
ourselves to adjust to them, rather than expect them to accommodate us.
(Participant 7, Interview 7)
On the other hand, conforming to the host society is perceived as beneficial for
immigrants even if that means relinquishing some of their own cultural background
(Lee, 1994). Boswell and Ciobanu (2008) argued that if one stays close to one’s co-
ethnics, one does not move far. It is also futile to spend one’s life resisting the
inevitable.
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Because you live in the real society here, not in the dream, your life has to change
in some way after immigration. How you work, how you entertain, how you make
friends, all of these have to be changed in order to carry on with your life.
(Participant 1, Interview 43)
However, to fit is not an easy undertaking. A commitment to a culture one has
known for most of one’s life may produce resistance to new ways of doing things.
Without a shared background, relating to the Australian culture appeared unnatural
to the participants. Even where there is a willingness to change, there is no desire to
be alike just to be accepted. As one participant stated:
If I had grown up here, if my Chinese cultural background was not that strong, I
could fit in more easily…When I first arrived here, I was full of interest to
communicate with locals. Now after a period of time, I am tired of forcing myself to
do so. (Participant 2, Interview 2)
Another participant put it this way:
Unlike you mix the juice together it is not easy to fit in to a new community. Even
for those who have been here for many years, they still feel the Chinese community
suits them better. It is like a fish, it is deemed to live in water. It does not like to live
in sand. (Participant 6, Interview 28)
Participants who perceived a need to conform and could not do so because of
inadequate cultural skills were subject to frustration. This frustration, over time, can
lead to criticism of the need to conform and therefore reduce that desire (Lee, 1994).
Some people may feel that we Chinese cannot fit in with the society here, but why
should we? What they like is only to have a drink. We do not enjoy that anyway.
What they talk about is also uninteresting to us. Even if they invite us to a party, it
is not fun at all. (Participant 16, Interview 16)
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As a result, the China-educated nurses may perceive fitting in an issue of lesser
importance to social and economic mobility which is the major objective of
immigration. An absence of assimilation does not in any significant way impede
achieving such a goal. As Gans (2007) has pointed out, assimilation and mobility are
two independent processes. This means that immigrants can assimilate without being
socially or economically mobile and vice versa.
In addition, as Kim (2001) proposes, the exposure to Western culture brings to
immigrants an understanding not only of the people and their culture in the new
environment, but of themselves and their home culture. As part of the immigration
experience, the China-educated nurses came to a greater appreciation of Chinese
culture.
After I went abroad, I realised there are many good things about the Chinese
tradition. The longer I am away from China, the more I am attracted to the beauty
of the traditional Chinese culture. Before I possessed it, but I never appreciated its
value. Now I cherish it more. (Participant 6, Interview 28)
Thus there appears in this study a tension between a need to assimilate14 and a wish
to preserve tradition. Indeed, Lee (1994) insisted that immigrants cannot realistically
choose between keeping their past self intact and becoming the same as the majority.
Living in a new society, some degree of conforming is necessary and unavoidable
(Kim, 2001). This can be explained in terms of the concepts of negotiating
boundaries and switching off.
Negotiating boundaries, as conceptualised in relation to the data, means making a
conscious decision about how far one will fit in or assimilate. It is said that there are
two broad spheres of culture: instrumental culture and expressive culture (Suarez-
Orozco, 2000). Instrumental culture involves behavioural level learning while
expressive culture involves a deeper level of transformation of behaviour linked with
14 The use of the term assimilation is more a pragmatic word choice. It is possible that some element of integration is also occurring. The use of term here is quite loose but is used to reflect the wording used by the participants about pressure to fit in, the reality that any change was on part of the nurses, and also to contrast the experience with the political rhetoric of integration.
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rview 31)
changes in value, meaning, and sense of inner self (Suarez-Orozco, 2000). Because
it is hard to assimilate completely (Kim, 2001), the China-educated nurses adopted
the rules of fit in at the behavioural level only. One participant made this point as
follows:
When you interact with Western people, you need to obey their etiquette. That is a
courtesy issue. Like the Chinese saying, “入乡随俗”15. But “follow” is more
about your behaviour, not your internal values. I don’t think we can reach the
value level of fitting in. (Participant 12, Inte
While living in Australia, the China-educated nurses sought to practice in
accordance with the local culture in order to build harmonious relationships. This
instrumental level of conforming means changing external behaviour to
accommodate the environment so that one does not appear too different from the
local people. However, deeply held values remain unchanged or barely changed.
This is what Marcelo (2000) referred to as “acting white”.
Learning another language and culture is not considered threatening, but additive
and instrumental. Instrumental skills are important because these can be a vehicle for
upward mobility. Through instrumental assimilation, the participants learned to
project externally the values of the dominant culture such as assertiveness,
independence, and individualism. Yet, they did not abandon the conformity,
connectedness, and interpersonal values of the collectivistic systems.
Fitting in to me is that I know the practice of being a local Australian, not that I get
rid of my Chinese element. (Participant 16, Interview 33)
Although the participants encouraged their children to cultivate the instrumental
aspects of culture in Australia that would make them more accepted and successful,
they remained ambivalent about their children’s exposure to some of the expressive
cultural elements.
15入乡随俗 is a Chinese idiom (cheng yu), which literally means “enter village follow customs”, but is usually translated as “when in Rome, do as the Romans do”.
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There is no need to fit in completely. The Western culture is not all good. If I have
a child in future, I hope he/she possesses more Chinese elements and less Western
elements in him/her. (Participant 22, Interview 22)
In broad terms, negotiating boundaries also means that participants adopted some
values and practices but not others and did so to differing degrees. It is impossible to
embrace all values and behaviours associated with both China and Australia because
of the internal tension. Rather than abandoning one to embrace the other, they
pursued a delicate balance between the two, locating themselves somewhere in the
middle.
I feel I am in the middle of Chinese and Australian cultures. Something about me
is never going to change. (Participant 6, Interview 28)
The assimilation is an ongoing process and it occurs both consciously and
subconsciously. At a conscious level, the participants evaluated the two cultures,
holding on to some “Chinese ways” (those elements that they like or consider good)
while taking on some “Australian ways” (in rejecting those they dislike or consider
bad). Subconsciously, the participants are influenced through their daily interactions
with local people and only come to realise the effect, when on visiting home, family
or friends point to changes. Oscillating between being more or less “Chinese” and
“Australian”, the participants managed two cultural realities with different levels of
comfort and efficacy.
Switching off is a further strategy the participants used to manage assimilation. This
meant behaving differently within different contexts. In the public sphere, the
Western culture shapes behaviour, while in the private sphere the Chinese tradition
dominates. It is the case, one participant said, that:
“入乡随俗” (When in Rome, do as the Romans do) is necessary as it is a kind of
respect for local people. However when we are back home and we close the door,
we should keep our own tradition. (Participant 12, Interview 31)
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Home represents a retreat from the workplace, a space of comfort with others like
themselves. Thus the participants chose to limit their association with the host
culture to their public life and had no strong desire to do so in private. As one
participant said:
I don’t have local friends and I don’t want to either. The involvement with locals at
work is unavoidable. As to life, I don’t want it to be so. (Participant 22, Interview
22)
Bun (2004) makes the point that the strategy of switching off is reflected in the
image of one face, many masks, or being “Chinese” now and not being “Chinese”
later depending on the nature of the situation. One reason for alternating is that the
workplace gave the participants little room for being “Chinese”. They behaved in the
Western way in order to be accepted and successful. But when it comes to home,
there is choice and after all it is totally their own business. Thus the China-educated
nurses lived “the Chinese way”16 but did not work “the Chinese way”.
In a broader sense, switching off is also adopted when the participants travel across
China and Australia. There is a need to conform to the Chinese culture and act
accordingly during home visits. On return to Australia, it is necessary to revert back
to being less Chinese.
Time can change a person. Each time when it is close to going back (to Australia),
I nearly change myself to a complete Chinese; however, after a few days’ stay in
Australia, I become Westernised again--like a double faced person. (Participant 9,
Interview 32)
Individuals have to distinguish when Chinese values and behaviours are to be
expressed and when they are to be concealed.
16 The quotation marks indicate our understanding that “the Chinese way” is neither homogenous nor static.
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So you need to act according to where you are. When interacting with Westerners,
you need to talk in the Western way. When you are among Chinese, you need to
return to your previous self. (Participant 1, Interview 43)
The common practice of adopting an English name for those whose Chinese names
are considered “difficult” is one indication of “obeying” the rules. According to Li
(1997), the use of an English name not only eases the difficulty Westerners have in
pronunciation and recall, it also has a symbolic meaning of being assimilated into a
Western society. While such a change may appear superficial, those going through
the process experience a transformation of identity, including some loss of their
previous sense of self. At home, most prefer to keep their Chinese names.
The participants were not so much interested in seeking either to become or to
mimic locals but simply to function successfully in Australia. As migrants, China-
educated nurses remain tied to the Chinese culture. The frequent moving back and
forth between China and Australia contributes to a sensation of, what Bagnoli (2004)
refers to as, being caught on the edge of a wave: neither in the sea nor on the beach.
Yet, there is no question of choice about being “Chinese” or “Australian” because
change is occurring anyway. As Kim (2001) has argued, no immigrants can
completely escape assimilation as long as they remain in and are functionally
dependent on the mainstream culture. In a similar vein, no matter how successful
immigrants may be in adjusting to a new culture, they can never reach full
assimilation (Kim, 2001). As a result, both cultures can exist and are expressed to
varying degrees across situations and over one’s lifetime. Although this may give
rise to a sense of “fitting in” in more than one place, equally possible is a feeling of
not belonging fully in either place (Falicov, 2005).
As to culture, I feel I am kind of marginalised. Having detached from Chinese
culture, I am not quite attached to Australian culture as well. (Participant 15,
Interview 30)
Not knowing where to belong can be a source of struggle and unhappiness. The
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double life of the immigrant underlies the inevitability of coping with duality
(Berger, 2004). Being both inside and outside a culture, the immigrant is involved
and detached at the same time (Bagnoli, 2007). This notion of living “nowhere and
everywhere”, “neither here nor there” is a key consequence of living between two
cultures.
I feel I am the middle of sandwich. Here, Australian people feel you are Chinese
since you are different. However back in China, you may also appear different to
Chinese. (Participant 20, Interview 41)
While living within “two cultures”17 is a painful experience, something valuable
may also be achieved. On one hand, the experience of going back and forth between
two countries can result in development of an outsider’s perspective on both cultures
(Berger, 2004). As Bagnoli (2007) points out, this enables participants to view both
societies with a degree of detachment. Seeing the advantages of both cultures also
opens wide the possibility of reconstructing the self (Bagnoli, 2007). That is to say,
one has two cultural resources on which to build and from which to learn. On the
other hand, moving between cultures makes participants aware of their own cultural
values and prejudices which is essential in increasing awareness and cultural
sensitivity towards others (Chenowethm, Jeon, Goff, & Burke, 2006). There is also
less adherence to the idea that there is a right and wrong in behaviours and
preferences. The participants pointed out that their lives had been enriched as a
result of exposure to other ways of life and to new and different people and
experiences.
You came across many people and events here, and you learned from the good
things, which is not bad…Also you came to a different world…You found
something quite interesting here and this broadened your eyesight. (Participant 1,
Interview 43)
Apart from caught between two cultures, the middle position of the participants also
17 The reference to “two cultures” does not suggest an unchanging situation. The participants perceived there to be two cultures even though it is clear that cultures are moving and mixing all the time.
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gave rise to the dilemma of whether to be Chinese or to be Australian.
6.1.2 To be Chinese or to be Australian Identity is closely linked to culture (Coté, 1996) and thus a change of cultural
environment may see a restructuring of self-concept. While the China-educated
nurses wanted to become part of the Australian community, they also needed to
sustain close ties with other Chinese. That is to say, they wanted at once to be the
same and different. One participant put this dilemma in the following terms.
On one hand, I want to fit into the society here; on the other hand, I don’t want to
completely lose my true self. I frequently question myself why I try so hard to fit
into their group, eat the same food, do the same thing, and think in the same way
each day, and try to change myself totally to pretend to be a Westerner. Actually I
am not. (Participant 3, Interview 3)
However, the participants found it hard to become Australians.
I have seen some nurses who have been here for many years. Language is no
longer a problem for them. But they still cannot bridge the gap. However hard they
try to fit in, they are still different from local people. (Participant 11, Interview 11)
This poses the question of why the difficulty in transforming one’s identity. We
draw from SI the understanding of identity as socially constructed (Hewitt, 2007). It
refers to the way in which an individual defines, locates, and differentiates the self
from others (Hewitt, 2007). Identity is multiple and it includes both individual and
collective senses of meaning (MacInnes, 2006). Here, individual identity refers to a
core sense of self (who I am) while collective identity refers to a sense of belonging
to a particular group (where I belong) (MacInnes, 2006).
The notion of collective identity therefore involves negation or difference: it can
only function to include and enclose because of its capacity to exclude and leave out
(Hall, 1996, p. 5). Thus a boundary has a dual role. First, it works to establish
insiders (members): those who belong to that group (Smith, 1991). The second
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function of the boundary is to establish outsiders (non-members): those who do not
belong (Smith, 1991). Yet, those who are perceived as belonging elsewhere may also
be excluded from belonging to other groups they wish to identify with.
Since people simultaneously occupy various positions in sets of structural relations
to others, this means that they possess multiple collective identities. A major form of
collective identity is called cultural identity, which represents an attachment to
places, events, symbols, histories, and traditions (Smith, 1991). Cultural identity is
often asserted through a process of exclusion where feelings of belonging depend on
being able to say who does not belong (Craib, 1998). The “Australian identity”
excluded the participants in many ways from identifying with “Australian culture”.
It is not that Australian individuals act to exclude, but rather it is the existence of an
Australian identity that sets up boundaries and marginalised the nurses. This
explains why the participants felt not so much that they were actively marginalised
but that they simply could not be Australian.
After all we have grown up in China and we received our education from China
and we have been influenced by Chinese culture. We don’t feel we can be
Australian. (Participant 17, Interview 34)
Identity claims also depend on others (Hubert, 2001). As Hermans (2001) argues,
identity evolves in response to an ongoing dialogical relationship with others. In
other words, people know who “they” are in relation to the other (Mead, 1934). The
significance of this concept is reflected in Cooley’s (1983) metaphor of the looking-
glass self where we often see our reflections in the eyes of others and even imagine
what they think of us. If Australians think of China-educated nurses as “foreigners”
(because of physical appearances and/or accents) and people who, despite living in
Australia do not belong to Australia, then the nurses will internalise and reflect upon
the way others view them (that is foreigners as outsiders).
I am still considering whether I should change my passport or not. Even if I do
make the change, local people will not think of me as an Australian because of my
physical appearance. (Participant 15, Interview 30)
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Cooley (1983) makes the further point that people’s perceptions of who they are, in
turn, are shaped by relating to who they are not. Identification with a particular
cultural identity appears to be influenced by the extent to which one “sticks out”, or
differs from the majority (Sundar, 2008). Hence, being a minority in a
predominantly Anglo-Saxon society may reinforce the sense of self of the
participants as “non-Australian”. Indeed, China-educated nurses are visibly different
from local Australian. Thus, the participants were more quickly defined as “the
other” compared to others.
As a foreigner, I need to be very careful. There are still people who label you as
Chinese. (Participant 12, Interview 12)
It is not that being Chinese has never been part of the identities of the participants.
However, a non-Chinese environment helps to define their “Chineseness”18 (Wang,
2001). Everything they do, every word they say and how others perceive them, is
mediated through the fact that they are Chinese. While the participants are proud of
who they are and that is being Chinese, their wish is that people relate to them as
human beings who are both similar and different.
The participants generally did not feel cut off from their cultural roots but they might
consciously play down or conceal their cultural identity in the face of real or
perceived hostility towards them. Experiences of racism have caused some to
minimise their “Chineseness” in an effort to be less vulnerable.
I don’t think it is a good idea to form a Chinese nurse organisation in Australia.
This could make Chinese nurses stand out and become isolated further.
(Participant 10, Interview 37)
However, as Weber (1978) argued, cultural identity, or at least cultural pride, is also
essential for immigrants in the struggle against a majority. A belief that one’s own
18 The quotation mark of “Chineseness” indicates that there is no fixed, static, and essential definition of Chineseness.
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culture is superior in some way can serve to maintain the “status honour” in times of
hardship. Living in Australia, the China-educated nurses were identified as Chinese
and they accepted a default distinction between themselves and local Australians.
Confronted with racism, the participants asserted their pride in Chinese culture and
emphasised solidarity.
Chinese culture is very good and I am proud of that. Why should we give it up?
One learns to respect older people and not to hurt others. These are all good
traditions. This five-thousand- year old heritage is second to none. (Participant 1,
Interview 43)
There are several consequences associated with being caught between two worlds.
For most of the participants, living between China and Australia meant that their
identities were at once plural and partial. They felt a distance and closeness to both
places. This can often lead to experiences of displacement, unsure of who they are or
where they belong (Berger, 2004). Apart from this, another possible outcome is that
the participants could still form a community with other Chinese and live a Chinese
life overseas.
Australia is a good place but it does not belong to us. We are not the mainstream
here…I notice that those Chinese still form a community with Chinese after so
many years in Australia and they don’t have much interaction with locals…To me,
they are living a Chinese life overseas. (Participant 1, Interview 1)
Wang (2001) argued it was possible to live as Chinese in a non-Chinese environment
for a long period of time. Modern communication enables ready contact with the
homeland. Everyday technologies such as the internet and phone allowed the
participants to sustain emotional links despite the physical distance. Food
preferences remained to a large extent within their control. People can actually
emigrate and to a large extent live, act, and eat, as if they had never left the
homeland (Wang, 2001).
Creating a Chinese community outside China is not only possible, it is preferable.
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Where they were unable to achieve full membership in the host society, the China-
educated nurses found in Chinese communities a setting where they felt at home and
could preserve a sense of status. Most of the participants, in at least the early stages
of settlement, required the social and emotional support and sense of security that
comes from being surrounded by what is culturally familiar. It was far easier to form
a community with other Chinese because of similar backgrounds and shared
language and culture. Finally, identify with a culture that treats you as “the other”
has psychological costs, including shame, doubt, and sometimes self-hatred (Suárez-
Orozco, 2005). Reclaiming one’s cultural identity is one way to regain pride (Boss,
2006).
The formation of a Chinese community allowed the participants to share values and
to conserve significant features of the Chinese tradition. However, this also meant
that they remained bound to the Chinese community and did not become familiar
with Australian society.
In this study, participants indicated that they had a clear sense of the existence of two
worlds following immigration. Living between two worlds, the nurses struggled to
come to terms with the differences. The participants thus have “their feet in two
societies”: one in China and one in Australia. A symbolic boundary exists, which is
constructed to make sense of an otherwise unpredictable social world (Fox, 1999).
Hence, the territorial boundary is somehow broken and yet the social and cultural
boundaries persist. This gives rise to the possibility that a foreigner will forever be
an outsider.
However, aware of the presence of boundaries, immigrants refuse to be confined to
any social cultural group (Kim, 2001). It appeared from the experience of the
participants that they functioned not merely to react to the boundaries before them
but to actively manipulate those boundaries to produce benefits. Here the ultimate
aim of reconciling was to rise above the boundaries and to move into another’s
world without losing oneself. With the passage of time, the participants moved on to
some measure of resolution despite never integrating completely with the host
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community. The middle position dilemma aside, there was also a strong perception
of you have a lot to learn which is the next sub-category.
6.2 You have a lot to learn When the China-educated nurses first arrived in Australia, everything appeared new
and there were many unknowns. Being the other, the participants struggled to be
accepted and recognised. Not wanting to be perceived as inferior or weak, the
participants had much to learn. The sub-category you have a lot to learn has two
properties: not knowing and coming to be recognised. Each of these will be
addressed in turn.
6.2.1 Not knowing Not knowing is a sense of disorientation and uncertainty that one experiences when
encountering a new environment. In this study, a sense of not knowing was very
strong among the participants. It focuses on following aspects: not knowing at the
beginning, not knowing the language, and not knowing tacit knowledge. The issue
for the nurses was not just about language, as many might assume.
Not knowing at the beginning is related to the vast differences in nursing practices
between China and Australia. Depending upon where in China the participants had
come from and their previous experiences, the extent of the gap varied. For those
working in theatre, the range of new technologies could be overwhelming.
The theatre here is totally different from China. Most equipment is different. I
didn’t know about it when I first started work. When people asked me for
something, I had no idea what was being asked for. (Participant 1, Interview 1)
Some procedures which are the domain of doctors in China, such as dressing
changes and the removal of stitches, are nursing functions in Australia. For more
familiar procedures, there is still much to learn because in some important aspects
they still differ. Although it may not be an issue of right or wrong, people tend to
assume local practice as legitimate and foreign practice as wrong. The nurses were
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also aware of the differences in the contexts of health care delivery and regulations
for nursing practice. Concerned about potential legal problems, the participants were
expected to conform to protocol.
Learning is also necessary because of the greater autonomy the China-educated
nurses experienced in Australia. The participants sought greater knowledge in order
to be confident in clinical decision making.
Nurses here need to know more professional knowledge because they have more
autonomy and they can make decisions within their scope of care. The more you
know the better care you can provide. (Participant 3, Interview 46)
The participants saw the level of unknowns as partly a consequence of short
preparation undertaken as a requirement for registration in Australia. Comprehensive
learning is not possible in a 24-week bridging course or 1 year transition course.
However, one participant who had completed a three year nursing bachelor degree in
Australia also expressed a similar concern.
I took my nursing courses again here. But I feel it is not as good as in China. There
is not enough practice components in the whole curricula. One needs to learn from
the beginning after coming to the clinical area. (Participant 28, Interview 35)
This comment resonates with the persistent debate over whether there is a
discrepancy between what student nurses are taught in an education setting and what
they experience in the practice of nursing (Chinn & Jacobs, 1983). Yet while
students may perceive the gap negatively, it is also argued that the clinical context
should have a different focus from theoretical learning (Corlett, 2000).
Language and communication is a further aspect of not knowing for the China-
educated nurses. A certain proficiency in language and communication skills is
required in order to function adequately. Language difficulties were associated with
informal language use such as Australian slang, idiom, jokes, or humour. The
participants were frustrated at not being able to interpret jokes or to grasp the
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humour in what was being said.
I can function well in daily work. However, when it comes to a joke, the thing is
that usually everyone laughs except me. (Participant 12, Interview 12)
I feel local people speak in a very informal way. However, we learn mostly
textbook English in China… It is indeed difficult at the beginning. Everyone feels
they have been talking in this way since they were young and they know what it
means when being spoken to, but not me. (Participant 11, Interview 11)
Just as identity is socially constructed so is language (Mead, 1934). Language is not
only about forms and patterns of expression, it is also about meanings. That is to say,
the actual usage of a language involves all manner of background knowledge and
local information in addition to grammar and vocabulary (Agar, 2006). Meanings
inherent to slang, jokes, and humour are established by long term usage and are
highly nuanced and contextual (Lee, 1994). To understand a joke, there must be
common ground which does not exist for immigrants.
In particular, where there is a lack of non-verbal cues, such as in telephone
communication, a social experience can be daunting for the China-educated nurses.
Fear of not understanding fully a message, concern over potential practice errors,
having difficulty in grasping an English name, and losing face in asking for
communication to be repeated are features of the experience. This is well described
in the following excerpt:
We dared not make a call or answer the phone at first. I had no idea where the call
was from. It took me a while to understand a patient’s name and I usually needed
to ask them to spell it out for me as well…Sometimes when I made a call, a simple
question from a doctor such as, “what is wrong with the patient” took me a lot of
time and effort to explain. (Participant 26, Interview 26)
Verbal communication becomes more so of an issue in cases of a clinical emergency.
As Laponce (1987) points out, the mind works more quickly and with less effort in a
unilingual semantic system. Second language speakers may think in one language
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and translate into another in speech which delays any response (Kirova, 2006). In
addition, colleagues usually become less patient and talk more quickly in an
emergency situation.
Technical language further exacerbated communication problems for the China-
educated nurses. English medical terminologies, English names of medicines,
medical jargon and abbreviations may be unfamiliar. Understanding the vast volume
of technical language was an inevitable challenge since the participants received
their basic nursing education in China and in Chinese.
Most participants had only limited experience in the use of English in China. For
second language speakers, language becomes a technical issue because of
constraints on natural expression. Subtleties of meanings are missed and
miscommunication results (Suarez-Orozco, 2005, p. 138). It is hard for one to
reproduce correct intonation and thus to project the subtleties of a culture. We see in
the following account the difficulties in achieving that balance:
Once, I had a patient who had difficulty in urinating. After examining the patient,
the doctor asked me to insert a urinary catheter. I informed the patient of this
decision and he could not accept this and was very upset. He jumped off the bed
and ran into the toilet quickly. After a lot of effort, he succeeded. He was crying
after because of the painful experience. I tried to comfort him (saying): it is
wonderful, now you don’t need a catheter anymore. To my surprise, the patient
lodged a complaint to my manager. He said I perceived it “wonderful” that he was
in great pain. Now when I look back, I realised that if I were a local nurse, this
kind of misunderstanding would not happen. (Participant 27, Interview 45)
While the participants were required to pass a language test, according to Wang and
Lethbridge (1995), a high score does not guarantee adequate language fluency when
working as an RN. Indeed, the language barrier is a long term issue. It is not a minor
accomplishment to transfer Chinese knowledge into English because the two
languages are quite distinct. English language acquisition, especially for an adult,
takes a great deal of time, patience, and learning.
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We assumed that our language would improve automatically and dramatically
once we had a chance to live abroad. That is not the case. You still need to learn
hard by yourself. (Participant 25, Interview 38)
As Xu (2007) indicated, language barriers flow to a range of implications. In the best
scenario it may mean that one is slower at work.
At the beginning, my language was not good enough to understand everything or to
express myself fully…and it usually took me much longer to finish one task.
(Participant 17, Interview 17)
Besides appearing slower, communication issues limit one’s work performance in
other ways. When encountering doctors’ complaints, the participants had no idea
how to appropriately handle such situations. The nurses were at a loss when
addressing patients’ psychological concerns. A limited range of words makes
comforting of a patient difficult.
I had a patient who was unhappy. He cried and lost his temper on my shift. I did
not know how to communicate with him and convey my sympathy. I just didn’t have
the words that come so naturally. (Participant 7, Interview 7)
Effective communication requires one to produce contextual appropriate language as
well as understand the nuances of a given situation, both of which pose great
challenges for the participants. This is because people often respond in anticipation
of what others will say (Mead, 1934). Social differences can cause misinterpretation
and thus misunderstanding arises when people attempt to relate to one another across
cultures. As a result, there is a strong relationship between perceptions of a foreign
nurse’s overall competency and the ability to speak English (Davis, 2004).
A shared view among the participants was that they had the knowledge but not the
words. The participants tended to remain silent during interactions with patients and
colleagues for fear of being ridiculed. An inability to speak out, furthermore, served
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to reinforce a stereotype of the Chinese nurse as shy, unassertive, and not equipped
to be a leader.
Sometimes when communicating with colleagues and patients, we don’t have the
words even though we have the knowledge. When your language is not good, you
appear stupid and people look down upon you. (Participant 23, Interview 23)
Language also functions to reinforce ideas of exclusivity. That is to say, sharing a
language binds some people together while separating others (Bach, 1997, p. 339).
Communication performs boundary work by affirming the collective experience and
shared perspective of the in-group with respect to the out-group.
Those locals are talking cheerfully and humorously over there, but you feel isolated
and cannot even insert one word. Such a feeling is really awful. (Participant 1,
Interview 43)
The experience of not grasping what a local person finds humorous reinforces a
sense of separateness and the sense that we do not belong together. Having a strong
accent marks the speaker as an outsider (Allan & Larsen, 2003). Language became a
marker of difference for the participants and they wanted to lose all trace of
difference, including accents, in order not to be seen as outsiders.
Not knowing tacit knowledge is a further challenge. Tacit knowledge is defined as
that which enters into the production of behaviours and/or the constitution of mental
states but is not ordinarily accessible to consciousness (Eliasmith, 2004). In this
study, it refers to common sense knowledge and taken-for-granted knowledge such
as how one deals with death and how decisions about care are made. These issues
can be problematic as the following quote indicates:
In our daily work, it is fine when there are no special circumstances. However
when you come across a patient who is dying, how to communicate with the patient,
how to comfort the family, that is an issue for us. (Participant 17, Interview 17)
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The taken-for-granted assumptions of a society are often pervasive and subtle, which
makes it difficult, although not impossible, for immigrants to develop a thorough
understanding. In addition, what is common sense in one culture may not be
common sense in another. A local Australian might have no idea about what is
problematic for an immigrant nurse. As a result, cultural knowledge for the
participants was often incomplete and fragmented and not organised in ways that
could be readily used. One aspect of tacit knowledge relates to the workings of the
Australian health care system.
When people here getting old, they may choose to go to a nursing home. We have
no idea of the steps involved in this process…This is considered common sense to a
local...They know it. But to me, I never know it before I go through it. (Participant
10, Interview 10)
Although hospitals have clear policies on many procedures, the information which is
regarded as common sense by local Australians is often omitted and thus was
unavailable to the participants. Lack of access to such tacit knowledge reinforced the
perception of being an outsider, which further alienated the nurses.
Coming to know tacit knowledge was a long learning process for the China-educated
nurses. No mechanisms exist to facilitate the obtaining of such knowledge.
Participants who attempted to act appropriately on arrival in Australia were
disillusioned. Through trial and error, they sought to develop tacit knowledge.
The sense of not knowing was pervasive for the China-educated nurses. In not
knowing at the beginning, not knowing the language, and not knowing tacit
knowledge, some learning was imperative to bridge the gap. Learning is necessary to
cope with daily work and to manage stress related to unknowns. It is also part of the
process of coming to be recognised.
6.2.2 Coming to be recognised Identity is simultaneously about sameness and difference. As argued above, it is the
identification of how we see ourselves and others in relation to being the same
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(Pullen & Simpson, 2009). Identity is also about difference or who we are not the
same as (Pullen & Simpson, 2009). Since there can be no “us” without “them”,
identity is about both who we are and who we are not. Living in Australia, the
China-educated nurses were perceived by local nurses as not only a minority but
also “the other”.
They (local nurses) think you are the one who has come from overseas. So you are
the outsider and you do not belong here…Therefore you feel excluded and
marginalised. (Participant 18, Interview 18)
At the beginning, local nurses treated me as the one from overseas, the one not as
good as them. I am not saying that they are being discriminating. But they felt you
were different so they isolated you. (Participant 21, Interview 21)
Here a symbolic boundary is drawn between us and them. Skin color, language, and
culture are all highly visible markers to rationalise the exclusion of others
(Kumashiro, 1999). Based on the culturally and historically defined “normal”
majority, visible differences denote a visible minority status in a particular social
environment (Hage, 1998). While “English”and “Whiteness” are privileged as
normal and normative in Australia, “Chinese” and “Asianness” are othered as
foreign and exotic (Haney Lopez, 1996; Lowe, 1996). The existence of the latter is
acknowledged only to accentuate the difference from the so-called “norm”.
Thus in being foreign and different, the China-educated nurses were labelled as “the
other” and literally the other is someone who belongs elsewhere. In addition,
definition of an identity is based on host society stereotypes. The other tend to be
perceived as strangers whose otherness cannot be tolerated (Gurevitch, 1988). The
otherness of the other also gives one a reason for not trying to understand (Gurevitch,
1988).
I feel quite isolated socially wherever I go…It was very obvious on one occasion.
My husband and I went to visit our son’s school before the semester started. Some
parents were talking to each other. However no one even noticed me. Two local
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Australians sitting next to me ran directly to each other, totally ignoring my
existence. (Participant 12, Interview 12)
Difference should not imply inferiority. Yet, the other is seen as having a language
and culture that is inferior, unacceptable, and even threatening to the norm (Goffman,
1963). Health care consumers in Australia might perceive that they are receiving a
sub-standard care from immigrant nurses. Having not been educated in Australia, the
participants tended to accept the implicit position of being less qualified.
After all we are from overseas; we should work hard and be extremely careful in
our work. (Participant 12, Interview 31)
Being the other means being less powerful and socially marginalised (Goffman,
1963). It also means not being trusted by others.
As long as the doctor sees a few nurses together, he will select the local one and
ask her for information. He never asks overseas nurses. This is so obvious. Even if
I am the one in charge that day, the doctor never bothers to try. It is really
distrusting of us. (Participant 22, Interview 22)
The predominant use of the English language in Australia reinforced the employer’s
authority and silenced China-educated nurses during their daily interactions. Tied to
a contract, the participants had little bargaining power and had to tolerate hardship
and mistreatment. The nurses benignly accepted this position when they first arrival.
When I first started work, I considered myself as a newcomer...In addition, I have
an Asian face. That is why I was in a disadvantaged position and I did a lot.
(Participant 26, Interview 40)
The participants experienced varying levels of vulnerability in Australia and yet
were determined to succeed. Unlike nurses from the Philippines who have access to
a more structured system to facilitate their immigration (Brush & Sochalski, 2007),
each China-educated nurse had to find her own way. Thus the participants required
great determination and in a sense were self-selected as more resilient and with a
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strong desire to learn.
The participants noted that obtaining a nursing license is extremely challenging.
Apart from the difficulty of coursework, many carried a financial burden in meeting
the costs of studying and living in Australia. This meant that some worked as
assistant registered nurses or carers, work that was emotionally difficult because it
was considered menial and low level in China.
Investment in the immigration adventure is large and there is no option to fail. The
desire to learn well in order to survive and the willingness to learn “advanced”19
Western knowledge drives self-discipline. The participants also carried the hopes of
their families and had no choice but to succeed regardless of the situation.
I resigned my job before I came to Australia. I had to make it and stay in Australia.
If not, I couldn’t find my own place back home as well. (Participant 17, Interview
17)
Success is closely associated with acceptance in the workplace by peers as valued
and contributing members. Through this looking-glass (Cooley, 1983) of colleagues,
the participants were aware of their own feelings about the views of others. A sense
of shame may result where they are aware of less than desirable evaluations by
others. This emotion, in turn, became a powerful motive for the participants to learn
in order to improve themselves.
In adopting a show of normalcy, people, according to Goffman (1959), are capable
of presenting themselves in a certain way in order to manipulate their impressions
before others. The strategy of self presentation was widely adopted by the nurses to
gain acceptance in the workplace. For example, being well prepared was necessary if
one wanted to appear more knowledgeable.
When you do the hand over to the ward nurse, you need to do some homework by
yourself. At least you need to be able to tell clearly what kind of operation has been
19 The quotation mark of “advanced” indicates that it is advanced in the participant’s eyes.
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done for the patient in the theatre...This is not easy…Those medical terminologies
are kind of difficult. However, you can read the doctor’s operation notes on the
way. (Participant 1, Interview 43)
As Goffman (1959) points out, people are not free to merely act the way they want,
instead, they wear social masks when performing in public. Indeed, the participants
made great efforts to influence their colleagues and patients to perceive them as they
would prefer. This fostering of certain impressions in the eyes of others had
implications for how others perceived, evaluated, and treated them, as well as for
their views of themselves (Goffman, 1959). However, it is clear that other
unintentional impressions were also “given off” (Goffman, 1959).
Sometimes when you talk to colleagues, your words are disordered or one of your
pronunciations is incorrect because you are in a hurry. They may react like, Aaa--,
like that. (Participant 3, Interview 3)
Of course not everyone has the same impact upon us. Some people are significant
others because one has frequent contact or is dependent upon them for valued
outcomes (Leary & Kowalski, 1990). For the nurses, work was the primary purpose
of immigration and the means for livelihood. Hence, the impressions of colleagues
and patients were important and influential.
The context of interaction also matters. Overall, the more public one’s behaviour, the
more likely one is to be concerned with how it appears to others and the more
motivated one will be to manage self presentation (Arkin, Appelman, & Burger,
1980; Bradley, 1978). Thus one’s impression in the workplace is considered more
important than in private life.
You can let it go anyway if you cannot understand those casual chats. However,
when it comes to the clinical area, you have to make sure you understand and
appear competent. (Participant 22, Interview 22)
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Fear of losing face is also strong motivation for not exhibiting inferior capabilities,
skills and knowledge in the workplace. This concern is evident in following excerpt:
Even if we speak in Chinese, we also have occasions of not being able to be
understood… However, you are still concerned whether local colleagues will make
fun of you because of an incident and the fact that you have been here for a while…
You feel it is a loss of face even if you are only slightly away from the ideal.
(Participant 3, Interview 3)
The concept of face, as Kim and Nam (1998) argued, exerts a significant influence
on human behaviour in a collectivist society such as China. These authors point out
that in Chinese society, the core cultural norm is to achieve and foster harmonious
relationships and interdependence among group members. In this cultural context,
individuals are socialised to focus on and respond to the external evaluation of
others. Thus, a person is expected to act in accordance with external expectations
rather than internal wishes and attributes in order to avoid the negative consequences
of shame. An individual’s attempts to “stand out”are discouraged. Rather, people are
encouraged to make an effort to “fit in” with others (Kim & Nam, 1998).
When competence was called into question by others through incidental remarks, the
participants engaged in various corrective practices to seek to restore positive
impressions. In this sense, face is retrieved not only by improving performance, but
by demonstrating an effort to meet expectations.
The necessity to prove oneself and the desire for recognition are powerful motives
for learning. Despite attempts on behalf of some health care employers to embrace
diversity of employees, the China-educated nurses experienced a lack of recognition.
As one participant stated:
When I first started work, I didn’t feel I was recognised by my colleagues…Maybe
because I was paid at year-9 level at that time, but actually I was not able to take
on responsibility as a senior nurse…As a result, I didn’t feel I was recognised in
the ward. (Participant 17, Interview 34)
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Several factors contributed to the level of recognition of the China-educated nurses.
Those participants who were employed at a senior level but initially unable to
perform at that level had a harder time gaining recognition. Whether a workplace has
been exposed to immigrant nurses previously and to what extent is a further factor.
Those organisations familiar with the situation of immigrant nurses understand
better the transition and have more realistic expectations.
For the China-educated nurses, the process of gaining recognition was not easy and
it came slowly. Along with self improvement, the participants found that the
attitudes of colleagues changed. With good technical skills and a good work ethic,
they were perceived to be good working partners. They were consulted more often
and colleagues were more willing to offer help. Being respected and treated as an
equal were also important indications of recognition.
At the workplace, I expect at least that they (local colleagues) do not label me as
an overseas nurse and perceive what I do is kind of strange to them. At least they
treat me as a colleague with a certain period of experience…I expect to be treated
equally at work, the same as local nurses. (Participant 17, Interview 34)
Confronting the new environment with the unfamiliar and the unknown, the China-
educated nurses had a lot to learn. Being the other, it was necessary for them to
improve themselves to gain acceptance and recognition from colleagues and patients.
The concern to appear competent and not to lose face also motivated learning. It
could be said that learning had become a central feature of their life. Despite the
extent of learning required, the participants perceived that it was their own business
to deal with the unknown.
6.3 This is your own business The desire to appear competent made it hard for the participants to disclose what
was not known and to seek support. Being the other, the social expectation was that
one be self-reliant and expect no extra help. Being away from family meant that the
participants had left behind strong support networks. The amount of support
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available in Australia was minimal. As a result, the nurses in this study very strongly
perceived it their own business to deal with the unknown. The sub-category this is
your own business consists of two main properties: to save face or to ask and
becoming self-reliant. Each will be addressed in turn.
6.3.1 To save face or to ask The unknown needs to be known in order to function properly. Bearing the markers
of the other, the participants were viewed as outsiders and were not initially fully
accepted and recognised. Being foreign and different also meant not being well
understood by local colleagues. It was therefore hard to disclose what one did not
know or understand.
If you ask, they (local colleagues) probably will answer you…However you still
don’t want to ask. Because people will judge you as unqualified if you ask too
much. That is also part of the evaluation towards you. (Participant 1, Interview 1)
Here we see that the dilemma for the participants was whether to reveal or to
conceal knowledge gaps. They feared that they might be judged as unqualified if
they asked too many questions or if the questions were too “simplistic”. They
concealed or underplayed their doubts and sought to work as normally as possible.
This concealment did not constitute a denial of the problem: it was a rejection of the
social significance of the problem and not rejection of the problem per se.
There are certain risks associated with not questioning such as patient safety or
where a lack of understanding is revealed anyway. As a result, the China-educated
nurses prioritised what was of immediate significance in a clinical situation.
I need to have my own judgment. If the question is something that I can learn at
home by myself then I just keep it to myself. If it is urgent, serious, or there is
potential risk involved, I have to ask colleagues immediately. (Participant 6,
Interview 28)
Thus there is an inherent tension between what should be shared and what should
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not. In facing the dilemma of whether to ask or not, the China-educated nurses
employed strategies to extend their control over what to disclose and to whom.
When I first started work, the ward manager and the ward facilitator asked me
what I didn’t know. I chose to tell them about those big issues such as ward
management and so forth. As to those common medicines which I had not heard of,
I didn’t tell them. I could learn them by myself. (Participant 26, Interview 26)
The anticipation of how colleagues might respond shaped whether participants chose
to disclose their unknowns. Where they considered it necessary to conceal, the
learning process for the nurse was at times isolated or hidden. It was also important
to whom one disclosed, as the following excerpt shows.
It depends on where you are and who you work with. If you work with other
overseas nurses, you can tell them your unknowns and they generally will teach
you. If it is local nurses, you are better not to attract their attention and make
trouble for yourself as they would suspicious of you once they realise you even do
not know this simple stuff. (Participant 26, Interview 26)
Being the other, there was also a lack of trust of local nurses who were considered
outsiders. A power separation from ward managers further contributed to the
reluctance to disclose. By contrast, other overseas nurses were effective confidants
because of shared experiences. As Heine (2001) indicated, Chinese view “in-group”
members as an extension of their selves while maintaining distance from “out-
group” members. There is an emergent sentiment of “we-ness” among those
confronting similar difficult situations in a foreign country (Fox, 1999).
It may also be argued that this strategic disclosure is used for self-protection
purposes. In Goffman’s (1959) terms, it is a form of impression management. People
seek to present the self in a particular way to others. Through strategic disclosure,
the participants conveyed to others an impression of a competent nurse, which was
consistent with the overall social expectation.
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I would try to be “smart” on something. I wouldn’t say I didn’t know. However I
would observe local nurses nearby and see how they did it. Sometime I feel it is
necessary to act this way as well as people would otherwise suspect your
qualifications if you said you didn’t know something which might considered
common sense to them. (Participant 12, Interview 31)
The practice of strategic disclosure can also be explained using the concept of face
(Ho, 1976; Hu, 1944). In collectivist cultures, a moral person behaves according to
the role expectation specified by the society. If the individual deviates from such
ideal behaviour, there is a risk of losing face (Ho, 1976). The Confucian emphasis on
fulfilling role obligations suggests that losing face could be potentially more
threatening for Chinese (Heine, 2001).
In addition, there is also the concern for the collective face. As noted by Hu (1944),
in Chinese culture one’s face not only belongs to the person, but to the community.
The author argues that a person does not simply lose his/her own face, public
disgrace or ridicule of a serious nature is bound to have an effect on the reputation of
the family or community (Hu, 1944). Indeed, a less than desired performance may
damage the reputation of all Chinese nurses.
I think for those of us who have worked here, we should try to do our job well in
order to foster a favourable impression about Chinse nurses as a whole. By this,
local people will welcome the arrival of future Chinese nurses, instead of resisting
them. (Participant 11, Interview 11)
It is not just that the participants were unwilling to ask questions when they should,
but they could not. Part of the reason was due to the unrealistic expectation of some
workplaces. The ward managers might expect these nurses to “hit the ground
running”; however the participants considered registration the first step of learning
to be a nurse in Australia. The divergent expectations make mutual understanding
difficult.
Not divulging and isolated learning are integral components of the participants’
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mechanism for coping with their unknowns. The fact that the nurses’ attitudes
towards disclosure differed in part confirms that they were hesitant, as revealing the
wrong information, or with a wrong person could have placed them in a
disadvantaged position. Yet, it is also a too simplistic and too stereotypical view to
conclude that China-educated nurses do not seek help.
Being the other and struggling to be accepted, the participants feared disclosing what
was unknown to an outsider as it would make acceptance more problematic. There
was also concern about what to disclose and to whom to disclose in anticipating the
response from colleagues. A concern over face issue when dealing with unknowns
also partially contributed to the nurses’ experience of becoming self-reliant in
Australia.
6.3.2 Becoming self-reliant Family represents an intimate group of people on which one can count for comfort
and care (Boss, 1999). Most participants had been well looked after at home in
China. After immigration, the nurses experienced a loss of social support. This was
further exacerbated by a lack of a social network initially in Australia.
I never did any house chores at home since I was the only child in the family…My
mother even handed chopsticks to me before I ate, but I still got angry sometimes
without a good reason. Now I live away from the family, I need to take care of
myself and there is no other way. (Participant1, Interview 1)
My father doubted my ability to live independently. He said: you never go far away
by yourself, besides, you are the youngest in the family, you never did any house
chores at home and we treated you as a queen…My father was really worried
about that and thought that I was unable to endure the hardship. (Participant 3,
Interview 3)
The participants perceived a lack of social support in Australia. One contributing
factor was that most participants have left their families behind. According to Wang
and Ollendick (2001), the tradition dictates that Chinese families are more
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supportive and encourage more dependence by the children on the parents. The
extended family is often a source of support for working mothers in China. Another
contributing factor relates to the fact that each participant was likely to have been the
only child in the family as a result of China’s one-child family planning policy.
Brought up in a prevailingly overprotective family environment, many participants
considered themselves to be indulged in their past lives. Loss of social support was
particularly acute for those who were accustomed to a collectivist culture where
group activities and interdependence were valued and the self was viewed as part of
a community (Noh & Kaspar, 2003).
Away from the family, the China-educated nurses turned to other sources such as
friends for support. However, most indicated that it was hard to make friends with
local Australians due to a lack of cultural capital and confidence. The demands of
learning also left them limited time and resources to interact socially.
In addition, colleagues were considered only appropriate in providing instrumental
support such as assistance in problem solving (by tangible help or information).
When it came to emotional support, both families and local colleagues were
considered unhelpful as they generally could not understand what the participants
were experiencing.
You may have local friends. However, when you get issues in your work or lose
confidence, it is better for you to talk to other Chinese nurses. (Participant 20,
Interview 20)
Families back in China don’t know your situation, so it is hard for them to
understand your experience. They thought you were good enough since you went
abroad. Actually life here is not that easy. (Participant 26, Interview 26)
It is assumed that fellow Chinese who had similar experiences could better
understand. Thus, the participants reached out to other Chinese for that support.
Fellow Chinese were more readily available and in most cases more acceptable and
accepting. Common experiences and identities not only made communication and
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understanding of needs easier, but the assistance they offered in the initial stages of
immigration was very real. It was also perceived to be less shameful to ask for inside
support (Heine, 2001).
We call each other. We meet each other from time to time. We ask each other the
experience of working in Australia…We encourage each other and exchange views
on how to stand on our own feet. All this emotional support is essential and
sometimes it is more than the family can offer. (Participant 26, Interview 26)
It is important to have Chinese friends who had similar experience as you here. We
can help and support each other...The mutual emotional support is very essential.
(Participant 20, Interview 20)
Support from fellow Chinese friends was essential and yet it was minimally used.
Most friends had many competing obligations and interests and were struggling to
care for themselves. Support from friends was also limited by their own needs and
resources and the participants did not want to be perceived as a burden for others.
In addition, the provision of support from the health care organisations was
inadequate and inconsistent. One possible reason was that some considered it not
their responsibility to provide support. The implicit assumption was that the China-
educated nurses came for their own purposes (either financial or non financial). They
were paid according to the level of qualification. A further reason was that domestic
nurses might sometimes perceive the support given to immigrant nurses as
preferential treatment and a form of discrimination.
There are always some local colleagues who look at you nearby and tease you.
They are indifferent to you and they will perceive it like this: now that you come
here to work, you have to be like everyone else, and so forth. (Participant 11,
Interview 11)
Inadequate support may also reflect the inappropriate support provided in some
workplaces.
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I found the support they provide is not what I needed. For example, they help you
to rent a room but all the rooms they get are too expensive for you. The support
they provide is not practical at all. (Participant 12, Interview 12)
Immigration of China-educated nurses to Australia is a relatively recent phenomenon
and to which few health care organisations in Australia have been widely exposed.
Also, the number of Chinese nurses in each workplace may be too few to warrant
close attention. The fact that immigrant nurses come from all over the world with
their own particular needs further complicates the issue.
The form of support available for China-educated nurses also differed from place to
place. Private health care organisations seemingly provided fewer resources than
public institutions for practical and financial reasons. Even within one organisation,
the support available varied across work units. The immediate nursing manager was
considered important in creating and maintaining the supportive environment in the
ward. The few colleagues with whom the China-educated nurses worked closely
could also make a difference.
Apart from lack of support in the workplace, participants also expressed their
concern about the meaning of support. They questioned the necessity for exclusive
management and the implications of differential treatment.
I don’t think it is necessary for the hospital to provide extra support for us. This
would make overseas nurses stand out even further. The fact that we need an extra
training program would render us disadvantaged rather than benefit us. It may
cause people to think that we are inadequate and lack of something. (Participant 7,
Interview 7)
The fact that few participants expected support may indicate that they are socialised
to take responsibility for themselves. There are several explanations to support this
proposition. First, without available support, the nurses had to rely on themselves.
Second, there was also the normative expectation that the participants should be able
to work independently since they were qualified. Being employed as competent
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nurses, the nurses also wanted to demonstrate their ability and to be seen as
responsible. Third, it was assumed that work performed equals the reimbursement
received for that work. The fact that they were paid at the same level as other nurses
made it evident that they were expected to make it on their own. As one participant
stated:
This is your own business. You come here to work and you get paid for your work.
People don’t pay you less simply because you are from overseas. The workplace
treats you equally so you have to be strict with yourself. (Participant 12, Interview
31)
What was not known therefore became the participants’ own business and thus left
lack of support largely unquestioned and unchallenged. It is likely that the nurses
took the asymmetrical social order as the norm. The inequalities embedded in the
social world are made invisible and taken-for-granted (Bourdieu, 2001). In an
individualistic society which values independence and self-reliance (Triandis, 1989),
the nurses considered it natural to “make it on their own” and to endure some
hardship.
Now that you are paid for your work, it is reasonable that the hospital regard all as
equal. The hospital won’t give you special treatment…You have to perform as
everyone else. So this process might be painful but you need to endure it yourself.
(Participant 1, Interview 1)
Where the immediate environment was lacking, the participants turned to places
open to them such as religious institutions.
I feel the church where I go to is quite good… I asked them for information and
they would help me. I think church is a good source (of support). (Participant 12,
Interview 12)
As Foner and Alba (2008) argued, church involvement not only addresses isolation
and loneliness, it also allows immigrants to acquire community acceptance and
practical help. The increased participation of immigrants in religious institutions can
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be partially attributed to the alienation inherent in the immigration experience and
the lack of sources of support.
The symbolic message of a lack of support has implications that go beyond dealing
with the specific problem at hand. Receiving support from others makes people feel
that they are being understood, cared for, and accepted (Baumeister & Leary, 1995).
The sense that they are supported by others makes people feel as though they belong
and relate. On the contrary, a sense of not having access to such support can alienate
one further and make the hardship more difficult to endure emotionally.
While facing highly uncertain and stressful situations, the China-educated nurses
lacked adequate support. Language inadequacy contributed to an inability to
successfully navigate the system. Insufficient knowledge about how the system in
Australia works limited means for seeking and obtaining needed support. There was
also a tension between the need for support and the social expectation of being self-
reliant. The assumption that immigrants have access to social networks in host
society simplifies the experiences, underestimating the difficulties they experience in
obtaining support.
6.4 Summary Caught between two worlds, you have a lot to learn, and this is your own business
constitute the process of struggling for China-educated nurses. Living between two
worlds, participants were caught in a dilemma. Facing a foreign world with which
one could not automatically relate, meant that there was a lot to learn. Being the
other and wanting to be accepted, participants perceived it was their own business to
deal with the unknown.
During the struggling process, the participants worked hard and were determined to
succeed, although at the same time lowering their expectations. They adopted a
range of strategies in seeking to project what they perceived was a socially
acceptable self. It was perceived that one needed a strong heart to endure this
process. One participant used the metaphor of drowning when both describing and
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visually representing the overwhelming experience of the first few months in
Australia. During and after struggling, China-educated nurses also engaged in
another component of reconciling, reflecting on their experience, which is explored
in the next chapter.
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Chapter 7 Reflecting 7.0 Introduction The concept of reflecting refers to a process whereby China-educated nurses, in
seeking to make sense of the immigration experience, reflected upon the gains and
losses associated with the move. There are several components of this experience.
First is a sense of loss, including loss of life components, loss for the family, and
loss of career opportunities. Second is a reconstructed sense of self where elements
of the old self are left behind and replaced with both feelings of vulnerability and
sense of personal growth. Third is the loss of a dream which is diminished by the
reality of the immigration experience. Yet, it is also hard to return to where the
dream began. This chapter explicates the category of reflecting, which consists of the
following three sub-categories: a sense of loss, reconstructing the self, and it is hard
to go back (Figure 3).
Figure 3. The category and sub-categories of reflecting
7.1 A sense of loss Although immigration brings multiple gains, it would be inaccurate to assume that it
is a loss-free process. Most critically, immigration removes individuals from many
relationships and predictable contexts (Suarez-Orozco, 2005). The losses involved in
the immigration process are loss of life components, loss for the family, and loss of
career opportunities. Each is addressed in turn.
7.1.1 Loss of life components Participants expressed a loss of their various life components following immigration.
As Australia is a developed country, participants had an implict expectation that life
here would be more colourful and convenient than in China. However life in
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Australia was overwhelmingly considered boring and inconvenient. Without
families and friends and in the absence of a social network in the new community,
life was lonely and homesickness ever present. The participants missed their homes,
the food from their hometowns, and the Chinese lifestyle. The loss of family life and
the loss of a familiar environment consisting of culture, language, and customs were
important and unavoidable. This is illustrated in the following quotes:
Indeed life here is not as colourful as in China. The supermarket and shops close at
night and you cannot go shopping after dark. You can only go to the pub or stay at
home if you don’t like that. (Participant 14, Interview 14)
Another thing is I feel it is inconvenient in life…Here I need to learn even a minor
thing. Too many things that locals take for granted pose a great challenge for me.
(Participant 12, Interview 31)
The bad side is that it is far away from home and you miss home and you don’t
have close friends and you feel bored after work…The leisure time is kind of boring
here. (Participant 3, Interview 46)
I lost the extended family as my parents are in China. It is hard for us to take care
of parents and it is hard for them to look after us too. Also, I lost all the social
relations established before after I came here. (Participant 17, Interview 34)
One’s conception of a good life is firmly rooted in custom (Wee, 2005, p. 138) and
thus there is a significant gap between how Chinese and Australians perceive
Australian life. Life in Australia is considered boring from the Chinese perspective.
Leisure activities differ and there is an absence of appropriate social life for Chinese
in Australia. Few Chinese like to go to “pubs” and clubs regularly. In contrast to
China, shops and restaurants in Australia open for relatively short periods and some
even close on weekends and public holidays. China has much more variety in
entertainment and such activities are readily available and affordable.
Coming from a tight knit community both materially and spiritually, the participants
also expressed concern about aging parents with whom they now could spend little
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time. Feeling alone and disconnected socially, the nurses missed the sense of
connectedness in China.
Entering an unfamiliar environment explains, in part, the inconvenience of
Australian life. The participants had no idea what was appropriate in Australia. The
norms of thinking and behaving do not come to them naturally. Rather, every minor
detail required a considerable effort (Berger, 2004). This loss of “at-home-ness”
translates into a sense of uprootedness, alienation, and insecurity (Berger, 2004).
Along with immigration, one’s mother tongue and culture, which are the symbols of
one’s national identity and homeland, are lost (Boss, 2006). Yet, it is both pragmatic
and an indication of resilience that immigrants learn the language and culture of the
country in which they now live (Boss, 2006). Apart from loss of life components,
there is also loss for the family.
7.1.2 Loss for the family Loss for the family relates primarily to issues surrounding a husband’s employment,
including marital conflict, and to the perceived poor marriage prospects for single
immigrant nurses. Most husbands experienced difficulty in finding appropriate
employment in Australia and many suffered psychologically because of a loss of
social standing.
Here most Chinese men cannot find the right job (at a level comparable to their
previous one). This is a common issue faced by immigrant nurses. For some men,
even if they have undertaken important jobs in China, they won’t find anything to
do here at all if their language is not good enough. (Participant 12, Interview 12)
The women (nurses) are quite good here, but their husbands are not since they
have lost their social status. Those married nurses experience great psychological
stress, both from their own and their husbands’ difficulties in accepting new
roles…The income is better but they still feel not so good inside. (Participant 6,
Interview 28)
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The China-educated nurses are often the first in their families to immigrate to be
followed by their husbands. Thus, the majority of the men are initially completely
dependent on their wives and then become secondary providers for the households.
It is not only the participants who faced issues of loss, but also their immediate
family. Indeed, loss of social status from the perspective of a husband is a shared
issue.
Most husbands relinquished their careers in China and entered the Australian labour
market in an inferior position. They have been compelled to take jobs far below their
education and training because their Chinese qualifications are not recognised and
their language proficiency and cultural skills are limited.
Many participants were hesitant to disclose the exact nature of their husbands’ work
and used vague terms when asked. In discussing loss of professional position for
their husbands, the participants tended to emphasise the social and psychological
aspects over financial loss. George (2005) describes the experience of men in this
position as twofold: a loss of status with respect to their wives and a loss of status
relative to their prior social position. Having immigrated before her husband and
having acquired better linguistic skills, the woman is now in charge (George, 2005).
The symbolic meaning of one’s value is partially reflected through the income one
brings home. Thus, work is not just a means of livelihood; it is an important source
of self (Shaffir & Pawluch, 2003). As George (2005) pointed out, the husbands lose
a central part of their identity as primary providers for the household. They feel their
masculinity is endangered because the earning capacity of their wives is greater.
When women become the primary providers, the dynamics of a family are changed
(George, 2005). Individuals are constrained by the people around them to some
extent in how they do gender (Holmes, 2009). In the research situation, the efforts to
preserve traditional gender roles usually failed when the men did not enjoy the same
employment opportunities as their wives. The change in the gender hierarchy may
give rise to potential conflict over gender relations (George, 2005). For the
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participants who valued family harmony, marital conflict was a hidden cost of
immigration. As one participant stated:
There is lots of family conflict among married immigrant nurses. The couple
quarrel with each other which hurts their affections. Personally, I consider it is a
great cost. If one doesn’t have a happy family life, one cannot be happy even if one
lives abroad and leads a comfortable life materially. (Participant 12, interview 31)
The traditional Chinese family value, where the woman’s place is “inside” the
family and the man is responsible for the “outside” (Mann, 2000), makes role
reversal difficult. Conventional gender roles may partially reverse for men and
women as they re-negotiate domestic labour and child care (George, 2005). It is also
possible that dependent men may feel their gender identity is threatened and are
therefore less likely to do “women’s work” in the home (George, 2005). The
ongoing connections to China and Chinese community may also accentuate existing
gender hierarchies and thus increase the likelihood of conflict.
As revealed in the data, some husbands accepted demotion as the price for
immigration and others did not. However, most men who stay made compromises
and adjustments in the household division of labour. The demotion in social status
was also partially compensated for by the relatively high income they could earn in
Australia and by a commitment to family interests.
For single immigrant nurses, the issues are different. It was difficult to find a partner
to marry in Australia and many were uncertain about their future.
Who will you marry, Chinese or Westerner? Where will you stay, back in China or
in Australia? We are struggling with which road to take for our lives in the future
and it is indeed a dilemma for us. (Participant 26, Interview 26)
Personally, I think I won’t go back to China to find a partner and then bring him
over Australia to form a family. Because I feel I am a 60% Australian and 40%
Chinese. I cannot accept many Chinese views and values now. But my experience is
that I have a big gap with local Australians as well. (Participant 7, Interview 42)
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The Chinese view is that marriage is necessary to secure a future and to create a
sense of home. Failure to marry at a certain age and to have children reinforces a
sense of rootlessness (Beynon, 2004). Thus, marriage and family remained important
dimensions of the participants’ lives.
However, immigration changed the nurses’ attitudes towards and expectations of
marriage. For a Chinese woman in a predominantly white society, it is more difficult
to find an appropriate male to marry since the choice is limited. In the eyes of single
immigrant Chinese nurses, it is unwise to marry Chinese men who live in China
because of the poor employment prospects for those men in Australia. As one
participant stated:
I am single but I am hesitating to find a boyfriend in China...If I find a boyfriend
working in China, it will bring a lot of trouble for me. He may do pretty well in
China but it is going to be hard for him to find a job here. (Participant 16,
Interview 33)
However, because of dissimilar world views, to marry a Western man living in
Australia is also undesirable. The pressure of time ultimately forces most single
immigrant Chinese nurses to confront the issue. Yet in making a marriage choice,
they are faced with decisions not only on a prospective partner, but also future living
arrangements. Loss for the family, both social and psychological, exerts a great
impact on the experience of immigration.
Most of the time, we do not live for work. Instead, we work for a better life. For
many nurses, they feel it is not a big deal that they receive some unfavourable
treatment in the work place. However, when they return home from work, they face
the issue of boyfriends still in China or husbands who have no job. I think this issue
is far greater than work issues. (Participant 10, Interview 37)
Apart from loss for the family, there is another form of loss, loss of career
opportunities.
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7.1.3 Loss of career opportunities In order to immigrate, many participants sacrificed career opportunities in China.
Career development is far less problematic in China where they would with ease
move into higher positions. Although some had come from teaching positions in
China, they found working at that same level in Australia extremely hard.
Maybe in China, your sense of value, and how to say, you may work in a
respectable position, you may be promoted to a high position. It is hard to find this
kind of feeling here. (Participant 17, Interview 17)
Although my job here is not counted as physically demanding, I have never worked
at clinic as a nurse in China. I taught in a university in China and that is less tiring.
(Participant 16, Interview 33)
The participants perceived that they were much less likely to rise to managerial
positions despite their qualifications and relative seniority. There is also the
difficulty of local nurses accepting immigrant nurses in positions of leadership. Even
where they were recognised as skilled and experienced staff, fewer promotion
opportunities were afforded them. The sense of loss and frustration is captured in the
following quote:
I don’t think I can compete with the locals here. Our language is not enough...We
can make money here but it is only a job, not a career. In China, we can have a
career, but here we only have a job. (Participant 26, Interview 40)
The nurses perceived that the higher the nurse level, the higher the requirement in
terms of language and cultural skills. Thus their career development opportunities
were constrained because of inadequate language skills and lack of familiarity with
the Australian system. Cultural knowledge is hard to absorb and promotion takes
more time even if desired.
After all, English is not our mother tongue. So we have fewer promotion
opportunities than locals. The main constraint for us is still language, also the
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unfamiliarity with the hospital system and the culture here. (Participant 21,
Interview 29)
What is interesting here is that the lack of opportunity for promotion was
constructed by the participants as their own problem, rather than an institutional
issue. At first sight, the main barrier to promotion is language, an inevitability of the
immigrant status. However, it is also the case that the nurses are socialised into
internalising this institutionalised disadvantage. Indeed, as Hunt (2007) has argued,
systems of promotion are not always transparent nor based on merit. It is
questionable why overseas qualifications and experience should be disregarded.
Moreover, the objective measures of qualifications and experience aside, judgment
of interpersonal and communication skills required in management positions are
underpinned by subjective attributes that are determined by the dominant culture
(Henry, 2007). Unable to demonstrate these attributes in a way deemed appropriate,
the participants took their disadvantageous position for granted. This unquestioning
acceptance, according to Larsen (2007), contributes to the production and
reproduction of “structural discrimination”.
Some participants believed that promotion was still possible but this was dependent
upon volition and individual improvement.
As to promotion and career development, I think there are many opportunities here
as long as you are capable enough, willing to show your ability, being confident
about yourself, fluent with English, and communicate well with doctors and
nurses…I think it is an issue of your personal capability and language skills.
(Participant 20, Interview 41)
The participants’ belief that promotion was still possible may also reflect their
coping strategies and resilience when faced with the ambiguities of discrimination.
In the terms of Larsen’s (2007) argument, for psychological reasons, the nurses may
have denied the centrality of institutional discrimination and resisted its destructive
effects. By explaining their experiences as their own inadequacies (which are
apparent and readily acceptable anyway), the participants managed to motivate and
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improve themselves and to sustain hope and aspirations despite barriers (Larsen,
2007). This capacity for meaning-making gave the nurses a sense of agency and
some level of control over the situation (Larsen, 2007).
Some participants also expressed satisfaction with the status quo and claimed to have
no strong desire to make a career move. Although this might be true for some, for
most it may well be a result of rationalisation after encountering the difficulties
during the early period of immigration. Even if being a manager means additional
responsibility with very little financial gain, it may bring much desired personal
recognition and satisfaction.
Immigration involves displacement and multiple losses (Berger, 2004, p. 5).
Although some tangible losses are inherent to the immigration experience, the
participants in this study emphasised social and psychological losses. The nurses
mourned their losses as they faced reality. However, for most the grieving gradually
dissolved and transformed into a way of coming to terms with, and in some cases,
benefiting from the experience.
Immigration also most often involves an element of choice to change one’s life
(Berger, 2004). For the participants of this study, the loss occurred as a consequence
of a voluntary decision. The fact that one can choose whether to immigrate renders
some people unsympathetic towards immigrants (Weiss & Berger, 2008). As one
participant stated:
Like my classmates, when they came across difficulties, they have no families
nearby. They have to comfort each other, also they cried a lot. (Sigh) There is no
way, no other way. It is we who chose to come by ourselves, not being forced by
others. As a result (we have no one to blame)… (a long sigh). (Participant 1,
Interview 1)
There are two properties of the loss: the invisible and the ambiguous. The loss is
invisible in that the gains of immigration come at considerable cost that could not
have been fully anticipated at the moment of departure. The meaning of loss
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becomes clear only after immigration. We as outsiders also cannot foresee what that
loss will be, what it means, and how the loss will impact upon family function.
The loss is also ambiguous in that the loss is unclear, incomplete, and partial (Boss,
1999). Everything is still there but is not immediately reachable or present (Falicov,
2005, p. 197). As Boss (1999) pointed out, for immigrants, part of what they thought
of as family was physically absent but psychologically present. They may hold close
their psychological family for warmth and support, albeit in imagined and
remembered ways. This ambiguous loss of families, friends, language, and culture
creates unique challenges for immigrants and they grieve and mourn occasioned by
physical, cultural, and social separation (Boss, 1999). The loss can be actual or
perceived and yet both have a great impact.
A further dimension to the ambiguity of loss is that loss and gain are not mutually
exclusive. Loss is often a necessary part of the transformation process and can result
in much desired change. Conversely, even where the circumstances of nurses were
improved in some ways after immigration, the overall consequence for the family
was ambiguous.
Although the broad areas of loss were readily identifiable in the study, the
participants interpreted the meaning of loss differently. Some considered whatever
lost was the most cherished and thus could never be offset. Some perceived the loss
as an inevitable part of immigration and that this “side effect” was innate and could
not be wished away. Still others thought it was more about personal choice and thus
people should anticipate the loss and be prepared.
To compensate for the invisible loss, the participants tried to spend more time with
their families and friends in China and kept frequent contact with them. An attitude
of adjusting one’s inner world, reinterpreting what cannot be changed in such a way
that it is no longer perceived as immobilising, is also helpful and stress-reducing
(Boss, 2006). Looking forward instead of backward can give one much needed hope.
The admiration from people in China made the participants feel that if immigration
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was much envied then no doubt it was the right decision. While immigration
involves a sense of loss, it is also a process where immigrants reconstructed the
sense of self.
7.2 Reconstructing the self Although immigration has become the norm for many people worldwide, it is still a
stressful and long-lasting transition and one that is not generally recognised by our
society as a whole (Hernandez & McGoldrick, 2005). During this process,
immigrants reconstruct a new sense of self by leaving elements of their old self
behind, encountering a sense of vulnerability, and experiencing growth through
adversity. In so doing, the China-educated nurses changed the sense of self and they
were no longer the same individuals as before. The sub-category reconstructing the
self consists of three properties: leaving pieces of old self behind, sense of
vulnerability, and growing through adversity.
7.2.1 Leaving pieces of old self behind After immigration, the changed reality and the hardship meant that the participants
lost a sense of pre-eminence they once enjoyed in China. Their previous advantages
disappeared and past accomplishments were soon forgotten in the new environment.
The nurses were more open to the need to learn from others. They started to realise
that they were no longer who they had been and they needed to leave the old self
behind and re-negotiate a new sense of self in the new country.
In China I can easily be the excellent one...But here I feel I cannot be as good as
them however hard I try. I feel I am only average…It is hardly achievable to be
better than locals…Also the advantage once I possessed is no longer there.
(Participant 12, Interview 12)
I used to be an excellent nurse in China, but I feel I am nobody here. At the
beginning, people did not understand me and they knew nothing about me. But I
didn’t change my sense of self, thus I hoped to get the same respect I had in China.
I felt very bad because I failed to gain that recognition from locals at the beginning.
(Participant 15, Interview 30)
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For the China-educated nurses, it was hard to satisfy those they worked with at the
outset. The result was a loss of confidence, a feeling of inferiority, and far less
ambition.
I felt each of us was born to be proud inside…But when you go abroad, you put
yourself very low…You start from learning how to walk. You become humble after
that. (Participant 10, Interview 37)
Chinese nurses who travel abroad to work in nursing tend to be those who are most
successful and revered in China and it is difficult for them to be so discounted.
My accent sounded very strange to others and I felt humiliated and lost my self
confidence. I even didn’t want to say any words at all. Theatre is such a quiet place
and whatever words I say would be heard by others. (Participant 1, Interview 43)
Actually I feel I am quite confident with my oral English, but still they feel
sometimes they cannot catch me and they ask me to repeat. This makes me feel very
bad and embarrassed. (Participant 6, Interview 6)
Thus there is a certain psychological toll involved in immigration which is often
ignored. One needs to undergo emotional pain to renounce one’s former self and to
embrace a new one. Past achievements are erased as if they never happened (Berger,
2004). The experience of immigration transforms the previous superior sense of self
and replaces it with a more humble, less ambitious self.
Several SI concepts are relevant in explaining how individuals reconstruct a new
sense of self. For Mead (1934), “taking the attitude of the other” towards one’s own
conduct is the essential characteristic of social conduct. The notion of self exists
only in relation to others and it is owing to language that we see ourselves as others
see us (Cooley, 1983). Other concepts such as “reflected appraisal” (Cooley, 1983),
“looking-glass self” (Cooley, 1983) and “social mirroring” (Winnicot, 1971) assume
that people’s views of themselves reflect the social view (Wiley, Perkins, & Deaux,
2008). As Cooley (1983) argued, our perception of self grows from our interaction
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with others. It is in the light of how others see us and in their reactions to us that we
form our views of self. Being always the “receivers of knowledge”, China-educated
nurses came to believe that they were inferior and less competent.
The participants observed that local people understood little about China and
Chinese culture. The popular construction of China is a country that produces mostly
inexpensive but low quality products and one where labour is extremely cheap.
Chinese are perceived to be poor and frugal, impolite, not knowing much, and
people who come to Australia to steal Australian jobs.
Whether accurate or not, the China-educated nurses encountered negative
perceptions in their daily interactions which undermined their confidence. They
responded with self-doubt and felt ashamed and this is reflected in the low
aspirations they now set for themselves. More than a century ago, Du Bois (1903)
argued that it is possible for people to experience a “double consciousness”, that is,
to detach their own views of self from the negative views of others. However, as
Crocker, Luhtanen, Blaine and Broadnax (1994) proposed, a collective culture might
intensify the process of social mirroring among people from Asian countries.
Through social mirroring, the old self was left behind and replaced with new self.
7.2.2 Sense of vulnerability Immigration appears to be a double-edged sword. On the one hand, it provides
economic opportunities; on the other hand, an unfamiliar environment. The
difficulties of fitting in contribute to the experience of being a foreigner or
“stranger” with associated feelings of weakness and isolation. This sense of
vulnerability is expounded through the following two concepts: ambiguity over
racism and discrimination and concern over foreign status.
It was generally the view that in immigrating to Australia, the China-educated nurses
had come to a better country. Although the environment in Australia is considered
superior in some ways, a sense of ethnic pride was undermined when colleagues
posed negative comments about China. They worried that they might be looked
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down upon simply because they were Chinese.
They (local colleagues) may ask you out of curiosity sometimes, such as “what did
you do in China?”, “How is that in China?” and slowly, the conversation will
reach to problematic issues in China. There is no way, it does exist in reality and
you cannot cover that up...Sometimes it is hard to avoid that and I try to pass on
quickly. It is hard to mention that, sometimes I feel a bit uncomfortable, that is to
say: are they discriminating against us by that? (Participant 3, Interview 3)
In some instances, the participants were uncertain whether they were the target of
racism or discrimination. Most people in Australia were polite but some behaved in a
hostile manner towards the nurses.
Sometimes we were bullied by the agency because of our foreigner status…That is
to say, they thought since they sponsored permanent residency for us, we had to
accept any shift as a return…Sometimes I was threatened that my visa would be
cancelled if I didn’t work the shift they demanded. (Participant 8, Interview 8)
Not waiting for me to finish my words, the family talked to me impatiently: “Could
you find another person who can understand me to answer the phone?”…Then I
hear a long sigh of “Ha---” before I put down the phone. I felt the extreme
impatience of him and I was quite uncomfortable… and felt like I was being
discriminated...He judged me in less than 3 minutes and put me in a very low
position. (Participant 3, Interview 3)
When I first started work, I was not familiar with the work procedure. I worked
with another local nurse and she was quite unhappy about that. She thought that I
knew nothing and I might even make trouble for her. There was another Indian
nurse who was also inexperienced…We all happened to work with her that day.
She was very grumpy and said to us “I will send you both home, I will talk to the
manager…”. I felt very bad at that moment and tears came from my eyes.
(Participant 27, Interview 27)
Public attitudes towards immigration and immigrants are more often negative and
particularly when unemployment rates are high (Espanshade & Belanger, 1998).
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These attitudes are, to a large extent, shaped by perceptions that immigrants compete
with members of the receiving society for economic resources and also for other less
tangible outcomes such as cultural dominance (Esses, Dovidio, Jackson, &
Armstrong, 2001). Immigration is often perceived as a threat to social cohesion and
immigrants are often blamed for their reluctance to “integrate” (Pécoud &
Guchteneire, 2007, pp. 17-18), for stealing jobs, and also for increased crime, drug
trafficking and disease even though statistics show no such evidence (Castles, 2000).
Surrounded by such attitudes, the participants may have implicitly or explicitly
accepted the legitimacy of such views.
I think Australians are very tolerant. After all, we are the ones who have come over
to take their jobs away and to earn their money. (Participant 11, Interview 11)
A tendency to scapegoat immigrants for social problems is often tacitly encouraged
by authorities and certain political parties (Castles, 2000). The portrayal of
immigrants as a cause of social insecurity and inadequate conditions can be used as
an excuse to ignore the protection of their human rights and to divert attention from
the real causes (Castles, 2000).
For example, it is rarely the case that immigrants and locals are perfect substitutes in
the labour market (Grossman, 1982). On the contrary, immigrants tend to carry out
jobs that local people are unwilling to undertake. Indeed, a segmented labour market
implies that immigrant workers can have a positive rather than negative effect on
domestic workers through an increase in the demand for native labour (Chang, 2000).
Nonetheless, research has found that it is extremely difficult to change local people’s
negative perceptions of immigrants (Esses et al., 2001).
The fear of discrimination and racism on the part of the participants was not without
grounds. On rare occasions, the participants experienced outright rejection from
patients. More often, they faced questioning of their professional qualifications. This
discrimination was also reflected in unequal opportunities and unfriendly attitudes as
a result of the visibility of the nurses’ minority status in terms of skin colour and
accent. All of this shaped the participants’ occasional feelings of being “second class
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citizens” in “another person’s country”.
Apart from negative verbal treatment, participants were also concerned that their
obvious foreign status made them more vulnerable to physical attack. The
recognition of increased vulnerability is demonstrated by one participant:
As a foreigner, I feel timid when I walk on the street. I am not saying that it is
discrimination, but some people will yell at you or ask money from you…If I am not
a foreigner, if I were a local, I feel they dare not to do that. (Participant 11,
Interview 11)
The sense that such attacks, whether threatened or real, was “their problem” or a
result of being “foreign” was reflected in a reluctance to complain.
Chinese nurses rarely complain…Even if they do, they will be concerned whether
this would influence their contract or visa. (Participant 9, Interview 9)
I just crunch my teeth and stick with it. As locals, they would complain about that
whatever. But as a Chinese, I dare not offend them…As a foreigner, it is hard.
(Participant 12, Interview 12)
If you feel uncomfortable, you can go to HR or the union to complain. But the thing
is Asian staff don’t like to nitpick (find fault) and we’d like others to ask us instead.
Also, we have a concern that this person is so close to the boss (and so) let the
issue go and give up the idea of complaining. (Participant 23, Interview 23)
The notion of not offending locals is constructed in daily interaction. The
participants feared retaliation from local colleagues. They also did not want to be
labelled as troublemakers and to damage working relationships. A lack of confidence
in the system and a belief that “nothing ever changes” also shaped inaction. This is
further reinforced by Chinese culture, where open and direct confrontation,
especially with those in power, is to be avoided at all cost (Xu & Davidhizar, 2005).
In addition, the participants worried that being Chinese may provoke a more
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punitive response if trouble did arise.
As a foreigner, I work very carefully ...You will encounter people who label you as
Chinese, a “Chinese” nurse… I feel it is going to be a different story for a Chinese
nurse to make the same mistake compare to a local nurse. (Participant 12,
Interview 12)
Participants shared the perception that as a Chinese nurse one’s mistakes would be
more visible. It is a common occurrence that mistakes made by immigrants invite
undue publicity while little publicity is given to offences against them (Fiscella,
Botelho, Roman-Diaz, Lue, & Frankel, 1997). Where an Australian nurse makes a
mistake, responsibility is attributed to the individual. Where a China-educated nurse
makes a similar mistake, it is reported in such a way that responsibility for the error
is shared by the whole immigrant population.
The Chinese population is greatly heterogeneous in composition. However, this
empirical reality is often glossed over or out rightly ignored, whatever the
underlying motives (Bun, 2004). Chinese people are indeed less similar than they
appear (to outsiders) (Bun, 2004, p. 194). The internal homogeneity of the ethnic
Chinese is a social construction of those external to the group: the social psychology
of intergroup perception (Bun, 2004, p. 194). The point here is that the term Chinese
nurses is not always a meaningful category.
This leads directly into issues of judgement of Chinese nurses. Locals may assume
themselves as the standard, or the unmarked norm, against which immigrants’
deviations, by appearances or behaviour, appear notable (Billig, 1995). The social
definition of deviants involves a power differential between those who define people
as deviants and those so labelled (Bustamante, 2002). In other words, the
vulnerability of immigrants is dependent upon the likelihood of being powerless
enough in another country to be labelled as deviants by nationals.
Immigrants’ vulnerability is also a social construct (Bustamante, 2002). Given the
very existence of an Australian national identity, the participants are perceived as
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“the other” and thus are subject to certain forms of exclusion and marginalisation.
While a particular nation might not accept discriminatory behaviour against
immigrants, the implicit assumption is that immigrants should not have the rights of
nationals (Bustamante, 2002).
7.2.3 Growing through adversity A sense of personal growth was reflected in an increased appreciation of life in
general, an awareness of personal strengths, a greater capacity to cope with adversity,
and a change in life priorities. Although immigration is stressful, it is also growth-
enhancing (Coll & Magnuson, 2005, p. 115). The participants viewed immigration
as a challenge and emerged from the ordeal more mature, stronger, and more
independent.
I went through lots of trouble, big and small, in the 3 years of life here. I clenched
my teeth and endured hardship when it was really difficult… My volition, my
endurance became stronger and I became less dependent on others. (Participant 3,
Interview 3)
After all it is not home, where everyone listens to you. Also, I grew up; became
mature psychologically…The work experience in the agency made me
stronger…Because the agency threatened me…I became stronger, stronger inside.
(Participant 8, Interview 8)
I become much more independent abroad. I manage everything myself. When you
make friends with others outside, you learn to give, you learn to compromise.
Unlike at home, everything is up to you. (Participant 1, Interview 43)
The process of personal growth as an integral part of the immigration experience is
important and yet often neglected. Removed from a well developed social network
and with little support in the new country, the participants had to be independent and
self-reliant. As the nurses endured the storm, they increased their self-knowledge
and became more aware of their potential (Berger & Weiss, 2002). Even the
suffering became satisfying on reflection.
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I feet I have learned a lot after going abroad and I don’t regret the decision to
immigrate. I feel it is worthwhile. I wouldn’t have my current experience,
qualifications, and level of knowledge if I had stayed in China. (Participant 3,
Interview 3)
Despite the difficulties and unmet support needs, the participants demonstrated great
strength and resilience. They remained positive and hopeful towards future life as
they absorbed the impact of settlement challenges (Stewart et al., 2008). Some felt
more accepting of life.
Now I am not too rushed towards anything and my mindset has become more
peaceful…The hardship of immigration made me grow up…My sense of values
changed. I pay less attention to material wealth and being more genuine in
interactions with others. My life attitude has changed. We should give ourselves
some hope anytime. (Participant 9, Interview 32)
I gained a lot, especially in my personal growth. Because I changed, I totally
changed…I became more peaceful and understood more about myself…Because
there was hardship, because I struggled…I am more independent spiritually now.
(Participant 28, Interview 35)
It is not so much the event, but rather the meaning made of the event, that
determines people’s action (Blumer, 1969). Throughout the immigration experience,
the participants ascribed meaning to what they had experienced and focused on the
broader picture, remaining hopeful while enduring the circumstances of the present.
Life abroad is cruel and to survive is cruel…I felt suffering but I learned many
things from it as well. Now when looking back, I feel it is a good exercise for my
personal growth. (Participant 26, Interview 26)
Positive changes can occur as a result of struggling with difficult circumstances
(Weiss & Berger, 2008). However, not all individuals appreciate this (we should also
keep in mind that positives never come out for some).
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Participants in this study reconstructed their sense of self through the immigration
experience. They left pieces of their old self behind, became aware of their increased
vulnerability, and grew out of the adversity. As a result, they were different persons
now and they had new perspectives on life pertaining to changes in priorities, values,
and appreciation of life.
Although immigration was associated with losses and adversity, the participants
perceived it was hard to go back for various reasons.
7.3 It is hard to go back The study participants had mixed feelings about immigration. The desire for a better
life goes together with the ubiquitous experience of suffering (Pajo, 2008).
Immigration was a dream of the fulfilment of expectations abroad. However, the
dream remained isolated from reality. There was a desire to go back but it was hard
to do so. The sub-category of it is hard to go back consists of three main properties:
dream of migrating, it is not that good, and it is hard to move backwards.
7.3.1 Dream of migrating Immigration is a conscious choice for many and it is reasonable to assume that
people hold expectations in relation to the new life. Historically, Chinese people
have perceived migration to the West as a desirable goal because “the West is a
better place and Western life is a better life”. As a result, the participants did not give
much thought to the decision to immigrate as evidenced in the following quotes:
For those who never go abroad, they have no idea of what life abroad looks like
and they think it is all good without much research…They think little or nothing at
all about the negative aspects of immigration. (Participant 1, Interview 43)
Lots of people who haven’t immigrated before, including my classmates, they felt it
was very good to work abroad. They thought I was very good and they wanted to
go abroad as well. (Participant 16, Interview 16)
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Several factors contribute to positive perceptions of immigration. The economic,
political, and social disparities between China and Western countries motivate many
to leave China (X. Li, 2004). Immigration provides hope and a means of escape for
Chinese people, as it is shown in the popular saying “where there is no light in the
East, there is light in the West” (Li, 1998b). The younger generation are full of
curiosity and longing for the outside world. Thus, migration to developed countries
is widely accepted as progressive and a vehicle for individual advancement. It is one
of the few both feasible and desirable ways to better one’s life and to enhance one’s
social status at home.
Also, historically, it is only the relatively few privileged Chinese who have had the
opportunity and means to immigrate and they achieve a level of admiration and
social prestige from their fellow Chinese. Those who have previously immigrated do
not consciously manipulate the perceptions of those who never left, but for cultural
reasons they do emit certain signs of success and do not make obvious the less
attractive aspects of immigration life abroad (Gardner, 2001, p. 371). This explains
why expectations are often high and unrealistic.
The development of “cultures of migration” and the construction of the migration
dream is reflected in the everyday words of mass media in China. The visible
material wealth and the invisible glory and status associated with immigration
shapes people’s views. Expressions such as going abroad wave (Xiao, 1989), going
abroad heat (Li, 1998a), going abroad fever (Wang, 1987), and going abroad frenzy
(Z. Li, 2004) have been common features of the Chinese mass media over the last
decade. Immigration is described as “becoming gold-plated” and people often refer
to those who go abroad as “gold diggers” (Wang & Lethbridge, 1995).
As revealed by the participants, many were discontented with the situation in China.
Inadequate spending on health care in China means that many nurses face low pay,
inadequate resources (lack of protective equipment), and poor working conditions.
Some left the country to escape unpleasant working environments and to seek more
room for personal freedom and development. Still others immigrated for educational
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purposes. Bringing with them a dream of migrating, the participants were
disappointed to find out that the reality in Australia was not that good.
7.3.2 It is not that good Few Chinese people have had exposure to the actual experience of living abroad.
They are exposed to the discourse of “overseas as progress” through personal
networks and advertising. Electronic mass media such as television and movies is
another source that communicates the image of Western life. These dominant images
shaped how the participants thought of their life-chances and possibilities abroad.
The asymmetry of information also means that the participants were usually clearer
about what they were moving away from than what they were going towards
(Bagnoli, 2007). Expectations are often high as the anticipated possibilities may
seem boundless (Suarez-Orozco, 2005, p. 137). The participants arrived in Australia
with high hopes of a more fulfilling life. Yet as reality unfolded, a discrepancy
appeared between what they thought would happen and what actually occurred.
Many people consider immigration to be a good thing as Australia lacks nurses
and they can stay after getting the nursing license. This is not the whole story.
(Participant 3, Interview 3)
Some people are sick of the living conditions and social circumstances in China.
They think it would be totally different abroad…The reality is, relationships
between people are different and the social circumstances are different here, but
one’s life and life quality is not as good as in China. (Participant 15, Interview 30)
As challenges during the settlement process emerged, the participants contended
with reality and lowered their expectations. It seems that well informed participants
tended to have more realistic expectations about the immigration experience. It also
appeared that the expectations about immigration life shaped the experience of the
participants to some extent.
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Indeed, immigration is like a fortress besieged for the China-educated nurses: those
who were outside want to get in, and once they were inside the wall, they were
frustrated to find that the characteristics and opportunities of Australia were very
different from what they thought when they made the decision to immigrate. They
started to question themselves about whether the right choice was made.
Too many things bring inconvenience to our lives. Not like in China, where you
know everything. Here you know nothing. (Participant 18, Interview 36)
At the beginning, you feel immigration is a good thing, a road to happiness. But
many people feel it is very difficult at last. They feel they lose a lot. (Participant 11,
Interview 11)
Newly arrived immigrants may assume that they will quickly integrate into the host
community only to discover that they are not warmly welcomed (Adams & Kirova,
2007). The nurses also thought it was not hard to work abroad as the technical
aspects of nursing present little challenge. It was hard to imagine that language and
communication would be an issue for them as they thought they would quickly learn
to speak fluently once in the new environment.
The study participants belong to a relatively privileged population group with a
stable job, income, and welfare in Chinese society. Immigration is usually selective
of those who are healthier, better educated, and more affluent (Anson, 2004;
Chiswick, 2000). The self-selectivity of immigrants may have contributed to the
sense of disappointment where the gap between China and Australia appeared
greater than perceived by others in different circumstances.
Immigration is psychologically tiring and the participants were ambivalent about the
experience, although the degree of ambivalence varied. Life in Australia may be
better but not necessarily better for each individual. On the one hand, they welcomed
the many advantages of working as RNs in Australia; on the other hand, they were
frustrated at losing the advantages and convenience of living in China and the sense
of belonging they once enjoyed.
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Maybe people would imagine that life abroad is very nice. Actually the first few
years after arrival are very difficult…The hardship dominates instead of nice
things and your life quality is not as good as before. (Participant 15, Interview 30)
Indeed the past two years has been quite a tiring process. Because it is not easy to
settle down a family…You feel rootless and unsettled abroad. Even after I bought
my own house and settled with my family physically, deep in my heart I still feel
unsettled. (Participant 18, Interview 36)
A further factor contributing to the ambivalence was the rapid social economic
progress China had experienced in recent years. The anticipated gap between China
and Australia was, for many historical more so than real. The improving situation in
China had shifted the reference points for comparison and hence there was some
ambivalence over the concept of a better life.
It is not that we could simply say it is good or bad to go abroad; it is far more
complex. Economic improvement and hardship go side by side and the participants
had a bittersweet view of their immigration experience. Although wages are better in
Australia, immigration does not ensure a happier life. The loss and transformation
that the China-educated nurses experienced in Australia cannot be overestimated.
Disappointment apart, the participants also perceived it very hard to move
backwards.
7.3.3 It is hard to move backwards Although immigration involves great losses and difficulties, it also brings many
advantages. The participants generally perceived that the work conditions for nurses
in Australia were superior to those in China.
Nursing work here is lighter compared to China and people here respect nurses
more. Patients and families regard nurses as professionals and they pay attention
to their opinion and listen to them. (Participant 25, Interview 38)
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Nurses here are treated better. In China, we don’t have many days of paid annual
leave. If there are not enough people in the ward, we even cannot take the leave
and we lose our leave if we cannot use it all during that year. Here you can roll
over to the next year. Also, if you feel uncomfortable, you can call on sick leave
here. In China you need to go to work even if you get a really bad cold and a
severe headache because if you don’t go, no one else can work that shift for you.
(Participant1, Interview 1)
Nurses in China are under recognised, dominated by doctors, and of low social
status. One advantage of working in Australia is that the participants gained a sense
of professional autonomy in their work. The advantage is also reflected in more
reasonable pay and better welfare (such as longer paid annual leave). In addition,
nurses enjoy a more flexible work schedule and more freedom in care delivery in
Australia. The workload here is also considered lighter in terms of nurse-patient ratio.
The advantages aside, ambivalent feelings remain. On the one hand, the nurses
disliked the idea that they may always be considered outsiders in Australia; on the
other hand, they were also reluctant to go back China and fit into their old ways of
life.
I am struggling whether to stay or not. Most probably I will stay here but I want to
go back China very much as well since my parents and brothers live there and I
feel it is very good if I had a decent job in China and I could visit my family on
weekends. (Participant 18, Interview 18)
Most possibly I will stay here for a long period, and then go back to China to see
whether there is a good chance for me. I really want to go back to China, but there
are many factors influencing my decision. (Participant 25, Interview 25)
All of the above point to a state of “in-between-ness”, caught between a “here” and a
“there” (Bagnoli, 2007). Immigrants’ identities accordingly reflect this ambivalence
of separation and entanglement. This makes the self long for a place when living in
another, identifying with home when abroad, and with abroad when home (King,
1995).
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In a time of increasing global mobility, the fact that one lives in an unstable and
uncertain world also makes one desire more strongly a secure and stable destination
(Harvey, 1989). “A place called home” can, then, be a retreat from an uncontrollable
world (Massey, 1995, p. 48). Participants aspired to return to “a place called home”
where they felt comfortable and did not look like a foreigner. A dream of return may
in fact be extremely important for immigrant identity and the return is then full of
symbolic meaning for immigrants (Bagnoli, 2007).
Indeed, places are often infused with meanings and feelings (Rose, 1995, p. 88). One
way in which identity is connected to a particular place is by a feeling of belonging.
A strong sense towards one place may inhibit the feeling for another (Rose, 1995).
As a stranger, one also feels little about a place (Rose, 1995). The participants may
not have felt welcomed in Australia and this may be one reason for developing a
feeling of hostility towards the place.
Here you get bullied as a newcomer. People also complain about you if don’t know
anything when you first arrive. Many people cannot stop developing a sense of
hostility. They dislike this place and hate the environment here. When I came back
from holidays this year, sitting in the car, I was quite sick even though the air is
very good and the sky is blue and the environment is clean…I felt very stuffy. I felt I
needed to fight the strong wind and heavy waves again by myself. I felt unhappy
because I was worried and I had no sense of security here. (Participant 1,
Interview 43)
However, places have no inherent meaning; it is only the humans who give the
meanings to them. Meanings attached to the home country are linked to meanings of
identity and the symbolic conceptualisation of belonging. Although physically
attached to Australia, the participants’ emotional attachment may well remain with
China. In addition, hardly any immigration is free of hardship. In light of challenges
in the new country, there is a tendency to remember the country of origin in rosy
hues (Berger, 2004). Returning home brings relief and happiness because at least it
is their own place. Criticising the host county is not uncommon among participants,
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while the homeland is often idealised and remembered with nostalgia. Being the
other and an outsider, Australia can be an ambivalent place to make home for the
nurses.
While many participants talked extensively about plans to return, for most this
remained a dream which was referred to as the “myth of return” (Anwar, 1979). It is
not that they do not want to go back, but it is hard to do so. There are some
components of wanting to go back (there are many disappointments) and some
components of wanting to stay (there are many things good). They are caught
between ideology and pragmatism. The following excerpts give a sense of being
caught.
I’ve thought of going back to China but found it is very hard… If there is a good
chance that I can develop my career and live a comfortable life, I will go back
definitely. Because now I am away from home…Local people still treat me as
Chinese and I cannot fit into the society here totally. (Participant 3, Interview 3)
Looking back, I have lived here for some time and the roots also start to sink
here…and it is very difficult to uproot again. (Participant 18, Interview 18)
Why do the participants not return home despite the yearning for what is missed?
How do they reconcile their visions of immigration as a pursuit of better life with
their experiences of hardship? Pajo’s (2008) conceptualisation of immigration as
socially imagined advancement is useful here to illustrate this point. According to
Pajo (2008), instead of a move of economic advantage, contemporary transnational
migration might be better understood as socioglobal mobility. A country’s repute as
“better” or “worse” in this global hierarchical order essentially means that different
countries allow for different degrees of individual achievement (Pajo, 2008).
Contemporary immigration might be driven by the social desire to advance from a
country of lower standing towards one of higher standing (Pajo, 2008).
The logic of socially imagined advancement is evident in the emphasis of the
participants on that which was absent or worse in China to prove that Australia was a
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better place. References were made to the poorer environment, lower incomes,
complex human relationships, and inadequate health care system as indicative of an
inferior China. But the assumption that Australia is superior does not necessarily
mean that an individual participant is better off in Australia. For the China-educated
nurses, despite enduring hardship and suffering, immigration was talked about as the
pursuit of a better life. This discourse reinforced their views of the world hierarchy
and the logic of socially imagined advancement (Pajo, 2008).
Indeed, when some participants encountered hardship and expressed their desire to
return, their families in China usually insisted that they should stay. While the
participants may face disappointment in Australia, it can be even more difficult to
convince families and friends back in China that life abroad is not that good. In their
eyes, it is almost a “universal truth” that Western countries are more advanced and
thus better places to live and work than China. This view is reflected in the
following quote:
Back home, nurses are not as comfortable as here. In China, the workload of
nurses is heavier and the salary is less and the paid annual leave shorter. So who
in their right mind would not want to choose here? (Participant 1, Interview 1)
The universal truth could also lead participants to doubt their own feelings. Instead
of acknowledging the hardship of life abroad, the nurses attributed this to their own
insufficient effort. Hardship is equated with not trying hard enough. The concern to
maintain face can also lead participants to tell partial stories of success which
perpetuate the universal truth. All these ensure that the notion of the universal truth
remains unchallenged.
People might wonder if the experience was so unsatisfactory, if the China-educated
nurses are so dissatisfied with the reality in Australia, why they do not return home.
It is assumed that since the option to return exists that they have few grounds for
complaint. Yet this issue is more complex than initially appears.
First, immigration is an objective pursued at great cost and cherished as a result.
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Since the participants have already endured the most arduous time in Australia and
perceive gradual improvement, there is an unwillingness to concede.
Second, immigration as understood as advancement in the world hierarchy also
explains why ultimately the immigrants could not envision their problems in the host
country as resolvable by returning to their homeland (Pajo, 2008). Despite the
absence of racial discrimination and inconvenience in life in the homeland, in the
intrinsic logic of immigration, returning home amounts to demotion (Pajo, 2008).
Third, it is possible that the participants do not return despite suffering because they
cannot face the reality of having held false hope or, what is worse, failing. The
implicit assumption is that returning home is an admission of one’s failure in an
adventure and deserving of loss of face. There is further concern of unfinished
business and unfulfilled dream.
Fourth, when one has moved forward, it is hard to move backwards. The issues of
leaving behind what had been achieved in Australia such as community ties and
social networks and the children’s education embedded in the Australian system
make it difficult, if not impossible, to go back. Investments in homes in the form of
mortgages and loan payments reflect a level of commitment which is not easy to
leave behind. While the China-educated nurses might identify themselves as Chinese
when in Australia, they felt “distant” and estranged from the people who were so
important to them when in China. It is difficult to adjust to life in China after so long
in another country. There is also a reluctance to go back to the old ways of life.
Finally, there is a lack of viable alternatives at home for the participants which
deems returning seemingly impossible. Going abroad is no longer something
mysterious and unattainable as years ago. The era when a returnee from overseas
was a highly sought after commodity treasure, and foreign experience a “gilt-lettered
signboard”, has passed. With time, immigration has become a more common
phenomenon and some returnees who have had problems finding suitable jobs in
China now constitute what is known as the “unemployed-from-abroad” (Hua, Jie, &
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Gang, 2005).
Originally I wanted to go back to China but I cannot find a suitable job there…The
income is a big concern for me. (Participant 16, Interview 16)
The ICU where I have worked in China is considered first class, but one nurse still
needs to take care of on average two to three patients during the day shift and four
at night. It is too risky to work that way. But since I don’t have the management
experience and I am not good at that as well, so I cannot work as a nurse manager.
So there are lots of difficulties if I want to go back home. (Participant 19, Interview
19)
Returning home is thus always a possibility for the immigrant but not a realistic
option. When immigrants do return, life at home may turn out to be more
problematic than expected (Bagnoli, 2007). For the participants, while immigration
to Western countries was hard, so was return to their home country after several
years’ away. However, the decision to stay in Australia was often made reluctantly
and it might take time for the nurses to come to terms with that decision. Indeed,
permanent return is more often a myth as living and working becomes inevitably
embedded in the Australian context.
Realising, struggling and reflecting comprise the reconciling process which is
nonlinear and recursive. Reflecting means making sense of the experience and
rationalising the gains and losses of immigration. Through reflecting, the China-
educated nurses developed new insights into the self. Over time, the participants
may become more familiar with the new society and feel more at ease with their life
and work in Australia. But this is not to be mistaken for a sign of assimilation or
adaptation, because the sense of outsider is ever present (Storti, 1990, p. 43). They
may achieve a deeper understanding of Australia and master more language and
local culture and yet tensions exist between the different worlds they now inhabit.
They may also become more aware of the permanence of the move and start to
mourn their losses and struggle to re-create a sense of worth and mastery of life. In
addition, new losses emerged such as the reluctant loss of a dream. Yet, they came to
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understand that the Australian way of life was not essentially better than the Chinese
life, but just different. Along with reflecting and new understanding, the participants
entered a new reality. The process now returns to realising but within a different
space and where what is realised is new. Thus the process of reconciling continued.
7.4 Summary A sense of loss, reconstructing the self, and it is hard to go back constitute the
process of reflecting. Looking back, the China-educated nurses perceived that it was
worthwhile to come despite the losses involved with immigration. They proudly
endured hardship and transformed their sense of self as a result. Looking ahead, the
participants were unsure where the future lay and which direction they should follow.
They hesitated and expressed confusion and uncertainty towards their tomorrow. To
return remained a dream since it was hard to go back.
To migrate was a dream where the reality was unknown and to return is a dream but
the reality is known. The thesis now turns to the core category and the overarching
theoretical explanation of the experience of the participants.
Chapter 8 Reconciling Different Realities 8.0 Introduction The purpose of this research was to generate a theoretical understanding of the
experience of China-educated nurses working in the Australian health care system.
This research found that the overarching experience of the participants was defined
by a sense of difference and reconciling emerged as the way in which the
participants responded to different realities. There are three phases of reconciling:
realising, struggling, and reflecting. It is a lengthy process and one never completed
and for many, is ultimately an experience of living a Chinese life overseas. This
chapter explains the core category (reconciling different realities) and addresses
some related literature on reconciling. Theoretical literature on immigration and the
experience of immigrant nurses is also revisited in light of the findings of this
research.
8.1 Core category: reconciling different realities Reconciling different realities is the basic social psychological process whereby the
participants manage different realities. The process includes three phases: realising,
struggling, and reflecting (see Figure 4). Realising refers to an awareness of the
discrepancies between different realities. Struggling refers to the dilemma of the
“middle position” and how being situated as “the other” was experienced. Reflecting
refers to making sense of the experiences one has gone through. Through reflecting,
the participants arrived at a new level of realising and the process of reconciling
continued.
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Figure 4. The core category of reconciling different realities
Realising
Struggling
Reflecting
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It should be noted at the outset that the three phases of reconciling are not to be
perceived as linear and nor do they present as a “how to” guide towards reconciling.
In addition, the sub-categories which underpin each phase should not be viewed as a
story unfolding to an inevitable conclusion because the experience itself is not
predictable. In other words, the participants can at once experience realising,
struggling, and reflecting, or can move back and forth between the phases.
A further point is that rather than objective truths, the different realities were socially
constructed. In growing up in China, the participants acquired a meaning system for
interaction through socialisation. This meaning system, shared by other Chinese,
reflected the social fabric of China. In other words, meaning systems are powerful
because they are the very essence of people’s realities (Marsella, 2005). People then
come to act as if their constructions are real and not to be questioned (Marsella,
2005). On arrival in Australia, the participants encountered different systems of
meaning and thus different views of reality. Where there is a reluctance to tolerate
such challenges because they introduce unacceptable levels of uncertainty and doubt
(Marsella, 2005), conflict is inevitable. To function in the new environment, it was
necessary for the nurses to navigate these new systems of meaning.
8.1.1 The concept of reconciling Understanding the concept of reconciling is essential in grasping the meaning of the
basic social psychological process of reconciling different realities. Despite wide
usage, the meaning of reconciling varies from context to context and the concept
remains “vague and ill-defined” (Hurley, 1994, p. 2). The definition of the verb to
reconcile means to bring into agreement or reach a point of harmony; to make
compatible, congruent, or consistent; to restore friendship; to adjust or settle
difference; and to render no longer opposed (Yallop, 2004, p. 1003). The term also
suggests an acceptance of something unpleasant; coming to terms with differences,
tensions, and conflicts; and making two different realities compatible (Moore, 2004,
p. 1078; Wilkes & Krebs, 1998, p. 1288).
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Reconciling reflects diversity in perspective and the human need to bring the
ambivalent, dialectical, and evolving experience into unity. Reconciling was the
main concern of the participants and it reflected the ways in which they responded to
different realities. Different meaning systems separate people into in-groups and out-
groups. Metaphorically, reconciling is a pragmatic response of the minority group
seeking to cross the boundaries of meaning systems to reach the dominant group
(Hamber & Kelly, 2005).
8.1.2 The properties of reconciling The properties of reconciling in this research are depicted as follows. First, the
concept of reconciling implies tensions/conflicts/ambivalence between different
constructed realities. Second, for reconciling to occur, change is required to manage
the differences. Here, reconciling is understood as a process instead of an event; it is
non-linear which means that one is moving back and forth among different phases
over time. A further property of the concept is that it is situational, a temporal state,
which implies that full reconciliation may never be reached. Finally, the concept
indicates that it requires bidirectional or two-way efforts to make reconciling
effective.
In relation to the first property, ambivalence is the dominant experience of
immigration where immigrants have conflicting emotions over a changing reality
and a desire to stay the same. One such example is that the participants lived in
close-knitted communities prior to immigration. Moving to Australia, the nurses
found themselves in a world of separate individuals where the supportive ties of
families were lost and their sense of connection and interdependence was substituted
by separation and independence. Reconciling is thus embedded with tensions,
conflicts and ambivalence and it is a process of incorporation, not erasure, of these
experiences.
Second is the property of change which, rather than merely reflecting the passage of
time, is actively required to ensure reconciliation. Thus change can be either
subtle/gradual whereby one may notice only after it has occurred, or profound where
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one consciously alters one’s self to accommodate a different reality. It must then be
the case that reconciling is not only about transitional change and conforming, but
also about transformation and growth. It involves intention, action, and effort to
make some change which is dialectic in nature to achieve a delicate balance.
From here, reconciling is understood not as a single, static outcome, but as a
continual process which involves negotiation over time as an immigrant grapples
with his/her place within the larger social structure. The process is never ending as
one needs to constantly interpret and reinterpret reality and to address differences
accordingly. Reconciling resulted in a blurring of previously perceived differences.
However, such blurring did not necessarily signify that the differences had been
erased.
Reconciling is also both a backward and a forward looking process which includes
the phases of realising, struggling, and reflecting. While these three phases remain
essential ingredients of reconciling, they are not discrete and do not always appear in
a strictly defined sequence. The process of negotiation is fluid, dynamic, delicate
and not stable or ever complete. Achieving reconciliation may not be an option and
may be achieved temporarily only to be lost at some later point. This is where one
may be painfully reminded that one’s “Chineseness” and “Australianness” are no
longer capable of harmoniously co-existing. A sense of difference may re-emerge
which forces one to acknowledge that one does not and possibly can never, fully
belong. Hence, reconciling does not necessarily mean complete agreement or
harmony as this may never be achieved. What it does depict is movement that is
ongoing and recurring, and is situated in multiple places, spaces, and situations.
Furthermore, reconciling can be unidirectional but it is most effective if a reciprocal
process. In other words, it is simplistic to assume that the burden of reconciling lies
primarily with individual immigrants. In this study, it appears to be an almost one-
way process (which, to some extent, may be explained by the study focus). Yet, to
reach a point of harmony, it is necessary to have input from both sides.
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8.1.3 The strategies of reconciling Reconciling strategies serve to bring different realities (what one expects/what one
encounters; the reality of China/the reality of Australia; different realities based on
different interpretations) into harmony. The extent of reconciling required is
influenced by the extent of difference between realities. There are two main
strategies employed in the process of reconciling revealed in this research: internal
(rationalising) and external (behaviour) change. In engaging with these strategies,
the participants came to view the world and to act differently. Whatever the reality, a
new norm had to be constantly negotiated.
Since disparities in perceptions of reality are socially constructed, transformation of
perspective is one way to ease the difference. Coming to Australia as adult Chinese,
the change encountered was overt and extensive for the participants. The strategy
was conceptualised as an internal shift or rationalising because it was based on a
change at the meaning level. Through a process of sense making, beliefs or opinions
were challenged and often changed.
The participants derived new meanings through frequent interaction with people
within the new context. Rationalising is a subtle, gradual process that takes place
over a period of time and not a dramatic and forced act. Based on the new lens, the
participants perceived both the self and outside world differently. They found
reasons to make sense of events, accepted what was unpleasant, and came to terms
with contention and losses.
One example of an internal shift in the reconciling process was related to the
reconstruction of meaning to realign expectations with reality. Along with an
unfolding reality, the participants adjusted (mainly through lowering) their
expectations and constructed a future more compatible with that reality.
A second example of reconciling through rationalising was the symbolic
reconstruction of past events for present purposes. Reframing what were now
unpleasant experiences as a common and natural feature of immigration rendered the
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experiences congruent with the everyday world and thus not a reason for undue
concern. The experience of the participants could then be considered a structural
rather than individual problem.
A further example of an internal shift was a focus on the positive aspects of working
in Australia, such as higher salaries and longer paid leave, rather than the negative
features such as increased vulnerability and what had been lost. Letting go was a
conscious decision to relinquish ideas that no longer corresponded with the current
reality.
Concentrating on the here and now and holding future plans in abeyance was also an
example of the reconciling that occurred shortly after the arrival of the participants
in Australia. By focusing on today, the participants gained a sense of control over
their actions, and by extension, a sense of control over self and situation. Only after
an initial period and having gained some evidence of security, such as obtaining
permanent residency, did the participants begin to project a long term future. In the
words of Cooley (1927, p. 205), plans “bring the future into the scene to animate the
present…Our plans are our working hopes and among our chief treasures”. The
emphasis on hope was important at this time as it plays a major role in the process of
meaning making (Feldman & Snyder, 2005) and consequently on understanding,
negotiating, and reconciling different realities.
The second key strategy of reconciling was to change one’s actions to accommodate
a new reality. This is conceptualised as external change as the target is behaviour.
Living in a society where negotiation favours the dominant groups, the participants
needed to learn new ways and to do things differently. A certain level of conformity
is not seen as a weakness but a strength. Through strategically presenting oneself,
the participants made the self compatible with the social norm.
Reconciling at the level of behavioural change is not all or none. Depending upon
the situation, the participants could avoid, tolerate, accommodate, and embrace
differences in realities. What follows is an example of each position.
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First, one who wants to participate in a dominant group may face a dilemma if the
differences are so great that they inhibit participation. Here, to participate means to
accept and adopt a new identity; and to try to participate means to be reminded of
one’s present identity. To minimise the discomfort, participants may avoid such a
situation.
Second, in other areas of conflict, there is a need to tolerate difference in order to
ensure a peaceful coexistence. This does not mean an “acceptance” of difference, but
rather a willingness to acknowledge such a difference and to respect its right to exist.
A willingness to interact and to cooperate with others in pursuing mutual goals
guides the behavioural component of peaceful coexistence. An understanding of a
“both/and” reality and an ability to deal with ambivalence is necessary to reconcile
the tensions within. Peaceful coexistence is not about “being at peace” because the
tensions, conflicts, and ambivalence are ongoing.
The third position, to accommodate, is to present oneself with the social expectations
in mind. It involves compromising or relinquishing, something that Goffman (1971)
has referred to as part of the “territories of the self”. Here one may not necessarily
agree with certain values, but can still present oneself in such a way in order to
conform to social expectations. The emphasis is more on functional purposes.
Goffman (1959) depicted this as presentation of self or performance whereby an
actor may have more or less belief in the part that he or she is playing and may or
may not adopt the standpoint of the other as one’s own. Scheff (1968) also
distinguished between reality which people sincerely believed and presented realities
which may only be dutifully followed.
Embracing a different reality is a fourth position assumed in the reconciling process.
Here one seeks to “improve oneself” to become more like the majority. One such
example is the modification of accent. The point here is that differences do not
necessarily result in conflict; they can serve as learning opportunities and enrich
experience. The meaning of difference is thus reconstructed to be beneficial and one
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is ready to embrace the difference to move forward.
Thus the way individuals reconcile different realities varies at different times and in
different contexts. For example, the strategies one applies in relation to private and
public realities usually differ depending on who is involved and how much choice is
available. The choice is not an individual’s but is socially constructed. In this study,
choice was limited at the functional level, particularly in the workplace. In terms of
space, the participants were more Chinese in the domestic sphere, while more
Australian in the public sphere. There is, however, no definitive pattern or formula.
Because reconciling is dynamic and ongoing, over time the participants periodically
embraced or abandoned different cultural features.
8.1.4 The selection of the core category Reconciling does not necessarily signify complete acceptance of Australian values
or behavioural patterns, but rather a search for some common ground. Reconciling
different realities was the storyline of the data and it captured the overarching
experience of the participants.
Several other factors explain the choice of reconciling different realities as the core
category in this study. Rather than an objective fact, a reality is socially constructed
(Blumer, 1969). In other words, one’s past experience informs (both enables and
constrains) the way one interprets the world (Blumer, 1969). In addition, the
constructed reality depends on an individual’s perspective/meaning system which
may not be attributed simply to culture. The term different realities is thus broader
than other terms such as cultural differences or different cultures. Reducing all to
culture obscures other factors which shape the construction of reality such as an
imbalance of power.
The analytical focus of this research was also on the complexities of the social
psychological process and not on outcomes of change such as acculturation,
assimilation, and integration. Rather than moving as a group towards a point of
“assimilation” or “integration”, the participants acted differently within different
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contexts. Far from unidirectional, the actions of participants unfolded in various
ways. The concepts of acculturation, assimilation, and integration may have some
meaning at some points in time but are inadequate to explain the experience as a
whole.
Finally, while physical immigration, that is, taking one’s body to a new land, is a
relatively short term event, social and psychological immigration is a separate and
long term process (Maines, 1978). Reconciling implies the crossing of symbolic
boundaries between different realities and how people resolve their concerns to
some extent. The overarching action on the part of the participants was constant
negotiation of differences between these constructed realties. As reconciling is the
key concept in this study, it is necessary to turn to the literature in this area to gain a
more in-depth understanding of the term.
8.1.5 Situating the core category in existing knowledge The literature on reconciling is sparse. It is largely focused on psychological,
political, interpersonal, and intrapersonal discourses of reconciliation and the
reconciliation of incongruencies. A review of literature in each area follows.
In psychology, the origin of understanding the concept of reconciling dates back to
the 1950s and is closely related to Festinger’s cognitive dissonance theory. Festinger
(1957) argued that the process of social interaction is inextricably a process of
creation and reduction of dissonance. To the extent that others with whom one
interacts do not share one’s opinions, these others are a potential source of
dissonance (Festinger, 1957). However, as Festinger (1957) pointed out, humans are
reconciling beings who strive towards consistency, and discomfort then motivates
the individual to try to reduce or eliminate dissonance. When the reality is basically
a social one, that is, when it is established by agreement with other people,
resistance to change is determined by the difficulty of finding persons to support the
new cognition (Festinger, 1957).
There are certainly differences in the degree to which, and in the manner whereby,
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individuals respond to dissonance. Some people are able to tolerate a large amount
of dissonance while others experience pain and intolerance (Festinger, 1957). In
addition, the change is not “all or none” and it will not happen suddenly. Indeed, it
may take some time and some opinions may be very resistant to change so that some
dissonance is never eliminated (Festinger, 1957).
Another prominent psychologist, Shaw (1966), argued that reconciliation is a major
type of transcendent behaviour where human beings bring contradictions into new
alignment through the generation of a higher-order construct that accommodates
both cognitions of a situation. Here, reconciliation is viewed as a human’s capacity
for releasing oneself from the confines of an existing framework (Shaw, 1966).
While the items have not changed, the disjunction—the source of the conflict, has
disappeared because the new principle suits both comfortably. Rather than consider
contradictions or conflict as a burden to be endured, it is proposed that creative
resources find expression through the resolution of conflict (Shaw, 1966).
The concept of reconciling in psychological discourse is partially relevant to this
research. It refers to a change at the level of meaning but not the level of behaviour.
The experience of dissonance by the participants following immigration is not only
predictable but perhaps inevitable. For instance, confronting a disconfirmation of
their perspectives in nursing practice, the participants were predictably motivated to
adjust their meanings to reduce the dissonance. If the participants choose to
reinforce the importance of their belief in the Chinese reality as a “one true way or
real nursing care”, they may become disillusioned, concluding that nursing in
Australia is wrong and not to be tolerated. Alternatively, the participants may choose
to embrace the new reality and to reject the Chinese way as irrelevant. Cognitive
dissonance is not a negative experience in itself because it presents a new learning
opportunity and forces people to think critically (Meyer & Xu, 2005). However,
without preparation to deal with different realities, the potential for maladaptive
response by individuals is significant.
In political discourse, it is argued that reconciliation is not cheap rhetoric (Hamber &
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Kelly, 2005) or a matter of apology or forgiving (Bloomfield, 2003). Instead, it is a
component of peace building work to restore or transform a damaged (or non-
existent) relationship between divided or estranged social groups (Hamber & Kelly,
2005). The level at which reconciliation is sought can be among nations,
communities, small groups, or it may be the interpersonal (Govier & Verwoerd,
2002). From this perspective, reconciling is a voluntary act and cannot be imposed
(Bloomfield, 2003). For genuine reconciliation to occur, four key issues must be
addressed: justice, truth, historical responsibility, and restructuring of the social and
political relationship between the parties (Govier & Verwoerd, 2002).
There are at least two aspects of political reconciliation: symbolic reconciliation
such as an apology by a head of state and practical reconciliation which usually
involves social, economic, and political change (Gale, 2001). These two aspects of
reconciliation are akin to the two sides of a coin (Gale, 2001). An emphasis on
commonalities such as human dignity, family values, health, and a greater sensitivity
to the spirit world is a way to move towards reconciliation. It is also important to
reduce the fear of the out-group and to reassure that differences between groups are
not necessarily a threat to security (Worchel, 2005). The political discourse of
reconciliation is partially applicable in this study in terms of accommodating and
respecting differences between groups. What differs is that in political discourse the
focus is more the macro-structure.
Reconciliation also refers to the reaching of agreement over conflicting views on
events. As Marsella (2005) argues, through shared meanings and behaviour patterns,
culture shapes our perceived realities. As individuals come to culturally construct
realities, they become grounded and inflexible in their assumptions and behaviours
(Marsella, 2005). Conflict emerges where parties with differing constructions of
reality come into contention regarding the distribution of power, control, and
influence (Marsella, 2005).
Reconciliation is further conceptualised as an interpersonal process of mending
damaged interpersonal relationships such as a father-son relationship (Katz, 2002) or
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couple relationship (Worthington & Drinkard, 2000). Here to reconcile involves the
restoration of trust through mutual trustworthy behaviours (Worthington & Drinkard,
2000). Reconciliation in this case is not about resolution of discord or forgiveness
(Worthington & Drinkard, 2000). The concept of reconciling in interpersonal
relationships differs from the current study in that it emphasises the restoration of a
previously established relationship.
There are several other studies that relate to the concept of reconciling. In a report of
a project concerning implementation of a school-based alcohol and drug prevention
program in secondary schools in British Columbia, Canada, the author pointed out
that prevention workers needed to reconcile the goals, values, and philosophy of the
project with those of the school (MacDonald & Green, 2001). In a study exploring
how patients with HIV make antiretroviral medication adherence choices, what
emerged was a theory of reconciling incompatibilities between illness symptoms and
medication side effects (Wilson, Hutchinson, & Holzemer, 2002). In Devers’s (1994)
study on experiencing the deceased, reconciling depicted a social process central to
experiencing the extraordinary. A further study on decision-making of rural older
adults during subacute care transitions revealed that decision-making was a process
of reconciling the differing realities of participants such as backgrounds, needs,
perceptions, expectations, and values (Gladden, 1998). The concept of reconciling in
all these studies resembles that in the current study as the focus is on differences and
readjustment. However, what these differences mean differ from this study.
8.2 Revisiting the literature The objective of this study was not to verify existing theory in the immigration area
but to gain a deeper understanding of the experience of China-educated nurses
working in Australia. Reconciling different realities emerged as the core category of
the study. It explains how the participants interacted in the new context and the
dynamics of negotiating difference while living between two worlds. To locate the
findings of the current study within the broader knowledge base, theoretical
literature on immigration and the experience of immigrant/overseas nurses working
in another country was revisited.
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The key analytic points are as follows. First, the concepts of acculturation,
assimilation, and integration are relevant but inadequate to explain the experience of
the participants. Second, the dominant emphasis on language and culture in the
literature ignores the issue of power. Third, there is a propensity in the literature to
view difference largely as a problem rather than something of value. Finally,
ambivalence as a theoretical concept in understanding the experience of immigrants
is either ignored or insufficiently addressed in the existing literature.
8.2.1 Acculturation, assimilation, and integration The immigration literature is dominated by the concepts of acculturation,
assimilation, and integration (Ea, 2007; Jose, 2008; Lopez, 1990; Sochan & Singh,
2007). These concepts have their roots in varied disciplines and are used in a range
of different ways (Alba & Nee, 1997; Teske & Nelson, 1974). As the findings of
current study suggest, these concepts while relevant, are inadequate to explain the
overall experience of the participants. It is also important to note at the start that it is
often the inappropriate application of these concepts, rather than the concepts
themselves, which is problematic. The argument here is that, in relation to the
findings of this research, these concepts are limited analytically. An explication of
the inadequacies and relevance of each concept follows.
Acculturation
As a prominent researcher in cross-cultural psychology, Berry (2005) defined
acculturation as the capacity of immigrants to manage two cultures and identities
following entry into and settlement in host societies. According to Berry (2005),
there are four ways that acculturation can take place: assimilation, integration,
separation, and marginalisation. This fourfold conceptual model of acculturation is
highly regarded and exerts a prominent influence on theory and research in the field
of immigration (Ward, 2008). However, acculturation and particularly Berry’s
conceptualisation of acculturation is inadequate in explaining the experience of the
study participants for following reasons.
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The first concern is that the concept of acculturation is grounded in the implicit
understanding that cultural boundaries are fixed and distinct. However, in reality,
culture is moving and mixing (Hermans & Kempen, 1998).
Second, Berry’s concept of acculturation captures mainly the attitudes or preferences
of immigrants as if they have free choice on what strategy to pursue. It obscures
other dynamics involved in the negotiating process result in the choice of one
strategy over another (Seelye & Brewer, 1970). Indeed, both the retention of
traditional cultural practices and the acquisition of a host culture may be voluntary
or involuntary depending on a number of factors. Furthermore, preferences are not
competencies. People generally want to be competent in their tasks (Bandura, 1997)
but it is not easy to acquire (among immigrants) and to maintain (in the next
generations) fluency in two languages (Boski, 2008).
Similarly, Berry’s (2005) concept of acculturation is essentially built at the level of
individual. The individual dimension, while relevant, is inadequate. Understanding
the immigration experience is more about how immigrants come to be socially
defined. This inadequacy may, to some extent, relate to Berry’s background in the
field of psychology which tends to focus on the underlying psychological processes
while overlooking the sociological processes of change.
A further inadequacy is that acculturation positions culture as the key explanation of
the process. This view ignores other factors (such as race, power, social and
situational factors) in construction of reality, which may reinforce racist stereotypes
and undermine understanding.
Finally, although acculturation claims to be a process, most literature focuses on
outcome which is the extent to which immigrants have absorbed the new culture or
retained the original one (Hong, Morris, Chiu, & Benet-Martinez, 2004). This
concept is thus inadequate in explaining why and how such a process unfolds over
time.
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Reconciling is a more appropriate concept in explaining the overall experience of the
study participants since it is not just about change from one identity to another, but
about being an insider and outsider at the same time. The reconciling process is not
without disharmony and tension and it involves constant negotiation with different
realities. Reconciling differs significantly from acculturation in explaining the
immigration experience in that it acknowledges a far more complex process than one
of cultural change. Without a solid understanding, the concept of acculturation is
often misapplied in the area of immigrant nurses.
Assimilation
In psychology, assimilation is defined as a process of change during which the
immigrant seeks to adapt to and identify with members of the host country and to
disengage with the country of origin (Berry, 2005). In sociology, assimilation refers
to a social process of the ethnic minority entering into the mainstream of a host
country (Alba & Nee, 1997). The underlying belief is that immigrants and their
descendents will become less distinguishable from the dominant group over time.
The key point is that the concept of assimilation implicitly assumes a break with the
home culture and the existence of a homogeneous mainstream in the host culture
with which immigrants can identify (Suarez-Orozco, 2000). Yet this is never the
case.
With globalisation, the degree of cultural contact is greatly intensified. As a result,
many immigrants today are already “Westernised” to varying degrees prior to
immigration (Rumbaut, 1999). In addition, immigration is no longer equated with a
“sharp break” with the country of origin that once characterised the experience
(Suarez-Orozco, 2000). Immigrants nowadays are more likely to be at once “here”
and “there”, in a state of in-between-ness and engaging in various transnational
activities (Lawson, 2000).
The assumption of the existence of a coherent and homogeneous mainstream culture
in the host society with which immigrants can assimilate is also problematic
(Suarez-Orozco, 2000). The reality of segmentation of the economy and society of
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most countries means that immigrants may assimilate to different sectors of host
societies rather than the uniform mainstream or middle class (Favell, 2003). Also, a
lack of adequate meaningful interaction with the host community can contribute to
an inability to assimilate and a shift of point of reference to co-ethnics (Suarez-
Orozco, 2000).
Another reason the concept of assimilation is inadequate is that it usually refers to a
generational process of a population and not the short term pursuits of an immigrant
group (Alba & Nee, 1997). The participants in the current study had been in
Australia for between 6 months to 4 years. This limited time frame explains to some
extent the finding that the assimilation of the participants was partial and that there
was a reluctance to assimilate.
Assimilation is relevant to the study findings in that the concept involves a removal
of difference between the participants and their local colleagues and changes (such
as adopting the host language and cultural practice) that enable the participants to
function in Australia. From the immigrant point of view, assimilation takes place in
the direction of the host culture, even if that culture is also changing through the
ingestion of elements from minority cultures (Alba & Nee, 1997). However, what
seems problematic is assimilating to what extent. The overwhelming pressure to fit
in at the workplace may compel the nurses to conform to the social norms. However,
if we take Teske and Nelson’s (1974) seminal definition of assimilation as change at
the level of value then whether assimilation is part of the experience of the study
participants is questionable. The concept of reconciling allows what Goffman (1959)
termed the presentation of the self which may or may not include adopting the
values of the host culture.
In addition, assimilation requires not only that immigrants have a positive
orientation towards and identification with the host community, but also acceptance
by the dominant group (Teske & Nelson, 1974). However, lack of membership in the
host community does not prohibit reconciling from occurring. The experience of the
China-educated nurses in this study most closely resembled segmented assimilation
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where they continued to identify as Chinese and maintain their ethnic distinctiveness
and consciousness.
Integration
The concept of integration is “difficult to define” (Costoiu, 2008) or is only loosely
defined (Boski, 2008). An implicit understanding is that integration means blending
of two cultures in different forms (Agar, 2006). However, there is no consensus on
what the forms should look like to be qualified as integration. It is also assumed that
immigrants who adopt the strategy of integration are not expected to give up their
original culture while taking on the host culture. Yet the concept of integration is
inadequate in explaining the experience of the study participants for the following
reasons.
The concept of integration implies a state of equilibrium that involves “becoming
effective in the new culture and remaining competent in the original culture”
(LaFromboise, Coleman, & Gerton, 1998, p. 148). This ignores the contested,
negotiated and sometimes painful experiences associated with living between
cultures (Bhatia & Ram, 2001), a finding of this study. It is also unclear whether
integration could happen when the salient norms of two cultures seem incompatible.
The concept, while claiming to be process oriented, does not address the dynamics
of adding a new culture to the existing culture.
Integration also implicitly assumes that both the dominant and minority groups have
equal status and power (Bhatia & Ram, 2009). However, in reality, becoming
integrated in the host society has to be explicitly or implicitly sanctioned by the
majority members of the culture (Bhatia & Ram, 2009). In addition, if we take
integration as a two-way process, determined not only by immigrants but also the
nature of host society and its reactions to new arrivals (Cox, 1987), the concept fails
to capture the fact that the participants carry most of the burden of change.
Furthermore, the concept of integration fails to recognise the reality that immigrants
can participate in two cultures with various degrees of preferences, loyalties, and
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competence. As Taft (1981) argued, immigrants can be physically in contact with a
host community while at the same time psychologically separated from that
community. Immigrants can also conform to the behaviour of a host culture yet
retain the values of their own culture (Boski, 2008).
Integration has relevance for the current study if we take it as any combination of
two cultures. Indeed, integration at a functional level is probably the most realistic
option for immigrants (Boski, 2008). As Boski (2008) argues, it is much easier to
have one culture dominant in one sphere of life and the other culture dominant in the
remaining spheres than to assume complete biculturalism. It appeared beneficial for
the study participants, at least in the early period after immigration, to maintain
Chinese culture in their private life. However, within the public sphere, it was
impossible for them to separate totally from the host culture.
Indeed, the ideological debate between assimilation and integration loses its logic as
well as its pragmatic relevance because some kind of change is an inevitable part of
immigration (Kim, 2001). Reconciling has greater relevance in its depiction of the
process as one of constant negotiation of difference. Far from the neatly bounded
processes implied by the concepts of assimilation or integration, the study
participants acted differently within different contexts.
In summary, an overwhelming emphasis on attitude and preference that obscures
structural factors, and an excessive focus on outcome (although these concepts claim
to be process-oriented) render the concepts of acculturation, assimilation, and
integration inadequate and less useful in explaining the experience of participants in
this study. The broader social debate over whether immigrants should assimilate or
integrate in the host society is also directly related to the way immigrants’ language
and cultural issues are framed.
8.2.2 It is not just language and culture In the existing and relevant literature there is an overwhelming emphasis on
language, culture, and practice differences as the key issues of adjustment for
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immigrant nurses (Magnusdottir, 2005; Sherman & Eggenberger, 2008;
Teschendorff, 1994; Xu, 2005; Xu, 2008; Xu et al., 2008; Yi & Jezewski, 2000). For
example, a GT study by Yi and Jezewski (2000) on Korean nurses in the US
produced five stages of the adjustment process: relieving psychological stress,
overcoming the language barrier, accepting USA nursing practice, adopting the
styles of USA problem-solving strategies, and adopting the styles of USA
interpersonal relationship. Here, adjustment is about lessening or eliminating
difference and overcoming language and cultural barriers. A UK study on the
experience of Filipino nurses concluded that the experience is primarily about
differences in the nursing role and communication issues (Daniel et al., 2001). A
review article in this area by Konno (2006) also emphasised the collision of cultures
when overseas nurses enter Australia and the resultant isolation in the workplace. A
further meta-analysis focused on Asian nurses working in Western countries
produced four overarching themes, three of which were language, culture, and
clinical practice differences (Xu, 2007).
Indeed, having English as a second language is perceived as a problem to be
managed, rather than as a performance-enhancing asset (Hawthorne, 2005). People
in the host country tend to think that overseas nurses are unsafe in their clinical
practice (“Skills of Overseas Nurses”, 2005). This idea partly comes from the
assumption that if an overseas nurse can misunderstand a simple word then how
dangerous might it be for a patient who says something critical. The media portrayal
of particular cases of error committed by overseas nurses contributes to this
perception.
It is true that the language issue is important; however, the connection between the
communication capability of immigrant nurses and patient safety (Xu, 2007; Yi,
1993) is unclear. Some authors have argued that language and communication
deficits pose great risk for patient safety and quality of care (Xu, 2008). It is of
concern that such a conclusion would be drawn by assumption and not on the basis
of evidence.
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Although language may create barriers to communication, it is not so inevitably
dangerous to a patient. Even in China, one cannot guarantee that nurses can
understand each patient, as many of them speak a local dialect. Also in a
multicultural society such as Australia, not every nurse can understand every
patient’s words. There are always occasions where patients are unable to
communicate with nurses for medical reasons, but it is not assumed that this poses
an immediate danger for the patients.
Nonetheless, a non-English speaking background is perceived negatively in the
workforce. This is evident in the study by Allan and Larsen (2003) which found that
communication was a form of stigma for internationally recruited nurses. Being
linguistically different from the dominant group, the study participants were
perceived to be inferior and incompetent. It is important to understand how the
process of stigma emerges for immigrant nurses during their social interactions.
From the symbolic interactionist perspective, issues of language and culture are
socially constructed by defining the situation from the dominant group perspective.
As Blumer (1971, p. 300) argues, a social problem “exists primarily in terms of how
it is defined and conceived in a society instead of being an objective condition with a
definitive objective makeup”. Thus for the participants, speaking English as a
second language was perceived to be a linguistic deficit while their bilingual
strength was largely overlooked.
Indeed, a reduction of all to language and culture is a simplistic view of the
experience of immigrant nurses. It is probable that the impact of language and
culture if repeated over and over again becomes the dominant discourse and is
exaggerated over time. The fact that most researchers in this area are white nurses
and most interviews are undertaken in English may also contribute to this superficial
interpretation when participants’ words are taken only at face value. It is also much
more difficult in a research community to challenge the dominant discourse and so
to risk having one’s research isolated. The emphasis on language and culture may
also reflect the perspective of health care organisations which impose Western
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understandings and meanings.
Yet, language issues reflect far more than simply communication barriers; they are
about power and “othering” (Creese & Kambere, 2003). The overwhelming
emphasis on language reinforces the implicit understanding that immigrant nurses
should bear the burden of speaking in an acceptable way, rather than local people
assisting in the process of meaning making. As Egan (1998) has argued, effective
communication involves active listening as well as being tuned, physically and
psychologically, into the person speaking. The communication problem, so
dominant in this body of literature on immigrant nurses, may be addressed to some
extent with a willingness to listen and to understand subtle nuances in speech and
body language on the part of the dominant group. By ensuring that any language and
cultural issues belong to the immigrant nurses, the power imbalance between local
and immigrants is sustained and perpetuated.
There is also an inherent danger in attributing the less than positive experience of
immigrant nurses to language and culture. Beyond the predominant discourse of
language barriers and cultural differences of immigrant nurses, it is important not to
lose sight of other key factors that shape the experience. Indeed, a few studies in
recent years have pointed out that it is not just about language and nor simply culture
(Allan & Larsen, 2003; DiCicco-Bloom, 2004; Raghuram, 2007). The social
disadvantage of the immigrant nurse is a key factor reflected in several studies.
The study by Baxter (1988) found that immigrant nurses were generally located in
the less prestigious institutions, specialties, and lower grades of nursing. As Smith
and Mackintosh (2007) have pointed out, the interaction of immigrant status and
ethnicity has repeatedly served to reinforce nursing and labour market hierarchies.
According to Sherwin (1992), the organisation of the health care system does not
merely reflect the power and privilege structures of the larger society, it perpetrates
them. The disadvantage of non-English speaking background is also well
documented in Australia (Hawthorne, 2002; Ho, 2006).
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Indeed, by rendering everything attributable to language and culture, other structural
factors that shape the complexity of the experience of immigrant nurses such as
gender (DiCicco-Bloom, 2004; Ho, 2006), race (DiCicco-Bloom, 2004), power
imbalances (Allan & Larsen, 2003), and the geopolitical context (Raghuram, 2007)
are overlooked. The experiences of immigrant nurses cannot be fully understood
without looking through these different lenses simultaneously. It is from this framing
that meanings of experiences are defined and dynamics of relationships understood
(Xu, 2007). The way immigrants’ language and cultural issues are framed is also
closely related to the practice of valuing diversity in host society.
8.2.3 The potential value of difference It is questionable why the appearance of difference in the form of an immigrant
nurse should be seen largely as a problem for the workplace rather than a
contribution. This is reflected in a lack of recognition or undervaluing of previous
learning, experience, and cultural differences of immigrant nurses in both the current
study and literature (Smith & Mackintosh, 2007). Indeed, an integrative review by
Kawi and Xu (2009) identified differences in areas such as language, culture, and
nursing practice as barriers to adjustment and thus difference was perceived as
largely negative.
Immigrant nurses are a rich resource for the nursing profession since they bring
special knowledge, sensitivity, and perspectives to nursing care in the host country.
However, this asset is largely unappreciated in practice. It seems that the participants
were not encouraged to share their previous experiences and expertise of nursing in
order to add to the diversity of nursing practices in Australia. Except on occasions
when caring or acting as unofficial interpreters for patients who share the same
background, the skills of immigrant nurses, as shown in Blackford and Street’s study
(2000), are usually invisible and unacknowledged. The hospital employment criteria
also give no recognition of the multiple language skills of the nurses (Blackford &
Street, 2000).
Regardless of whether one system is considered better or worse than another, two-
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way learning where nurses learn with, from, and about each other is considered
enriching (Dubois, Padovano, & Stew, 2006). One possible reason that difference
does not appear to be valued in Australia is that the Western world is generally
perceived as superior.
As different and being the other, immigrant nurses are often not tolerated. As
Wilkinson (1996) has argued, the white racial identity is rarely questioned by white
people: differences in race and culture mean belonging to the other. Indeed, one
participant in this study noted that local nurses use the interpreter service when they
care for minority patients. However, few people would consider it acceptable if an
immigrant nurse requested to use such a service when caring for an English speaking
patient. It seems apparent that immigrant nurses are not entitled to such a service in
clinical practice even if the situation deems it necessary for the benefit of the patient.
Even the slightest idea that some immigrant nurses may need or want to use such
service will quickly be interpreted as an inadequacy.
The intolerance of difference is also reflected in the criticism emanating from local
nurses when immigrant nurses do not immediately live up to pre-determined
expectations. As Xu (2007) noted, both language skills and cultural knowledge
require years of immersion and accumulation through persistent effort. However, in
reality, there is a lack of resolve to allow immigrant nurses adequate time for
learning.
Immigrant nurses are usually seen as ready-made workers who are recruited to fill a
shortage gap. They are rarely treated as people in transition and newcomers who
need support and direction as they find their way in a new society which is alien to
them (Castles, 2000). The health care organisations take local nurses’ lives and
experiences for granted and render overseas nurses’ social needs and experiences
invisible or as the other.
In addition, it is essential to remember that immigrant nurses are not a homogeneous
group and thus making generalisations about any group of nurses is misleading and
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undesirable. It is important to assess each nurse’s performance individually rather
than based on where they come from. By labelling immigrant nurses as inadequate
when they appear different, the stereotyping about these nurses will be further
reinforced. In fact, it appears in the data that patients were generally more receptive
of the participants compared to colleagues and patients’ families.
When difference is seen as a problem and even a threat, the implicit assumption is
that immigrant nurses should cast off their differences and adopt the ways of the
workplace. Indeed, an in-depth look at the literature reveals much of the work on the
experience of immigrant nurses either overtly refer to assimilation or slip into the
idea of assimilation unintentionally as evidenced in the following examples.
In an Australian study of 26 non-English speaking background nurses, Blackford
and Street (2000) found that emphasis was given to knowledge and skills that
maintained Anglo-Australian health care practices and a failure of the nurses to
comply with the “rules” resulted in marginalisation. In the report of a study on the
experience of Chinese nurses in the US, the authors used the term integration in the
description (Xu et al., 2008). However a closer look revealed that the notion of
“becoming integrated” involved the unlearning of Chinese values, beliefs, and
behaviours by the Chinese nurses and the learning of new ways in order to become
accepted as a legitimate member of the local nursing community. A meta-analysis of
research on Asian nurses also concluded that these nurses felt compelled to change
who they were to varying degrees in order to adapt successfully to the new culture
and work environment (Xu, 2007).
The essence of integration is about inclusion, participation, and equality which
respects and values difference rather than seeking its elimination. However, as
Raghuram (2007) has pointed out, in practice what sets out to be integration usually
becomes assimilation, that is, the mitigation of differences between immigrant
nurses and local nurses. Although nursing practice is inherently variable, the
differences of immigrant nurses tend to be emphasised while the variations of local
practice are largely ignored (Raghuram, 2007). If the concept of integration is taken
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seriously, the China-educated nurses would not be made to feel that they have to
lose their differences and learn the new way in order to be accepted in the workplace.
In addition, in theory integration is a two-way process (Alba & Nee, 1997) and yet
in practice it appears as one-way because of the power imbalance (Raghuram, 2007).
It is the migrant nurses who have to conform to current practices, what and how
“non-migrant nurses” are contributing towards integration is generally overlooked
(Raghuram, 2007).
Integration, as defined, would require that immigrants be granted equal rights and
participate fully in all spheres of the new society without giving up their diversity
(Costoiu, 2008). Thus in theory, integration is desirable but in reality extremely
difficult because of the social and political location of immigrants (Rudmin, 2003).
Few migrant nurses would consider that they were in a position to shape and reshape
nursing practice in the host country through the knowledge they bring (Raghuram,
2007). As an Australian study shows, the ability of non-English speaking
background nurses to bring about change to the dominant Anglo-Australian health
care system is minimal (Blackford & Street, 2000). Similarly, Xu (2007) revealed
that Asian nurses perceived that they had little power to change the status quo,
particularly given their migration status and the foreign contexts.
Difference can serve a constructive function if handled with understanding and
sensitivity. Speaking a different language and belonging to a different culture may
appear initially as a barrier to both immigrant nurses and the host country, but with
time will become an asset to the organisation and the diverse populations they serve.
It is therefore necessary to respect and value diversity rather than merely tolerating
someone who is different (Alexis & Chambers, 2003; Brunero, Smith, & Bates,
2008; Ho, 2006; Vestal & Kautz, 2009).
However, for difference to be valued, we must move beyond the rhetoric of a change
in attitude that so dominates the literature (Alexis, Vydelingum, & Robbins, 2007;
Allan & Larsen, 2003; Jose, 2008; Murphy, 2008; Vestal & Kautz, 2009; Xu et al.,
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2008). It is not meaningful and definitely not enough to say that people should
“value diversity”. Indeed, the focus should be shifted to what diversity means, why
diversity is not valued, and what broad social structural changes are required to
move from rhetoric to a change in practice.
Clearly, theoretical attention to difference is largely ignored in the literature on
immigrant nurses and in the practice of nursing. Simmel (1991) argued that
distinctions and differences were essential to human recognition. However, the
symbolic boundary which divides the norm and the deviant is socially constructed
and thus permeable and open to change over time. The point is that differences
should not be judged as if they were the root of our political, social, and cultural
problems (Marotta, 2008). Rather, it is how we deal with these differences that
matters. Boundaries can be oppressive and limiting, or the grounds for respecting the
otherness of the other and being open to difference (Marotta, 2008). It is important
for one to live with and learn from difference even if it challenges one’s taken-for-
granted view of the reality. Yet while difference might or might not be valued, it is
also the source of ambivalence for immigrant nurses.
8.2.4 Ambivalence as a theoretical concept Ambivalence as a theoretical concept became clear at the latter stages of the analysis,
although tensions of all forms appeared much earlier. For example, in the category
of realising, there was tension over the different realities of nursing work and care
delivery in China and Australia; and over the loose human connections in Australia
and the complex human relationships in China. In the category of struggling,
tensions were embedded in the China/Australia middle position dilemma, the not
knowing and the need to know, and the desire to appear competent and the need to
seek support. However, it is only in the category of reflecting that the concept of
ambivalence became explicit and particularly within the last sub-category it is hard
to go back.
It is important to distinguish between the concepts of ambivalence and ambiguity.
While ambivalence refers to simultaneously opposing affects and conflicting
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feelings towards the same object, the term ambiguity connotes uncertainty and lack
of clarity (Zielyk, 1966). It is possible that ambiguity contributes to ambivalence,
but it does not necessarily imply opposed perceptions or emotions.
In the sociological literature, it is proposed that the concept of ambivalence has two
dimensions: sociological ambivalence and psychological ambivalence. Sociological
ambivalence refers to “incompatible normative expectations of attitudes, beliefs, and
behaviour” (Merton & Barber, 1963, pp. 94-95). These expectations arise when an
actor is faced with a particular situation that simultaneously values contradictory
courses of action that are rooted within the wide social structure (Connidis &
McMullin, 2002). Psychological ambivalence is a property of the individual mind or
psychological experience of immigrants (Luescher & Pillemer, 1998). The critical
component of psychological ambivalence is the presence of both positive and
negative perceptions by an individual (Luescher & Pillemer, 1998). In addition,
ambivalence cannot be reduced to negative feelings only as shown in the literature
(Gilbert, 2005).
This study shows that it is naïve to define the experience of the immigrant nurses as
good or bad, or positive or negative as it is surrounded by ambivalence. However,
literature in this area revealed the experience either as largely negative/unhappy
(Alexis & Vydelingum, 2007; Allan & Larsen, 2003; Brunero et al., 2008; Collins,
2004 ; DiCicco-Bloom, 2004; Hardill & MacDonald, 2000; Jackson, 1996; Jose,
2008; Konno, 2006; Krinsky, 2002; Likupe, 2006; Murphy, 2008; Omeri & Atkins,
2002; Sochan & Singh, 2007; Xu, 2007) or as a struggle with a happy ending
(Jackson, 1996; Jose, 2008; Magnusdottir, 2005; Yi & Jezewski, 2000).
One possible reason that the experience is conceived as largely negative might relate
to the focus of research on what is problematic rather than what is normal. The
proposition of “the experience” as negative is belied in part by the fact that most
immigrant nurses choose to stay after immigration and many more continue to come.
Another possible reason is that most of the literature only captures the struggling
aspects of the experience while overlooking the growth that comes from the
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experience.
The experience is also posed as a linear process where immigrant nurses move from
one position/culture to another and finally reach a happy ending. Here it is assumed
in the literature, implicitly or explicitly, that immigration is essentially an experience
where the individual immigrant nurses overcomes challenges and barriers to finally
win through or to find a place, with the hint of success as evidence of the end point
(Jackson, 1996; Jose, 2008; Magnusdottir, 2005; Yi & Jezewski, 2000).
Yet ambivalence exists even in the best immigration circumstances. First,
immigration is usually perceived as a rational choice by individuals who have
calculated and behaved rationally to maximise their benefits (Borjas, 1989).
However, in reality, immigration decisions are based on incomplete information and
individuals are quite often influenced by others, constrained by norms, or act
impulsively. This irrational component in decision making contributes to the mixed
feelings about the immigration experience.
Second, choosing one opportunity often means giving up other possibilities. It is not
easy for immigrants to leave behind previous ties and to go through the uncertainties
in the new country. Opportunities and challenges often go hand in hand and
immigrants take on hardship in the hope of a promising future (Grzywacz et al.,
2006). The level of investment in the immigration move could unintentionally raise
pre-migration expectations which tend to increase the possibility of disappointment
with the reality encountered.
Third, ambivalence is also created when the benefits/gains of immigration only
come at considerable costs/losses which could not have been fully anticipated at the
moment of departure. This is particularly so where emotional and psychological
costs are felt when immigrants are separating from families and adjusting to a new
environment. A new society offers immigrants boundless possibilities, yet also
presents many constraints (Lawson, 2000). Feelings of uncertainty about acceptance
further contribute to the ambivalence of immigrants about their place in the host
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society.
In addition, the dual reference points of comparison also contribute to the
ambivalent feelings. Immigrants want what is good from both societies but cannot
be fully satisfied with either (Smelser, 1998). While a comparison of their current
situation with local nurses may bring dissatisfaction to the China-educated nurses, a
comparison with those less fortunate in China may bring some comfort. While the
situation in Australia is not without suffering and hardship, the admiration from
people in China reinforces their increased social status at home and brings much
needed psychological compensation.
Lastly, ambivalence also existed where the participants found the experience in the
new country far less than fulfilling and yet it was hard to go back. As Smelser (1998)
argued, immigrants are often “locked in” by personal commitment or other
situational circumstances and can escape only at great cost. The fact that the
participants choose to stay does not mean that they are without contradictory
feelings. On the contrary, both strong positive and negative feelings towards
immigration can coexist and the use of a single measure may eschew the complexity
of such experience.
Although some participants noted that the immigration experience is worthwhile,
overall, this should not be taken to mean that the whole experience is a positive one
or one with a happy ending. That it is worthwhile may well be an expression of
ambivalent feelings. Indeed, the participants held contradictory emotions and mixed
feelings towards immigration, when excitement, hope, opportunities coexisted with
frustration, disappointment, and challenges. The inherent paradox and conflict
suggests that ambivalence is the feature of the immigration experience.
Indeed, the interaction of immigrants with others can be interpreted as the
expression of ambivalences and as efforts to manage such ambivalence. As Lüscher
(2002) argued, ambivalence may never be completely reconciled and immigrants
must live with more or less ambivalence. The notion of ambivalence can inform our
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understanding of immigration experience and explain a range of behaviours and
situations beyond the scope of rational-choice explanations (Grzywacz et al., 2006;
Smelser, 1998). To date, ambivalence as a theoretical concept in understanding the
experience of immigrants has either been ignored or insufficiently addressed in the
literature.
In summary, a revisiting of the literature on the experience of immigrant nurses
suggests that there is insufficient theoretical understanding in this area. The
theorising on acculturation, assimilation, integration, difference and ambivalence
takes place within the broader immigration research area while the nursing literature
remains descriptive in general. More engagement between nursing research and
social theory is required. This study contributes to the nascent body of research that
draws together these two areas of knowledge.
In spite of the uniqueness of some findings in this study, areas of the experience are
shared with those in the literature regardless of the nationality of immigrant nurses.
This merely reinforces the view that the experience of immigrant nurses is
foremostly social. The experience of immigrant nurses is shaped by systemic
processes of privilege and disadvantage. Where the identity of the dominant group is
constructed through its opposition to the minority group, immigrant nurses are
collectively referred to as them. Such a classification of membership means that the
similarities in experience among these nurses are far greater than the differences.
This suggests that it might be too simplistic to link the experience only to nationality.
The construction of the other is not just about someone from another country, but
more about power generally. It is thus important to explore what is going on socially
instead of looking at the individual. The assumption that this is far more about the
social experience also suggests that there is a need to bring social change to improve
the experience.
This research concludes that the concepts of acculturation, assimilation, and
integration while relevant, are inadequate to explain the overall experience of the
participants. It is simplistic to reduce the experience of immigrant nurses to language
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and cultural issues. The difference of immigrant nurses is usually posed as a problem
instead of strength. The inherent ambivalence of the immigration experience renders
reconciling a necessary part of the process.
Reconciling different realities explains the experience of the China-educated nurses
working in Australia. The aim of reconciling is to reach a point of harmony with the
coexistence of differences. This does not mean complete acceptance, but rather
constant negotiation over difference. Reconciling is a dynamic, ongoing, and
nonlinear process. Over time, the participants moved on to some measure of
resolution despite never reaching full reconciliation. The thesis now turns to the final
chapter which draws the overall theoretical conclusions of the research, addresses
potential limitations and methodological tensions of the study, and poses some
implications of the findings in the form of recommendations.
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Chapter 9 Conclusion 9.0 Introduction This research sought to explore the socially constructed meanings that form the
experience of China-educated nurses working in Australia and the actions that flow
from those meanings. This chapter constitutes the conclusion of the study in
addressing a summary of the research and key findings followed by a consideration
of the limitations and methodological tensions of the study. The chapter concludes
with a discussion of the broader implications of and recommendations that arise
from the study findings as they relate to nursing practice, future research, and policy
consideration.
9.1 A summary of the research Transnational nurse migration is a growing phenomenon. One key influence is the
global nurse shortage, particularly as it exists across developed countries. It was
noted that in the US, it is predicted that there will be a shortfall of over one million
nurses by the year 2020 (HRSA, 2006). In Canada, a nurse shortage of 78,000 is
projected by 2011 (Nelson, 2004). In Australia, the estimation is that there will be a
shortfall of 40,000 nurses by 2010 (Karmel & Li, 2002). International recruitment
appears to be the policy of choice as national policy makers seek to alleviate nurse
labour shortages. It is speculated that China, by virtue of the size of its labour force,
will become the country that dominates the export of nurses. Although overseas
nurses constitute 23.6% of the nurse workforce in Australia (Omeri & Atkins, 2002)
and the trend is expected to increase (Joen & Chenoweth, 2007), relatively little is
known about the experiences of these nurses, and particularly about non-English
speaking background nurses such as China-educated nurses who are working in the
Australian health care system.
The purpose of this research was to explore the ways in which China-educated
nurses construct the meaning of the experience of working in Australia. The intent
was to produce an in-depth theoretical understanding rather than a description of the
experience.
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The symbolic interactionist approach and more specifically the interactionist
Chicago School (Blumer, 1969; Mead, 1934) and Dramaturgical School (Goffman,
1959, 1961, 1963, 1983) underpin the theoretical perspective applied in this study.
The perspective of SI places a clear emphasis on meaning, interpretation, self, and
social interaction (Blumer, 1969). According to this view, human beings are not
passive but construct actions on the basis of how they define and interpret situations
(Blumer, 1969). A second assumption is that meanings are not inherent to objects or
things; rather they are socially constructed (Blumer, 1969). A further point is that
human society consists of people engaging in ongoing action and interaction
(Blumer, 1969). However, the view of SI in this research acknowledges that human
actions occur within social constraints and as such are firmly located within the
broader political, economic, social, and cultural contexts (Hall, 1987; Strauss, 1982).
It also takes into account how emotions guide human conduct.
The methods in this research constituted a modified constructivist GT building on
the works of Charmaz (2000, 2006). From Charmaz’s perspective, a constructivist
GT places emphasis on meaning, context, and how data are interpreted. This view
acknowledges that data collection and analysis are influenced by the researcher’s
theoretical beliefs and interactions with participants. However, the method applied in
this study shifted somewhat from the relativist position of Charmaz towards a
critical realist view. A relativist view assumes there are multiple realities, while a
critical realist argues that although there exists a real world it is one that can only be
known through interpretation (Searle, 1995). The adoption of a modified
constructivist position moved GT methods to an interpretive framework compatible
with Blumer’s emphasis on meaning and the existence of a real world.
This research was carried out in two major cities in Australia: Brisbane and Adelaide.
Purposive sampling and theoretical sampling were used and the main source of data
was 46 face to face in-depth interviews with 28 China-educated nurses. The
interviews were conducted in Chinese and audio-recorded. The interview data were
generated through the eyes and ears of a Chinese nurse for a period of 13 months.
Following the completion of each interview, field notes were written by the
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researcher to record details of observations and encounters. In addition, a reflexive
journal was kept to record the researcher’s impressions, thoughts, problems, and
decisions generated during the research process. Finally, relevant literature was
consulted as data to address issues arising during the analysis.
In accordance with GT methods, data analysis commenced directly following the
first interview. Constant comparisons of data, concepts, and categories were
conducted through three reiterative coding steps: initial coding, focused coding, and
theoretical coding (Charmaz, 2006). Chinese was used as the coding language and
English translation of analysed codes occurred following focused coding. It is
important to note that coding is not purely a mechanical process but requires a
theoretical sensitivity to reach analytic depth. In addition to coding, memos were
written during the analysis to record the researcher’s thinking about the coding and
questions and directions for further data generation.
This study found that reconciling different realities captured the patterns of meaning
that reflected the experience of China-educated nurses. The core category is
composed of three categories: realising, struggling, and reflecting. Realising served
as the starting point where the participants recognised the discrepancies between
different realities. This created the need and context for reconciling on the part of the
nurses.
The three sub-categories of realising were addressed in Chapter 5. The first two sub-
categories of realising (it is indeed different, this is the Western way) captured a
sense of difference in the nature of nursing work and the way nursing care was
delivered. Here it was argued that difference was to be understood as socially
constructed and not an objective truth. Insufficient knowledge or understanding
about immigration life partially contributed to the perception of difference. The
difference situated the nurses differently. More significantly, it predisposed them to
be seen as unqualified or inadequate. Aware of the difference and the negative
associated meanings, the participants accommodated themselves to the social norm
of the work setting.
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The experience of superficial collegial relationships was reflected in the third sub-
category of realising (you are you and I am I). Immigration meant a relinquishment
of previous social ties and the effort of building new connections was characterised
by barriers. It was presumed that one needed to embrace the host culture in order to
mix with locals. However, exposure to the experiences of locals highlighted the
tension between personal and social values. These seemingly insurmountable
tensions between the participants and local colleagues gave rise to a moment of we
cannot live a life like that. Without common experiences, meaning is not readily
shared which makes joint action problematic and community building difficult. The
social psychological distance existing between the nurses and local colleagues
functioned as an invisible wall which resulted in a sense of we are among but not in.
Furthermore, the ideology of individualism which prevails in Australia implies a
preoccupation with self and loose human connections. A comparison of human
relationships in Australia to those in China exacerbated a perception of it is
courteous but not close. Although the superficial relationships had some advantages,
loneliness was the price paid.
In Chapter 6, the second category struggling was explored. This category refers to
the dilemma of the “middle position” of the participants and how being situated as
“the other” was experienced. It consists of three sub-categories: caught between two
worlds, you have a lot to learn, and this is your own business.
The first sub-category caught between two worlds highlighted the dilemma of the
middle position of the China-educated nurses. There was a tension between a desire
to hold on to the old self and a need to conform to the new society. By adopting
strategies such as negotiating boundaries and switching off, a delicate balance was
constantly constructed by the participants. Here, the middle position also gave rise to
the dilemma of whether to be Chinese or to be Australian. But the portrayal of an
Australian identity set up boundaries and marginalised the nurses. This uncertainty
over their acceptance created ambivalence for the China-educated nurses about their
place in the Australian society. The result was an identity that was at once plural and
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partial. The nurses felt both a distance and closeness to China and Australia. The
resultant feelings of alienation saw participants form a community with other
Chinese and as such live a Chinese life overseas.
The sub-categories you have a lot to learn and this is your own business captured the
participants’ strong motivation and determination to transform challenges into
occasions of learning and to remain hopeful in the face of hardship. The participants
displayed resilience and agency through persistence, remaining positive, hard work,
and continuous learning. First, a sense of not knowing underpinned the differences in
nursing practices between China and Australia. The change in environment
inevitably exacerbated a sense of the unfamiliar. Learning was necessary to cope
with daily work and to manage stress related to unknowns. In addition, being foreign
and different, the participants appeared to be the other in Australia. This meant that
the nurses had to prove themselves to be accepted and recognised. Yet while the
desire to appear competent and not to lose face motivated learning, it also made
difficult the disclosure of what was not known. Moreover, the experience was
isolating. Being away from family implies the participants have left behind a strong
support network. The support from fellow Chinese friends in Australia was essential
but also minimal. The support from workplace was inconsistent and inadequate.
Furthermore, being the other, the social expectation was that the nurses would be
self-reliant and should expect no extra help. All these shaped a strong perception of
this is your own business.
The last category reflecting was the focus of Chapter 7. This category is about
making sense of the experience and reflecting on the gains and losses of immigration.
It consists of three sub-categories: a sense of loss, reconstructing the self, and it is
hard to go back.
The first sub-category is a sense of loss. Immigration removed the participants from
many relationships and predictable contexts. This contributed to a strong perception
that life in Australia was boring and inconvenient. A sense of loss was also related to
a perception of limited career opportunities, the uncertain prospect of marriage, and
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the reduced social status of husbands in Australia. The loss occurred as a
consequence of a voluntary choice, so it was both invisible and ambiguous. The loss
was invisible because it was not anticipated, involved emotional, social, and
psychological components and was difficult to articulate. The loss was ambiguous in
that it was unclear, incomplete, and partial (Boss, 1999). That this loss is poorly
understood is evident in the scarce attention it has received in the literature.
The sub-category reconstructing the self includes three components. First, a change
in reality meant that the participants left behind aspects of a previous self and
possibly a sense of pre-eminence once enjoyed in China. Since they were no longer
who they had been, they needed to re-negotiate a new sense of self in Australia.
Second, a sense of vulnerability emerged from the immigration experience. This is
reflected in the actual or perceived stereotyping and racial discrimination emanating
from the host society. Vulnerability is the result of being labelled as the other where
one does not conform to what is socially defined as a national (Bustamante, 2002).
Third, a sense of personal growth arises out of hardship and challenge. The
struggling was at once painful and fulfilling. The participants became more mature,
stronger, and more independent. This feature of the experience is not adequately
emphasised in the immigration literature.
A feeling of ambivalence towards the immigration was captured in the sub-category
it is hard to go back. Although few participants had been exposed to the actual
experience of living abroad, there was anticipation that immigration would result in
a better life. Indeed, the nurses were much clearer about what they were leaving
behind than what was to be encountered. The expectations were boundless and yet as
the reality of immigration unfolded there was a disjuncture between what had been
anticipated and what actually occurred. Indeed, the gains of immigration were
associated with difficulties, disappointments, costs, and losses. This gave rise to
mixed feelings about living in Australia. Drawing comparisons between one life and
another added to the ambivalence of the experience. A desire to return home was in
the minds of the participants. The dream of migration transformed into a dream of
returning after encountering the new situation. Nonetheless, experiencing the
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advantages of working as nurses in Australia (such as reasonable workloads, higher
salaries, higher professional status, and autonomy), the participants were also
reluctant to move back to their old ways of life. This sense of ambivalence, which is
essential to the experience of the participants, is not well addressed in the existing
literature.
This research found that the overarching experience of the participants was defined
by a sense of difference and reconciling emerged as the way in which the
participants responded to different realities. While the three phases (realising,
struggling and reflecting) remain integral ingredients of reconciling, they are not
discrete and thus do not always occur in sequence. Furthermore, the concept of
reconciling represents a process of ongoing negotiation. This core category depicts a
process not obvious in the dominant body of literature in the area which tends to
assume that immigration is about cultural difference and that the experience is a
process of acculturation, assimilation, or integration. Here it was argued that while
these concepts have some relevance for this research, they are inadequate to explain
the totality of the experience of the participants.
The theorising turned to the concept of “doing reconciling” which was
conceptualised as two strategies: an internal shift (rationalising) and external
(behavioural) change. An internal shift refers to a transformation of perspective to
ease the differences. Through a change at the level of meaning, the participants
started to perceive the self and the immediate world differently and to have their
beliefs or opinions challenged. An external shift refers to modifying one’s behaviour
to avoid, tolerate, accommodate, or embrace differences in realities. Reconciling in
this thesis did not refer to complete acceptance but depicted a process of ongoing
negotiation over difference. The aim of reconciling is to reach a point of harmony.
Through reconciling, the participants experienced resolution at different levels and
in a variety of ways despite never reaching full reconciliation.
In some important aspects, the findings of the current study are supported by the
literature on immigrant nurses and particularly that deriving from Asian countries or
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China. This includes, for example research on language and cultural issues (Allan &
Larsen, 2003; DiCicco-Bloom, 2004; Xu et al., 2008); differences in nursing practice
and the stigma of basic nursing care (Allan & Larsen, 2003; Daniel et al., 2001; Xu
et al., 2008; Yi, 1993), deskilling and technical nursing (Allan & Larsen, 2003;
Brunero et al., 2008; O’Brien, 2007); otherness, imposed loneliness, or
homesickness (Allan & Larsen, 2003; Jackson, 1996; Magnusdottir, 2005; Xu et al.,
2008); a keen desire of learning and enhancing oneself (Xu et al., 2008; Yi, 1993);
and reconstructing the self (Xu et al., 2008).
However, the shared themes on experience in this body of work are most often
articulated at the descriptive level. Indeed, it is usually the case that the focus is
confined to what the experience looks like, leaving the how and why of such an
experience unaddressed (Brunero et al., 2008; Palese, Barba, Borghi, Mesaglio, &
Brusaferro, 2007; Pilette, 1989; Sochan & Singh, 2007; Winkelmann-Gleed &
Seeley, 2005; Xu, 2005). Reducing the immigration experience to a typology of
factors makes invisible the social actions and social processes that give rise to the
descriptors. The significance of this research is that the study results move beyond
description to theorising and offer a more in-depth understanding of the experience
of immigrant nurses.
This also appears to be the first interpretive study on the experience of China-
educated nurses working in Australia. In this respect this research makes a
significant contribution to a growing knowledge base in the broad area of immigrant
nurses. One other study of a similar population was undertaken by Xu and
colleagues (Xu et al., 2008) in the US. However, the study differs in a number of
respects. First, the current research is a SI study with a focus on theoretical
understanding, while the Xu et al. study adopted a phenomenological approach with
a focus on describing the lived experience. Second, in the Xu et al. study the
participants constituted nine ethnic Chinese: seven from Mainland China and two
from Taiwan. It is disputable whether the social economic situation and the nature of
nursing practice in Taiwan mirror that of Mainland China. A further feature is that
the interviews in the Xu et al. study were undertaken in English while Chinese was
237
the interview language in this study. The authors of the US study acknowledged that
at least two of the participants when speaking English were, at times, less
comprehensible or even incomprehensible during interview (p. E43). It is possible
that the use of English as the interview language may have limited expression and
distorted the meanings of participants.
The significance of this study is further reflected in the growing number of
immigrant nurses worldwide and a prediction that this trend will continue in the
foreseeable future (Aiken et al., 2004). In addition, immigrant nurses not only
alleviate the nursing shortage but also contribute to the diversity of nursing
workforce (Omeri & Atkins, 2002). This study thus offers fresh insight into and
deepens our understanding of the experience of this group of nurses. The key
findings of this study are summarised in the following.
First, the core category developed in this study is reconciling different realities
which inserts a theoretical understanding beyond acculturation, assimilation, and
integration. The concept of reconciling as conceived in this research acknowledges
the diversity of factors that construct different realities. Acculturation, assimilation,
and integration, on the other hand, assume culture as the key explanation.
Second, this research found that the experience of immigrant nurses was not just
about language and nor was it simply about culture. The dominant emphasis on
language and culture in the literature obscures other dynamics such as power which
shape the experience.
Third, rather than focus on the negative aspects of difference, this study points to the
importance of recognising the social value of difference. Converting difference into
learning opportunities is in the interest of immigrant nurses and host societies.
Politically this means the adoption of a more integrationist rather than assimilationist
approach.
Finally, the prevailing view in the literature that the experience of immigrant nurses
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is largely negative belies its complexities. This research concludes that it is
problematic to define the experience as either good or bad. Rather, ambivalence is
the essential feature of the experience of immigrant nurses and a more appropriate
theoretical concept.
9.2 Study limitations No research is perfect and this study is no exception. There are a number of
limitations to consider. First, due to practical constraints (time, access, and finance)
and the difficulties of implementation, observations were not adopted as methods of
data generation in this study. Given the emphasis of SI, observation of the actions
and interactions of China-educated nurses and their colleagues and patients in the
work setting would have contributed further to the analysis.
Second, the study was constrained in the choice of participants. While it was
appropriate that all participants had completed their basic nursing education in China,
all had come to Australia within the five years prior to their participation in this
study. The period of experience was thus relatively short and the findings may have
evolved differently if time in Australia had been longer.
A further and somewhat obvious constraint may be that this study was informed by
the perspective of SI. Understanding and interpretation might be extended if the data
was subjected to analysis from an alternative theoretical perspective (such as
feminism). However, difference in theorising does not necessarily mean
disagreement; it is about the different emphases of research.
9.3 Methodological tensions A tension arose during the latter stages of the analysis between the adherence to the
GT structure and a desire to be free from the method and to continue the analysis in
a relatively unstructured way. It appeared that GT not only shaped the analysis
process for this study but also the structure of research findings. One example is the
concept of ambivalence in this study. Although the concept appeared implicitly
throughout the data, the over emphasis of the GT method on producing “neat”
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categories combined with the SI focus on action and process may have rendered the
concept obscure. However, during the latter stage of analysis, the concept became
clearer and stronger after all the categories and sub-categories were integrated. If the
concept had been generated earlier, an explicit theoretical sampling strategy could
have been applied to further its development and refinement.
At times, the researcher was attracted to the notion of constructing a substantive
theory rather than producing a theoretical understanding. A set of neat categories,
while useful, is unavoidably a simplification of the complexities of social reality.
Thus the conflict was over, on the one hand, a desire for an orderly format of
generation of categories and sub-categories and on the other hand, a more in-depth
understanding of the research phenomenon. There was also the difficulty of reducing
the diverse and complex experiences to fit neat categories.
In addition, the notion of a resultant theory in GT is somehow obscure. While the
research findings do make a theoretical contribution, it is uncertain whether those
findings constitute a “theory”. However, sociological knowledge is essentially the
attribution of different significance to, or a reordering of, what is already known
(Williams, 1988). As Thomas and James (2006) have argued, understanding is a no
less worthy effort than a claim to theory.
Furthermore, saturation was used as a guiding concept only in this study and it is
disputable whether real saturation could have been (and is ever) achieved. It is
acknowledged that some sub-categories in this research need further development
and refining, and that the theoretical explanations presented may be modified if
exposed to constant comparison with new data. Thus the findings presented in this
study present as theoretical inferences only and are not for generalisation.
9.4 Implications and recommendations The findings of this study not only contribute to theoretical understanding of the
study phenomenon, but could also be translated into practice for the benefit of
China-educated (or more broadly, immigrant) nurses in Australia, their colleagues,
240
employers, and patients. Finally, some implications for future research and policy
consideration are drawn from the study.
9.4.1 Implications and recommendations for practice The implications for practice from this study are threefold: for nurses in China who
are considering immigrating to Australia, for China-educated nurses who are
currently working in Australia, and for Australian health care organisations.
Although the propositions here are focused on China-educated nurses, most are
applicable to immigrant nurses generally.
This study found that China-educated nurses considered immigration as fulfilling a
dream of better life. They were unaware of the struggles that lay ahead. Unrealistic
expectations predisposed the nurses to many hardships, disappointments, and
frustrations in the journey. It is desirable, therefore, that Chinese nurses who wish to
immigrate have access to adequate and realistic information to ensure a balanced
view of immigration life. One possible channel is to invite those China-educated
nurses who have previously immigrated to provide relevant information on working
abroad.
It appears from the study that peer support is essential for reducing psychological
stress during immigration and thus resources to promote psychological health are
needed. The establishment of an overseas Chinese nurses association in Australia
may be helpful in facilitating the exchange of information and sharing of
experiences among the nurses.
This study found that the support provided to the China-educated nurses during their
transition was inconsistent and inadequate. Once recruited, the nurses were largely
left alone. The presumption was that these nurses, because they were qualified,
should be able to work independently. However, research here and elsewhere
indicates that the obtaining of registration does not dissipate the considerable
challenges and problems that these nurses have to confront (Parrone, Sedrl,
Donaubauer, Phillips, & Miller, 2008).
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Moreover, although the participants were highly motivated and considered it their
own business to deal with what was unknown, this does not mean that support was
not needed or wanted. Indeed, Australian health care organisations could harness and
develop further the high motivatation displayed by nurses such as these through
more appropriate support services.
However, as the study reveals, the issue of support is much more complex than the
dominant literature suggests. Support strategies such as tailor made orientation
programs, buddy programs, and overseas nurse support program (Brunero et al.,
2008; Gerrish & Griffith, 2004; Sherman & Eggenberger, 2008), while beneficial,
are insufficient. Indeed, more conversation and discussion needs to take place to
promote mutual understanding and to make support services more effective. One
issue to be addressed is how to create a non-threatening work environment. Another
concern is the negative connotation of support. A further issue is how to ameliorate
the social cultural differences between immigrant nurses and local colleagues. Given
the circumstances of immigrant nurses (being situated as the other), it is inadequate
to merely offer some education in an effort to achieve this goal.
9.4.2 Implications and recommendations for future research Since the experience is about China-educated nurses in Australia, the sample in this
study was limited to those nurses who were currently registered and practicing. It did
not include China-educated nurses who had left the nursing profession or who did
not succeed in gaining registration. It would therefore be interesting to explore these
two cohorts of China-educated nurses to determine whether there are significant
differences in experience. In addition, although the participants referred to the
process of seeking nursing registration, this was not the focus of current study. In
future, a study with a focus on the experience of China-educated nurses gaining
registration in Australia would be of value.
The findings of this study also suggested that the husbands of the China-educated
nurses experienced significantly diminished social status and employment prospects
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following immigration. It is assumed that the emotional experience of the husbands
exerted a considerable influence on these nurses. It is suggested that future studies to
be conducted with a focus on the husbands in relation to their experience of
settlement and the changing dynamic of families following immigration.
This study explored the experience of China-educated nurses from an emic
perspective. Further studies might examine the experiences and expectations of local
Australian nurses who work with these nurses. It would also be of interest to explore
the issue of China-educated nurses from the perspective of Australian patients who
are cared for by these nurses.
Longitudinal studies to follow up a cohort of China-educated nurses would be
informative in revealing how the experience changes over time and would better
determine how the process of reconciling unfolds. In addition, the concepts of
reconciling and ambivalence need to be explored further in immigration studies.
Finally, a more in-depth analytical and theoretical focus is desirable in this research
area.
9.4.3 Implications and recommendations for policy consideration The findings of this research also have implications for policy consideration in
Australia. First, participants in the study referred to instances of bullying and
discrimination in the workplace but did not know where to locate assistance and
were concerned over visa implications and retaliation from employees. It is therefore
necessary to review current policy to ensure the rights of immigrant nurses are
protected.
In addition, the findings of the study indicated that China-educated nurses are made
to feel they have to “fit in” in the workplace to be accepted. Thus both this study and
the literature suggest it is necessary to promote an inclusive culture which values
rather than eliminates diversity (Brunero et al., 2008; Wickett & McCutcheon, 2002).
However, as the study findings shows, for difference to be valued some social-
structure change, rather than merely a change of words on paper, is required.
243
In conclusion, the aims of this research have been addressed. First, in-depth
interviews were conducted to explore the experience of China-educated nurses
working in Australia. Second, a modified constructivist GT approach informed by SI
was used to analyse the experience. Theoretical understandings were generated from
the analysis about the study phenomenon. Finally, recommendations on how to
enhance support for these nurses were posed based on the research findings.
244
245
References Abbott, A. D. (1988). The system of professions: An essay on the division of expert
labor. Chicago: University of Chicago Press. Adams, L. D., & Kirova, A. (2007). Introduction: Global migration and the
education of children. In L. D. Adams & A. Kirova (Eds.), Global migration and education: School, children, and families (pp. 1-12). Mahway, N.J.: Lawrence Erlbaum Associates.
Agar, M. (2006). Culture: Can you take it anywhere? International Journal of
Qualitative Methods, 5(2), Retrieved May 4, 2009, from http://www.ualberta.ca/~iiqm/backissues/5_2/pdf/agar.pdf
Aiken, L. H., Buchan, J., Sochalski, J., Nichols, B., & Powell, M. (2004). Trends in
international nurse migration. Health Affairs, 23(3), 69-77. Ainlay, S. C., & Crosby, F. (1986). Stigma, justice, and the dilemma of difference. In
S. C. Ainlay, G. Becker & L. M. Coleman (Eds.), The dilemma of difference: A multidisciplinary view of stigma (pp. 17-37). New York: Plenum.
Alba, R., & Nee, V. (1997). Rethinking assimilation theory for a new era of
immigration. International Migration Review, 31(4), 826-874. Alexis, O., & Chambers, C. (2003). Exploring Alexis’s model: Part one valuing
resources. Nursing Management, 10(4), 29-33. Alexis, O., & Vydelingum, V. (2007). Migrating registered nurses in the UK: Black
and minority ethnic overseas nurses’ perspectives. International Journal of Health Care Quality Assurance, 20(5), 441-452.
Alexis, O., Vydelingum, V., & Robbins, I. (2006). Overseas nurses’ experiences of
equal opportunities in the NHS in England. Journal of Health Organization and Management, 20(2), 130-139.
Alexis, O., Vydelingum, V., & Robbins, I. (2007). Engaging with a new reality:
Experiences of overseas minority ethnic nurses in the NHS. Journal of Clinical Nursing, 16(12), 2221-2228.
Allan, H. T., & Larsen, J. A. (2003). “We need respect”: Experiences of
internationally recruited nurses in the UK, Royal College of Nursing, London, Retrieved August 22, 2009, from http://www.rcn.org.uk/__data/assets/pdf_file/0008/78587/002061.pdf
Allan, H. T., Larsen, J. A., Bryan, K., & Smith, P. A. (2004). The social reproduction
of institutional racism: Internationally recruited nurses’ experiences of the British health services. Diversity in Health and Social Care, 1(2), 117-125.
246
Allen, D. (1997). The nursing-medical boundary: A negotiated order? Sociology of Health & Illness, 19(4), 498-520.
Allen, D. (2001). Narrating nursing jurisdiction: “Atrocity stories” and “boundary-
work”. Symbolic Interaction, 24(1), 75-103. Anders, R. L., & Harrigan, R. (2002). Nursing education in China: Opportunities for
international collaboration. Nursing Education Perspective, 23(3), 139-141. Angen, M. J. (2000). Evaluating interpretive inquiry: Reviewing the validity debate
and opening the dialogue. Qualitative Health Research, 10(3), 378-395. Annells, M. (1996). Grounded theory method: Philosophical perspectives, paradigm
of inquiry, and postmodernism. Qualitative Health Research, 6(3), 379-393. Anson, J. (2004). The migrant mortality advantage: A 70 month follow-up of the
Brussels population. European Journal of Population, 20, 191-218. Anwar, M. (1979). The myth of return: Pakistanis in Britain. London: Heinemann. Arakelian, C. (2003). On speaking terms. Nursing Standard, 17(44), 23. Arango, J. (2000). Explaining migration: A critical view. International Social
Science Journal, 52(165), 283-296. Arango, J. (2004). Theories of international migration. In D. Joly (Ed.),
International migration in the new millennium: Global movement and settlement (pp. 15-35). Aldershot, Hants, England: Ashgate.
Arends-Kuenning, M. (2006). The balance of care: Trends in the wages and
employment of immigrant nurses in the US between 1990 and 2000. Globalizations, 3(3), 333-348.
Arkin, R. M., Appelman, A. J., & Burger, J. M. (1980). Social anxiety, self-
presentation, and the self-serving bias in causal attribution. Journal of Personality and Social Psychology, 38(1), 23-35.
Arminio, J. L., & Hultgren, F. H. (2002). Breaking out from the shadow: The
question of criteria in qualitative research. Journal of College Student Development, 43(4), 446-460.
Auerbach, D. I., Buerhaus, P. I., & Staiger, D. O. (2007). Better late than never:
Workforce supply implications of later entry into nursing. Health Affairs, 26(1), 178-185.
247
Australian Bureau of Statistics. (2007). Migration, Australia 2005-2006. Retrieved April 16, 2007, from http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/E0A79B147EA8E0B5CA2572AC001813E8/$File/34120_2005-06.pdf
Australian Nursing and Midwifery Council. (2006). 14th annual report 2005-2006
ANMC. Retrieved August 22, 2009, from http://www.anmc.org.au/docs/ANMC%20docs/ANMC%20AR05-06web.pdf
Australian Nursing and Midwifery Council. (2007). Position statement: Ethical
recruitment of internationally qualified and registered nurses and midwives. Retrieved August 23 2009, from http://www.anmc.org.au/docs/guidelines_and_position_statements/Ethical%20Recruitment%20of%20Internationally%20Qualified%20and%20Registered%20Nurses%20and%20Midwives.pdf
Australian Nursing Federation. (2005a). Elective surgery cancelled at RHH.
Australian Nursing Journal,13(3), 9. Australian Nursing Federation. (2005b). Overseas nurses increasing. Australian
Nursing Journal,12(10), 5. Australian Nursing Federation. (2006a). Language skills review. Australian Nursing
Journal,14(3), 9. Australian Nursing Federation. (2006b). Tasmanian nurse shortage a reality.
Australian Nursing Journal,14(2), 9. Bach, R. L. (1997). Recrafting the common good: Immigration and community. In D.
Y. Hamamoto & R. D. Torres (Eds.), New American destinies: A reader in contemporary Asian and Latino immigration (pp. 333-346). New York: Routledge.
Bach, S. (2003). International migration of health workers: Labour and social issues.
Geneva: International Labour Office. Bagnoli, A. (2004). Constructing the hybrid identities of Europeans. In G. Titley
(Ed.), Resituating Culture (pp. 57-67). Strasbourg Cedex: Council of Europe. Bagnoli, A. (2007). Between outcast and outsider: Constructing the identity of the
foreigner. European Societies, 9(1), 23-44. Bailey, C., White, C., & Pain, R. (1999). Evaluating qualitative research: Dealing
with the tension between ‘science’ and ‘creativity’. Area, 31(2), 169-178. Baldwin, J. M. (1894). Mental development in the child and the race: Methods and
processes. New York: Macmillan.
248
Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman. Barbour, R. S. (2001). Checklists for improving rigour in qualitative research: A case
of the tail wagging the dog? British Medical Journal, 322(7294), 1115-1117. Barnes, D. M. (1996). An analysis of the grounded theory method and the concept of
culture. Qualitative Health Research, 6(3), 429-441. Baumeister, R. F., & Leary, M. R. (1995). The need to belong: Desire for
interpersonal attachments as a fundamental human motivation. Psychological Bulletin, 117(3), 497-497.
Baxter, C. (1988). The black nurse: An endangered species. Cambridge: National
Extension College for Training in Health and Race. Becker, E. (2005). The self as a locus of linguistic causality. In D. Brissett & C.
Edgley (Eds.), Life as theater: A dramaturgical sourcebook (2nd ed.)(pp. 117-128). New Brunswick, New Jersey: AldineTransaction.
Becker, G., & Arnold, R. (1986). Stigma as a social and cultural construct. In S. C.
Ainlay, G. Becker & L. M. Coleman (Eds.), The dilemma of difference (pp. 39-57). New York: Plenum.
Becker, H. S. (1973). Outsiders: Studies in the sociology of deviance. New York:
Free Press. Benzies, K. M., & Allen, M. N. (2001). Symbolic interactionism as a theoretical
perspective for multiple method research. Journal of Advanced Nursing, 33(4), 541-547.
Berg, B. L. (2009). Qualitative research methods for the social sciences (7th ed.).
Boston: Allyn & Bacon. Berger, P. L., & Luckmann, T. (1967). The social construction of reality: A treatise
in the sociology of knowledge. London: Penguin. Berger, R. (2004). Immigrant women tell their stories. New York: Haworth Press. Berger, R., & Weiss, T. (2002). Immigration and posttraumatic growth: A missing
link. Journal of Immigrant and Refugee Services, 1(2), 21-39. Berry, J. W. (2005). Acculturation: Living successfully in two cultures. International
Journal of Intercultural Relations, 29(6), 697-712. Beynon, L. (2004). Dilemmas of the heart: Rural working women and their hopes
for the future. In A. M. Gaetano & T. Jacka (Eds.), On the move: Women and rural-to-urban migration in contemporary China (pp. 131-174). New York: Columbia University Press.
249
Bhatia, S., & Ram, A. (2001). Rethinking ‘acculturation’ in relation to diasporic
cultures and postcolonial identities. Human Development, 44, 1-18. Bhatia, S., & Ram, A. (2009). Theorizing identity in transnational and diaspora
cultures: A critical approach to acculturation. International Journal of Intercultural Relations, 33, 140-149.
Billig, M. (1995). Banal nationalism. London: Sage. Blackford, J., & Street, A. (2000). Nurses of NESB working in a multicultural
community. Contemporary Nurse, 9(1), 89-98. Blazer, D. G. (2002). Self-efficacy and depression in late life: A primary prevention
proposal. Aging & Mental Health, 6(4), 315-324. Bloomfield, D. (2003). Reconciliation: An Introduction. In D. Bloomfield, T. Barnes
& L. Huyse (Eds.), Reconciliation after violent conflict: A handbook (pp. 10-18). Stockholm: IDEA.
Blumer, H. (1958). The rationale of labor-management relations. Rio Piedras: Labor
Relations Institute, College of Social Sciences, University of Puerto Rico. Blumer, H. (1969). Symbolic interactionism: Perspective and method. Englewood
Cliffs, N.J.: Prentice-Hall. Blumer, H. (1971). Social problems as collective behavior. Social Problems, 18,
298-306. Bola, T. V., Driggers, K., Dunlap, C., & Ebersole, M. (2003). Foreign-educated
nurses: Strangers in a strange land? Nursing Management, 34(7), 39-42. Borjas, G. J. (1989). Economic theory and international migration. International
Migration Review, 23(3), 457-485. Boski, P. (2008). Five meanings of integration in acculturation research.
International Journal of Intercultural Relations, 32(2), 142-153. Boss, P. (1999). Ambiguous loss: Learning to live with unresolved grief. Cambridge,
MA: Harvard University Press. Boss, P. (2006). Loss, trauma, and resilience: Therapeutic work with ambiguous loss
(1st ed.). New York: W.W. Norton. Boswell, C., & Ciobanu, O. (2008). Culture, utility or social systems? Explaining the
cross-national ties of emigrants from Borsa, Romania. Ethnic and Racial Studies, doi:10.1080/01419870802245026
250
Bourdieu, P. (2001). Masculine Domination (R. Nice, Trans.). Cambridge, UK: Polity Press.
Boychuk Duchscher, J. E., & Morgan, D. (2004). Grounded theory: Reflections on
the emergence vs. forcing debate. Journal of Advanced Nursing, 48(6), 605-612.
Bradley, G. W. (1978). Self-serving biases in the attribution process: A reexamination
of the fact or fiction question. Journal of Personality and Social Psychology, 36(1), 56-71.
Brettell, C. B. (2000). Theorizing migration in anthropology: The social construction
of networks, identities, communities, and globalscapes. In C. B. Brettell & J. F. Hollifield (Eds.), Migration theory: Talking across disciplines (pp. 97-135). New York: Routledge.
Brittan, A. (1973). Meanings and situations. London: Routledge & K. Paul. Browne, A. (2005, December 8). Health crisis: Chinese doctors tell patients to pay
upfront, or no treatment. Wall Street Journal, Retrieved August 22, 2009 from http://www.ncpa.org/sub/dpd/index.php?Article_ID=2627
Brunero, S., Smith, J., & Bates, E. (2008). Expectations and experiences of recently
recruited overseas qualified nurses in Australia. Contemporary Nurse, 28(1-2), 101-110.
Brush, B. (1999). Has foreign nurse recruitment impeded African American access
to nursing education and practice? Nursing Outlook, 47, 175-180. Brush, B., Sochalski, J., & Berger, A. (2004). Imported care: Recruiting foreign
nurses to U.S. health care facility. Health Affairs, 23(3), 78-87. Brush, B. L., & Sochalski, J. (2007). International nurse migration: Lessons from the
Philippines. Policy, Politics, & Nursing Practice, 8(1), 37-46. Bryant, A. (2002). Re-grounding grounded theory. Journal of Information
Technology Theory and Application (JITTA), 4(1), 25-42. Bryant, A. (2003). A constructive/ist response to Glaser. Forum: Qualitative Social
Research Journal, 4(1) Art.15, Retrieved August 22, 2009 from http://nbnresolving.de/urn:nbn:de:0114-fqs0301155
Buchan, J. (2001). Nurse migration and international recruitment. Nursing Inquiry,
8(4), 203-204. Buchan, J., & Calman, L. (2004). The global shortage of registered nurses: An
overview of issues and actions. Geneva: International Council of Nurses.
251
Buchan, J., Kingma, M., & Lorenzo, F. M. (2005). International migration of nurses: Trends and policy implications. Geneva: International Council of Nurses.
Buchan, J., & Seccombe, I. (2006). From boom to bust? The UK nursing labour
market review 2005/6. Edinburgh: Royal College of Nursing. Buchan, J., & Sochalski, J. (2004). The migration of nurses: Trends and policies.
Bulletin of the World Health Organization, 82(8), 587-593. Bucknall, T., & Thomas, S. (1997). Nurses’ reflections on problems associated with
decision-making in critical care settings. Journal of Advanced Nursing, 25(2), 229-237.
Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2004). New signs of a
strengthening US nurse labor market? Health Affairs, 23(6), 526-533. Bun, C. K. (2004). Interrogating identity, ethnicity and diaspora: Three case studies
of the ethnic Chinese. In D. Joly (Ed.), International migration in the new millennium: Global movement and settlement (pp. 180-199). Aldershot, Hants, England: Ashgate.
Burns, N., & Grove, S. K. (2001). The practice of nursing research: Conduct,
critique, & utilization (4th ed.). Philadelphia: WB Saunders. Bustamante, J. A. (2002). Immigrants’ vulnerability as subjects of human rights.
International Migration Review, 36(2), 333-354. Castles, S. (2000). Ethnicity and globalization: From migrant worker to
transnational citizen. London: Sage. Castles, S. (2002). Migration and community formation under conditions of
globalization. International Migration Review, 36(140), 1143-1168. Chan, S., & Wong, F. (1999). Development of basic nursing education in China and
Hong Kong. Journal of Advanced Nursing, 29(6), 1300-1307. Chang, H. F. (2000). The economic analysis of immigration law. In C. B. Brettell &
J. F. Hollifield (Eds.), Migration theory: Talking across disciplines (pp. 205-230). New York: Routledge.
Charmaz, K. (1980). The social construction of self-pity in the chronically ill.
Studies in Symbolic Interaction, 3, 123-145. Charmaz, K. (2000). Grounded theory: Objectivist and constructivist methods. In N.
K. Denzin & Y. Lincoln (Eds.), Handbook in Qualitative Research (2nd ed.). (pp. 509-535). London: Sage.
252
Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. London: Sage.
Charmaz, K., & Olesen, V. (2003). Medical institutions. In T. R. Larry & N. J.
Herman-Kinney (Eds.), Handbook of symbolic interactionism (pp. 637-656). Walnut Creek, CA: AltaMira Press.
Charon, J. M. (2007). Symbolic interactionism: An introduction, an interpretation,
an integration (9th ed.). New Jersey: Pearson Prentice-Hall. Chatterjee, M. (2005). Does the UK need to go to China to find nurses? Nursing
Times, 101(15), 10-11. Chayko, M. (2002). Connecting: How we form social bonds and communities in the
Internet age. Albany, NY: State University of New York Press. Chen, Y. (2001). Chinese values, health and nursing. Journal of Advanced Nursing,
36(2), 270-273. Chenowethm, L., Jeon, Y. H., Goff, M., & Burke, C. (2006). Cultural competency
and nursing care: An Australian perspective. International Nursing Review, 53(1), 34-40.
Chinn, P. L., & Jacobs, M. K. (1983). Theory and nursing: A systematic approach. St.
Louis: C.V. Mosby. Chiovitti, R. F., & Piran, N. (2003). Rigour and grounded theory research. Journal of
Advanced Nursing, 44(4), 427-435. Chiswick, B. R. (2000). Are immigrants favorably self-selected? An economic
analysis. In C. B. Brettell & J. F. Hollifield (Eds.), Migration theory: Talking across disciplines (pp. 61-76). New York: Routledge.
Clark, M. E. (2002). In search of human nature. London: Routledge. Clausen, J. A. (1968). Perspectives on childhood socialization. In J. A. Clausen (Ed.),
Socialization and Society (pp. 130-181). Boston: Little Brown. Cluskey, M., Jackson, J. E., Brubaker, C. L., Cram, E. M., & Awl, C. P. (2006).
Summer residential program: A university model for recruiting high school students to nursing. Nursing Education Perspectives, 27(6), 324-326.
Coll, C. G., & Magnuson, K. (2005). The psychological experience of immigration:
A developmental perspective. In M. M. Suárez-Orozco, C. Suárez-Orozco & D. Qin-Hilliard (Eds.), The new immigration: An interdisciplinary reader (pp. 105-133). New York: Routledge.
253
Collins, E. M. (2004). Career mobility among immigrant registered nurses in Canada: Experiences of Caribbean women. Unpublished doctoral dissertation, University of Toronto, Canada.
Colomy, P., & Brown, J. D. (1995). Elaboration, revision, polemic, and progress in
the second Chicago school. In G. A. Fine (Ed.), A second Chicago school? The development of a postwar American sociology (pp. 17-81). Chicago: University of Chicago Press.
Connidis, I. A., & McMullin, J. A. (2002). Sociological ambivalence and family ties:
A critical perspective. Journal of Marriage and the Family, 64(3), 558-567. Cooley, C. H. (1927). Life and the student: Roadside notes on human nature, society,
and letters. New York: Knopf. Cooley, C. H. (1983). Human nature and the social order. New Brunswick, NJ:
Transaction. Corbin, J. M. (1998). Alternative interpretations: Valid or not? Theory & Psychology,
8(1), 121-128. Corlett, J. (2000). The perceptions of nurse teachers, student nurses and preceptors
of the theory-practice gap in nurse education. Nurse Education Today, 20(6), 499-505.
Costoiu, A. (2008). Modes of minorities’ integration: Explaining historical,
economic and political factors. Journal of Identity and Migration Studies, 2(2), 2-17.
Coté, J. E. (1996). Sociological perspectives on identity formation: The culture-
identity link and identity capital. Journal of Adolescence, 19(5), 417-428. Cowin, L., & Jacobsson, D. (2003). The nursing shortage: Part way down the
slippery slope. Collegian, 10(3), 31-35. Cox, D. R. (1987). Migration and welfare: An Australian perspective. Sydney:
Prentice Hall. Craib, I. (1998). Experiencing identity. London: Sage. Creese, G., & Kambere, E. N. (2003). “What colour is your English?”. The Canadian
Review of Sociology and Anthropology, 40(5), 565-574. Crocker, J., Luhtanen, R., Blaine, B., & Broadnax, S. (1994). Collective self-esteem
and psychological well-being among White, Black, and Asian college students. Personality and Social Psychology Bulletin, 20(5), 503-513.
254
Cutcliffe, J. R., & McKenna, H. P. (2004). Expert qualitative researchers and the use of audit trails. Journal of Advanced Nursing, 45(2), 126-135.
Daniel, P., Chamberlain, A., & Gordon, F. (2001). Expectations and experiences of
newly recruited Filipino nurses. British Journal of Nursing, 10(4), 254-265. Davis, C. R. (2004). Crossing borders: International nurses in the U.S. workforce.
Imprint, 51(2), 49-51. Davis, C. R., & Nichols, B. L. (2002). Foreign-educated nurses and the changing
U.S. nursing workforce. Nursing Administration Quarterly, 26(2), 43-51. Davitz, L., Davitz, J., & Sameshima, Y. (1976). Foreign and American nurses:
Reactions and interactions. Nursing Outlook, 24(4), 237-242. de Veer, A., den Ouden, D.-J., & Francke, A. (2004). Experiences of foreign
European nurses in the Netherlands. Health Policy, 68(1), 55-61. Dennis, A., & Martin, P. J. (2005). Symbolic interactionism and the concept of
power. The British Journal of Sociology, 56(2), 191-213. Denzin, N. K. (1969). Symbolic interactionism and ethnomethodology: A proposed
synthesis. American Sociological Review, 34(6), 922-934. Denzin, N. K. (1977). Notes on the criminogenic hypothesis: A case study of the
American liquor industry. American Sociological Review, 42(6), 905-920. Denzin, N. K. (1992). Symbolic interactionism and cultural studies: The politics of
interpretation. Oxford, UK: Blackwell. Department of Human Services Victorian Government. (2004). Nurses in Victoria: A
supply and demand analysis 2003–04 to 2011–12. Retrieved March 19, 2007 from http://www.health.vic.gov.au/workforce/downloads/nurses_in_victoria_report.pdf
Department of Immigration and Multicultural and Indigenous Affairs. (2005).
Australian Skills Recognition Information (ASRI). Nurse - Registered Nurse 2323-11 Retrieved March 19, 2007 from http://www.immi.gov.au/asri/occupations/n/nurse-registered-nurse-2323-11.htm
Devers, E. (1994). Experiencing the deceased: Reconciling the extraordinary.
Unpublished doctoral dissertation, University of Florida. Dewey, J. (1896). The reflex arc concept in psychology. Chicago: University of
Chicago Press.
255
Dewey, J. (1957). Human nature and conduct: An introduction to social psychology. New York: The Modern Library.
Dey, I. (1993). Qualitative data analysis: A user-friendly guide for social scientists.
London: Routledge. DiCicco-Bloom, B. (2004). The racial and gendered experiences of immigrant
nurses from Kerala, India. Journal of Transcultural Nursing,15(1), 26-33. Dombeck, M.-T. (2003). Work narratives: Gender and race in professional
personhood. Research in Nursing & Health, 26, 351-365. Doult, B. (2005). Exploited foreign nurses end up washing dishes. Nursing Standard,
19(23), 9. Du Bois, W. E. B. (1903). The souls of black folk. Chicago: McClung & Co. Dubois, H. F. W., Padovano, G., & Stew, G. (2006). Improving international nurse
training: An American-Italian case study. International Nursing Review, 53(2), 110-116.
Duchscher, J. E. B., & Morgan, D. (2004). Grounded theory: Reflections on the
emergence vs. forcing debate. Journal of Advanced Nursing, 48(6), 605-612. Duck, S. (2007). Human relationships (4th ed.). Los Angeles: Sage. Ea, E. E. (2007). Facilitating acculturation of foreign-educated nurses. Online
Journal of Issues in Nursing,13(1) Retrieved June 16, 2009 from www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/ForeignEducatedNurses.aspx
Eastwood, J., Conroy, R., Naicker, S., West, P., Tutt, R., & Giovannetti, P. (2005).
Loss of health professionals from sub-Saharan Africa: The pivotal role of the UK. The Lancet, 365(9474), 1893-1900.
Edgley, C. (2003). The dramaturgical genre. In L. T. Reynolds & N. J. Herman-
Kinney (Eds.), Handbook of symbolic interactionism (pp. 141-172). Walnut Creek, CA: AltaMira Press.
Egan, G. (1998). The skilled helper: A problem-management approach to helping
(6th ed.). Pacific Grove, CA: Brooks/Cole. Eliasmith, C. (2004). Dictionary of philosophy of mind. Retrieved May 5, 2009 from
http://philosophy.uwaterloo.ca/MindDict/tacitknowledge.html
256
Espanshade, T., & Belanger, M. (1998). Immigration and public opinion. In M. Suarez-Orozco (Ed.), Crossing: Mexican immigration in interdisciplinary perspectives (pp. 365-403). Cambridge, MA: Harvard University Press.
Esses, V. M., Dovidio, J. F., Jackson, L. M., & Armstrong, T. L. (2001). The
immigration dilemma: The role of perceived group competition, ethnic prejudice, and national identity. Journal of Social Issues, 57(3), 389-412.
Falicov, C. J. (2005). Ambiguous loss: Risk and resilience in Latino immigrant
families. In M. M. Suárez-Orozco, C. Suárez-Orozco & D. B. Qin (Eds.), The new immigration: An interdisciplinary reader (pp. 197-206). New York: Routledge.
Fang, Z. Z. (2007). Potential of China in global nurse migration. Health Services
Research, 42(3), 1419-1428. Favell, A. (2003). Integration nations: The nation-state and research on immigrants
in Western Europe. Comparative Social Research, 22, 13-42. Fawcett, J. T. (1989). Networks, linkages, and migration systems. International
Migration Review, 23(3), 671-680. Feldman, D. B., & Snyder, C. R. (2005). Hope and the meaningful life: Theoretical
and empirical associations between goal-directed thinking and life meaning. Journal of Social and Clinical Psychology, 24(3), 401-421.
Festinger, L. (1957). A theory of cognitive dissonance. Stanford, Calif: Stanford
University Press. Fine, G. A. (1993). The sad demise, mysterious disappearance, and glorious triumph
of symbolic interactionism. Annual Review of Sociology, 19, 61-87. Fine, G. A. (2003). Occupational aesthetics: How trade school students learn to cook.
In D. A. Harper & H. M. Lawson (Eds.), The cultural study of work (pp. 75-95). Oxford: Rowman & Littlefield.
Fiscella, K., Botelho, R., Roman-Diaz, M., Lue, B. H., & Frankel, R. (1997). ‘Being
a foreigner, I may be punished if I make a small mistake’: Assessing transcultural experiences in caring for patients. Family Practice, 14(2), 112-116.
Foner, N., & Alba, R. (2008). Immigrant religion in the U.S. and Western Europe:
Bridge or barrier to inclusion? The International Migration Review, 42(2), 360-392.
257
Fox, J. E. (1999). Identity formation in migration: The case of Transylvanian Hungarian guest workers. Paper presented at the Conference on Diasporas and Ethnic Migrants in 20th Century Europe, Humboldt University, Berlin, Germany, May 1999, Retrieved May 3, 2009 from http://www.hks.harvard.edu/kokkalis/GSW1/GSW1/05%20Fox.pdf
Fox, R. (2001). Constructivism examined. Oxford Review of Education, 27(1), 23-35. Franks, D. D. (2003). Emotions. In T. R. Larry & N. J. Herman-Kinney (Eds.),
Handbook of symbolic interactionism (pp. 787-809). Walnut Creek, CA: AltaMira Press.
French, H. W. (2006, January 14). Wealth grows, but health care withers in China
The New York Times, p. A1. Retrieved May 8, 2009 from http://www.nytimes.com/2006/01/14/international/asia/14health.html
Friedman, E. A. (2004). An action plan to prevent brain drain: Building equitable
health systems in Africa. Boston, MA: Physicians for Human Rights. Gadamer, H.-G. (1994). Truth and method (2nd rev. ed.). New York: Continuum. Gale, P. (2001). Representations of reconciliation: Bridges, symbols and substances.
In M. Kalantzis & B. Cope (Eds.), Reconciliation, multiculturalism, identities: Difficult dialogues, sensible solutions (pp. 123-133). Altona, Vic: Common Ground.
Gans, H. J. (2007). Acculturation, assimilation and mobility. Ethnic and Racial
Studies, 30(1), 152-164. Gao, M. C. F., & Liu, X. (1998). From student to citizen: A survey of students from
the People’s Republic of China (PRC) in Australia. International Migration 36 (1), 27-48.
Gardner, K. (2001). Desh-Bidesh: Sylheti images of home and away. In H.
Goulbourne (Ed.), Race and ethnicity: Critical concepts in sociology (pp. 361-378). London: Routledge.
Gasson, S. (2003). Rigor in grounded theory research: An interpretive perspective on
generating theory from qualitative field studies. In M. E. Whitman & A. B. Woszczynski. (Eds.), The handbook of information systems research (pp. 79-102). Hershey, PA: Idea Group.
George, S. M. (2005). When women come first: Gender and class in transnational
migration. Berkeley and Los Angeles, CA: University of California Press. Gerrish, K., & Griffith, V. (2004). Integration of overseas Registered Nurses:
Evaluation of an adaptation programme. Journal of Advanced Nursing, 45(6), 579-587.
258
Gilbert, D. (2005). Interrogating mixed-race: A crisis of ambiguity? Social Identities,
11(1), 55-74. Gladden, J. C. (1998). Reconciling differing realities: Decision-making of rural
older adults during subacute care transitions. Unpublished doctoral dissertation, University of Colorado.
Glaser, B. G. (1978). Theoretical sensitivity: Advances in the methodology of
grounded theory. Mill Valley, CA: Sociology Press. Glaser, B. G. (1992). Emergence vs forcing: Basics of grounded theory analysis. Mill
Valley, CA: Sociology Press. Glaser, B. G. (1998). Doing grounded theory: Issues and discussions. Mill Valley,
CA: Sociology Press. Glaser, B. G. (1999). Keynote address from the fourth annual Qualitative Health
Research Conference: The future of grounded theory. Qualitative Health Research, 9(6), 836-845.
Glaser, B. G. (2001). The grounded theory perspective: Conceptualization contrasted
with description. Mill Valley, CA: Sociology Press. Glaser, B. G., & Kaplan, W. D. (1996). Gerund grounded theory: The basic social
process dissertation. Mill Valley, CA: Sociology Press. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies
for qualitative research. Mill Valley, CA: Sociology Press. Goffman, E. (1955). On face-work: An analysis of ritual elements in social
interaction. Journal of Interpersonal Relations, 18(3), 213-231. Goffman, E. (1959). The presentation of self in everyday life. Carden city, New York:
Anchor Books. Goffman, E. (1961). Encounters: Two studies in the sociology of interaction.
Indianapolis: Bobbs-Merrill. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity.
Englewood Cliffs, New Jersey: Prentice-Hall. Goffman, E. (1971). The territories of the self. In E. Goffman (Ed.), Relations in
public: Microstudies of the public order (pp. 28-41). Penguin: Harmondsworth.
Goffman, E. (1983). The interaction order: American Sociological Association, 1982
Presidential Address. American Sociological Review, 48(1), 1-17.
259
Goffman, E., Lemert, C., & Branaman, A. (1997). The Goffman reader. Malden,
Mass: Blackwell. Gonda, J., Hussein, V., Gatson, J., & Blackman, I. (1995). Migrant nurses: Their
unique value. In R. Pratt & G. Gray (Eds.), Issues in Australian Nursing (Vol. 5). Melbourne: Churchill Livingstone.
Goodin, H. J. (2003). The nursing shortage in the United States of America: An
integrative review of the literature. Journal of Advanced Nursing, 43(4), 335-350.
Govier, T., & Verwoerd, W. (2002). Trust and the problem of national reconciliation.
Philosophy of the Social Sciences, 32(2), 178-205. Grossman, J. B. (1982). The substitutability of natives and immigrants in production.
The Review of Economics and Statistics, 64(4), 596-603. Grzywacz, J. G., Quandt, S. A., Early, J., Tapia, J., Graham, C. N., & Arcury, T. A.
(2006). Leaving family for work: Ambivalence and mental health among Mexican migrant farmworker men. Journal of Immigrant and Minority Health, 8(1), 85-97.
Guba, E. G., & Lincoln, Y. S. (1989). Fourth generation evaluation. Newbury Park,
CA: Sage. Gurevitch, Z. D. (1988). The other side of dialogue: On making the other strange
and the experience of otherness. The American Journal of Sociology, 93(5), 1179-1199.
Gusfield, J. R. (2003). A Journey with symbolic interaction. Symbolic Interaction,
26(1), 119-139. Hage, G. (1998). White nation: Fantasies of white supremacy in a multicultural
society. Annandale, Sydney: Pluto Press. Hagey, R., Choudhry, U., Guruge, S., Turrittin, J., Collins, E., & Lee, R. (2001).
Immigrant nurses’ experience of racism. Journal of Nursing Scholarship, 33(4), 389-394.
Haley, R., Zhao, M., Nolin, J. M., Dunning, K., & Qiang, S. (2008). Five myths of
the Chinese health care system. The Health Care Manager, 27(2), 147-158. Hall, P. M. (1972). A symbolic interactionist analysis of politics. Sociological
Inquiry, 42(3-4), 35-75. Hall, P. M. (1987). Interactionism and the study of social organization. Sociological
Quarterly, 28(1), 1-22.
260
Hall, S. (1996). Introduction: Who needs ‘identity’? In S. Hall & P. D. Gay (Eds.),
Questions of cultural identity (pp. 1-17). London: Sage. Hall, W. A., & Callery, P. (2001). Enhancing the rigor of grounded theory:
Incorporating reflexivity and relationality. Qualitative Health Research, 11(2), 257-272.
Hamber, B., & Kelly, G. (2005). A place for reconciliation? Conflict and locality in
Northern Ireland. Belfast: Democratic Dialogue. Haney Lopez, I. F. (1996). White by law: The legal construction of race. New York:
New York University Press. Hardill, I., & MacDonald, S. (2000). Skilled international migration: The experience
of nurses in the UK. Regional Studies, 34(7), 681-692. Harrison, S. (2004). Asian staff hoodwinked by rogue recruitment agencies. Nursing
Standard, 19(8), 4. Harvey, D. (1989). The condition of postmodernity: An enquiry into the origins of
cultural change. Oxford: Blackwell. Hassmiller, S. B., & Cozine, M. (2006). Addressing the nurse shortage to improve
the quality of patient care. Health Affairs, 25(1), 268-274. Hatton, T. J., & Williamson, J. G. (2002). What fundamentals drive world migration?
Cambridge, MA: National Bureau of Economic Research. Retrieved September 10, 2007 from http://www.nber.org/papers/w9159
Hawthorne, L. (2001). The globalisation of the nursing workforce: Barriers
confronting overseas qualified nurses in Australia. Nursing Inquiry, 8(4), 213-229.
Hawthorne, L. (2002). Qualifications recognition reform for skilled migrants in
Australia: Applying competency-based assessment to overseas-qualified nurses. International Migration, 40(6), 55-91.
Hawthorne, L. (2005). Picking winners: The recent transformation of Australia’s
skilled migration policy. International Migration Review, 39(3), 663-696. Hay, D. (2000). Spirituality versus individualism: Why we should nurture relational
consciousness International Journal of Children’s Spirituality, 5(1), 37-48. Heath, P. (2002). National review of nursing education 2002: Our duty of care.
Retrieved March 20, 2007, from http://www.dest.gov.au/archive/highered/nursing/pubs/duty_of_care/duty_of_care.pdf
261
Heath, H., & Cowley, S. (2004). Developing a grounded theory approach: A
comparison of Glaser and Strauss. International Journal of Nursing Studies, 41(2), 141-150.
Heine, S. J. (2001). Self as cultural product: An examination of East Asian and North
American selves. Journal of Personality, 69(6), 881-906. Henry, L. (2007). Institutionalized disadvantage: Older Ghanaian nurses’ and
midwives’ reflections on career progression and stagnation in the NHS. Journal of Clinical Nursing, 16(12), 2196-2203.
Herman-Kinney, N. J. (2003). Deviance. In T. R. Larry & N. J. Herman-Kinney
(Eds.), Handbook of symbolic interactionism (pp. 695-720). Walnut Creek,CA: AltaMira Press.
Hermans, H. J. M. (2001). The dialogical self: Toward a theory of personal and
cultural positioning. Culture Psychology, 7(3), 243-281. Hermans, H. J. M., & Kempen, H. J. G. (1998). Moving cultures: The perilous
problems of cultural dichotomies in a globalizing society. American Psychologist, 53(10), 1111-1120.
Hernandez, M., & McGoldrick, M. (2005). Migration and the family life cycle In B.
Carter & M. McGoldrick (Eds.), The expanded family life cycle: Individual, family, and social perspectives (3rd ed.) (pp. 169-184). New York: Pearson Allyn & Bacon.
Hewison, A. (1995). Nurses’ power in interactions with patients. Journal of
Advanced Nursing, 21(1), 75-82. Hewitt, J. P. (2007). Self and society: A symbolic interactionist social psychology
(10th ed.). Boston: Allyn & Bacon. Ho, C. (2004). Migration as feminisation: Chinese women’s experiences of work and
family in contemporary Australia. Unpublished doctoral dissertation, University of Sydney, Australia.
Ho, C. (2006). Migration as feminisation? Chinese women’s experiences of work
and family in Australia. Journal of Ethnic and Migration Studies, 32(3), 497-514.
Ho, D. Y.-f. (1976). On the concept of face. The American Journal of Sociology,
81(4), 867-884. Hochschild, A. R. (1979). Emotion work, feeling rules, and social structure. The
American Journal of Sociology, 85(3), 551-575.
262
Holmes, M. (2009). Gender and everyday life. London: Routledge. Hong, Y., Morris, M. W., Chiu, C., & Benet-Martinez, V. (2004). Multicultural
minds: A dynamic constructivist approach to culture and cognition. American Psychologist, 55(7), 709-720.
HRSA. (2006). What is behind HRSA’s projected supply, demand, and shortage of
registered nurses? Retrieved February 28, 2007 from http://bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/index.htm
Hu, H. C. (1944). The Chinese concepts of “face”. American Anthropologist, 46(1),
45-64. Hua, S., Jie, G., & Gang, C. (2005). Can foreign diplomas be exchanged for
“Chinese opportunities”? Chinese Education and Society, 38(3), 81-86. Hubert, J. M. H. (2001). Mixing and moving cultures require a dialogical self.
Human Development, 44(1), 24-28. Hughes, E. C. (1971). The sociological eye: Selected papers. Chicago: Aldine
Atherton. Hulbert, J. (2005, November 28). Nursing shortage heads for crisis. Taranaki Daily
News, p. 3, Retrieved August 22, 2009 from http://gateway.library.qut.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=anh&AN=TNL0511280031-NURSEDR-ED&site=ehost-live
Hunt, B. (2007). Managing equality and cultural diversity in the health workforce.
Journal of Clinical Nursing, 16(12), 2252-2259. Hurley, M. (1994). Reconciliation in religion and society. Belfast: Institute of Irish
Studies, Queen’s University Belfast. Hwang, L. (2005). Foreign outsourcing at home: Dameron hospital exploits migrant
RNs. California Nurse, 101(3), 4. International Council of Nurses. (2001). ICN position statement on ethical nurse
recruitment (2001). Retrieved April 24, 2007 from http://www.icn.ch/psrecruit01.htm
International Council of Nurses. (2003). Global issues in the supply and demand of
nurses. SEW News January-March. Retrieved July 17, 2006 from http://www.icn.ch/sewjan-march03.htm
Iredale, R. (2001). The migration of professionals: Theories and typologies.
International Migration, 39(5), 7-26.
263
Jackson, D. (1995). Constructing nursing practice: Country of origin, culture and competency. International Journal of Nursing Practice, 1, 32-36.
Jackson, D. (1996). The multicultural workplace: Comfort, safety and migrant
nurses. Contemporary Nurse, 5(3), 120-126. James, W. (1890). The principles of psychology. Chicago: H. Holt. Jeon, Y. H., & Chenoweth, L. (2007). Working with a culturally and linguistically
diverse (CALD) group of nurses. Collegian, 14(1), 16-22. Jiang, Y., Shen, N., & Yan, R. (2004). Analysis and advice of nursing human
resources in China. Journal of Nursing Administration, 4(2), 19-21. Jose, M. M. (2008). A phenomenological study of the lived experiences of foreign
educated nurses working in the United States of America. Unpublished doctoral dissertation, University of Texas Medical Branch.
Josselson, R. (1996). The space between us: Exploring the dimensions of human
relationships. Thousand Oaks, CA: Sage. Karmel, T., & Li, J. (2002). The nursing workforce-2010. Retrieved August 15, 2009
from http://www.voced.edu.au/docs/dest/TD_TNC_71_719.pdf Katovich, M. A., Miller, D. E., & Stewart, R. L. (2003). The Iowa school. In L. T.
Reynolds & N. J. Herman-Kinney (Eds.), Handbook of symbolic interactionism (pp. 119-139). Walnut Creek, CA: AltaMira Press.
Katz, S. H. (2002). Healing the father-son relationship: A qualitative inquiry into
adult reconciliation. Journal of Humanistic Psychology, 42(3), 13-52. Kawi, J., & Xu, Y. (2009). Facilitators and barriers to adjustment of international
nurses: An integrative review. International Nursing Review, 56(2), 174-183. Kemper, T. D. (1978). A social interactional theory of emotions. New York: John
Wiley & Sons. Kendall, J. (1999). Axial coding and the grounded theory controversy. Western
Journal of Nursing Research, 21(6), 743-757. Kim, J. Y., & Nam, S. H. (1998). The concept and dynamics of face: Implications for
organizational behavior in Asia. Organization Science, 9(4), 522-534. Kim, Y. Y. (2001). Becoming intercultural: An integrative theory of communication
and cross-cultural adaptation. Thousand Oaks, CA: Sage.
264
King, R. (1995). Migration, globalization and place. In D. Massey & P. Jess (Eds.), A place in the world? Places, culture and globalisation (pp. 5-44). Oxford: Oxford University Press.
Kingma, M. (2001). Nursing migration: Global treasure hunt or disaster-in-the-
making? Nursing Inquiry, 8(4), 205-212. Kirkham, R. L. (1995). Theories of truth: A critical introduction. Cambridge, MA:
Massachusettes Institute of Technology Press. Kirova, A. (2006). Moving childhoods: Young children’s lived experiences of being
between languages and cultures. In L. D. Adams & A. Kirova (Eds.), Global migration and education: Schools, children, and families (pp. 185-202). Mahway, New Jersey: Lawrence Erlbaum Associates.
Kline, D. S. (2003). Push and pull factors in international nurse migration. Journal
of Nursing Scholarship, 35(2), 107-111. Koch, T., & Harrington, A. (1998). Reconceptualizing rigour: The case for
reflexivity. Journal of Advanced Nursing, 28(4), 882-890. Konno, R. (2006). Support for overseas qualified nurses in adjusting to Australian
nursing practice: A systematic review. International Journal of Evidence-based Health, 4, 83-100.
Krinsky, L. (2002). Finding our way: Immigrant nurses in Toronto. Unpublished
master’s thesis, York University, Canada. Kumashiro, K. K. (1999). Supplementing normalcy and otherness: Queer Asian
American men reflect on stereotypes, identity, and oppression. Qualitative Studies in Education, 12(5), 491-508.
Kvale, S. (1996). Interviews: An introduction to qualitative research interviewing.
Thousand Oaks, CA: Sage. Kwan, K. M., & Tsang, E. W. K. (2001). Realism and constructivism in strategy
research: A critical realist response to Mir and Watson. Strategic Management Journal, 22(12), 1163-1168.
LaFromboise, T., Coleman, H. L. K., & Gerton, J. (1998). Psychological impact of
biculturalism: Evidence and theory. In P. B. Organista, K. M. Chun & G. Marin (Eds.), Readings in ethnic psychology (pp. 123-155). New York: Routledge.
Lague, D. (2005, August 20). Health care falls short, Chinese tell leaders.
International Herald Tribune [serial online]. Retrieved May 8, 2009 from http://en.ccer.edu.cn/ReadNews.asp?NewsID=5112
265
Lamertz, K., Martens, M. L., & Heugens, P. P. (2003). Issue evolution: A symbolic interactionist perspective. Corporate Reputation Review, 6(1), 82-93.
Lamont, M., & Moln´ar, V. (2002). The study of boundaries in the social sciences.
Annual Review of Sociology, 28, 167-195. Laponce, J. A. (1987). Languages and their Territories. Toronto: Buffalo University
of Toronto Press. Larsen, J. A. (2007). Embodiment of discrimination and overseas nurses’ career
progression. Journal of Clinical Nursing, 16(12), 2187-2195. Larsen, J. A., Allan, H. T., Bryan, K., & Smith, P. (2005). Overseas nurses’
motivations for working in the UK: Globalization and life politics. Work, Employment and Society, 19(2), 349-368.
Lawson, A. (2005, September 4,). Nurses from overseas to fill shortage. Sun-Herald,
p. 42. Retrieved August 15, 2009 from http://www.smh.com.au/news/national/nurses-from-overseas-to-fill-shortage/2005/09/03/1125302782137.html
Lawson, V. A. (2000). Arguments within geographies of movement: The theoretical
potential of migrants’ stories. Progress in Human Geography, 24(2), 173-189. Leary, M. R., & Kowalski, R. M. (1990). Impression management: A literature
review and two-component model. Psychological Bulletin, 107(1), 34-47. Lebra, T. S. (1987). The cultural significance of silence in Japanese communication.
Multilingua, 6(4), 343-357. Lee, D. (2001). ‘Accompany the sick’ (pei ban): A unique practice in Chinese
hospitals by patients’ relatives and friends. Contemporary Nurse, 10, 136-141.
Lee, E. S. (1966). A theory of migration. Demography, 3(1), 47-57. Lee, W. (1994). Communication about humor as procedural competence in
intercultural encounters. In L. A. Samovar & R. E. Porter (Eds.), Intercultural communication: A reader (7th ed.)(pp. 373-382). Belmont, CA: Wadsworth.
Lewis, W. A. (1954). Economic development with unlimited supply of labour. The
Manchester School of Economic and Social Studies, 22(2), 139-191. Li, D. C. S. (1997). Borrowed identity: Signaling involvement with a Western name.
Journal of Pragmatics, 28, 489-513.
266
Li, N. (1998a). Going abroad to study is hard, and so is coming back after completing one’s studies. Chinese Education and Society, 31(2), 86-92.
Li, N. (1998b). Why it is hard for the “going-abroad fever” to cool down. Chinese
Education and Society, 31(2), 80-85. Li, X. (2004). A study by the Chinese academy of sciences on the benefits of study
abroad. Chinese Education and Society, 37(2), 61-87. Li, Z. (2004). Foreign study frenzy. Beijing Review, 47(35), 16-20. Lichtman, R. (1970). Symbolic interactionism and social reality: Some Marxist
queries. Berkeley Journal of Sociology, 15, 75-94. Likupe, G. (2006). Experiences of African nurses in the UK National Health Service:
A literature review. Journal of Clinical Nursing, 15(10), 1213-1220. Lim, F. A. (2001). Diagnosis: Benign paroxysmal homesickness: Reflections of a
former registered alien nurse. American Journal of Nursing,101(10), 43. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage. Llana, S. M. (2006). Global stopgap for US nurse deficit. Christian Science Monitor,
98(68), 2-4. Locke, K. (1996). Rewriting the discovery of grounded theory after 25 years?
Journal of Management Inquiry, 5(3), 239-245. Lomborg, K., & Kirkevold, M. (2003). Truth and validity in grounded theory - a
reconsidered realist interpretation of the criteria: Fit, work, relevance and modifiability. Nursing Philosophy, 4(3), 189-200.
Lopez, N. (1990). The acculturation of selected Filipino nurses to nursing practice
in the United States. Unpublished doctoral dissertation, University of Pennsylvania.
Lowe, L. (1996). Immigrant acts: On Asian-American cultural politics. Durham, NC:
Duke University Press. Lowell, B. L., & Martin, S. (2005). Research on migration and development.
Retrieved September 5, 2007 from http://www.un.org/esa/population/meetings/fourthcoord2005/P15_Lowell&Martin.pdf
Luescher, K., & Pillemer, K. (1998). Intergenerational ambivalence: A new approach
to the study of parent-child relations in later life. Journal of Marriage and the Family, 60(2), 413-425.
267
Lüscher, K. (2002). Intergenerational ambivalence: Further steps in theory and research. Journal of Marriage and the Family, 64(3), 585-593.
Ma, X. (2005). Speech at 2005 National Working Meeting on Nursing. Chinese
Journal of Nursing, 40 (11), 801-808. MacDonald, M. A., & Green, L. W. (2001). Reconciling concept and context: The
dilemma of implementation in school-based health promotion. Health Education & Behavior, 28(6), 749-768.
MacInnes, J. (2006). Castells’ Catalan routes: Nationalism and the sociology of
identity. British Journal of Sociology, 57(4), 677-698. McNeil-Walsh, C. (2004). Widening the discourse: A case for the use of post-
colonial theory in the analysis of South African nurse migration to Britain. Feminist Review, 77,120-124.
Maggs-Rapport, F. (2001). “Best research practice”: In pursuit of methodological
rigour. Journal of Advanced Nursing, 35(3), 373-383. Magnusdottir, H. (2005). Overcoming strangeness and communication barriers: A
phenomenological study of becoming a foreign nurse. International Nursing Review, 52(4), 263-269.
Maines, D. R. (1977). Social organization and social structure in symbolic
interactionist thought. Annual Review of Sociology, 3, 235-259. Maines, D. R. (1978). Bodies and selves: Notes on a fundamental dilemma in
demography. Studies in Symbolic Interaction, 1, 241-265. Manias, E., & Street, A. (2001). The interplay of knowledge and decision making
between nurses and doctors in critical care. International Journal of Nursing Studies, 38(2), 129-140.
Manion, J. (2004). Nurture a culture of retention. Nursing Management, 35(4), 29-
39. Mann, S. (2000). Work and household in Chinese culture: Historial perspectives. In
B. Entwisle & G. E. Henderson (Eds.), Re-drawing boundaries: Work, household, and gender in China (pp. 15-32). Berkeley, CA: University of California Press.
Manning, P. (1992). Erving Goffman and modern sociology. Cambridge, UK: Polity
Press. Marcelo, M. S.-O. (2000). Everything you ever wanted to know about assimilation
but were afraid to ask. Daedalus, 129(4), 1-29.
268
Marchal, B., & Kegels, G. (2003). Health workforce imbalances in times of globalization: Brain drain or professional mobility? International Journal of Health Planning and Management, 18, s89-s101.
Marotta, V. P. (2008). The hybrid self and the ambivalence of boundaries. Social
Identities, 14(3), 295-312. Marsella, A. J. (2005). Culture and conflict: Understanding, negotiating, and
reconciling conflicting constructions of reality. International Journal of Intercultural Relations, 29(6), 651-673.
Marshall, C., & Rossman, G. B. (1995). Designing qualitative research (2nd ed.).
Thousand Oaks, Calif: Sage. Martin, S. (2005). Migration, development, and population: Prepared for the David
and Lucile Packard Foundation Population Program Review Task Force, August 2005. Retrieved September 4, 2007, from http://www.packard.org/assets/files/population/program%20review/pop_rev_martin.pdf
Massey, D. (1995). The conceptualization of place. In D. Massey & P. Jess (Eds.), A
place in the world? Places, cultures and globalization (pp. 45-85). Oxford: Oxford University Press.
Massey, D. S., Arango, J., Hugo, G., Kouaouci, A., Pellegrino, A., & Taylor, J. E.
(1993). Theories of international migration: A review and appraisal. Population and Development Review, 19(3), 431-466.
May, C., & Fleming, C. (1997). The professional imagination: Narrative and the
symbolic boundaries between medicine and nursing. Journal of Advanced Nursing, 25(5), 1094-1100.
Maynard, D. W., & Clayman, S. E. (2003). Ethnomethodology and conversation
analysis. In L. T. Reynolds & N. J. Herman-Kinney (Eds.), Handbook of symbolic interactionism (pp. 173-202). Walnut Creek, CA: AltaMira Press.
Mays, N., & Pope, C. (2000). Assessing quality in qualitative research. British
Medical Journal, 320, 50-52. McCallin, A. (2003). Grappling with the literature in a grounded theory study.
Contemporary Nurse, 15(1-2), 61-69. McCloskey, J. C., & Aquino, N. S. (1988). Job effectiveness of foreign nurse
graduates. Western Journal of Nursing Research, 10(4), 477-491. Mcelmurry, B. J., Solheim, K., Kishi, R., Coffia, M. A., Woith, W., & Janepanish, P.
(2006). Ethical concerns in nurse migration. Journal of Professional Nursing, 22(4), 226-235.
269
McIntosh, B., Val Palumbo, M., & Rambur, B. (2006). Does a ‘shadow workforce’
of inactive nurses exist? Nursing Economic$, 24(5), 231-237. Mead, G. H. (1913). The social self. Journal of Philosophy, Psychology and
Scientific Methods, 10(1913), 374- 380. Mead, G. H. (1938). The philosophy of the act (CW Morris, Ed.). Chicago:
University of Chicago Press. Mead, G. H. (1936). Movements of thought in the nineteenth century (MH Moore,
Ed.). Chicago: University of Chicago press. Mead, G. H. (1934). Mind, self, and society: From the standpoint of a social
behaviourist (CW Morris Ed.). Chicago: University of Chicago Press. Mead, G. H. (1980). The philosophy of the present (AE Murphy Ed.). Chicago:
University of Chicago Press. Mead, G. H., & Strauss, A. (1964). On social psychology: Selected papers. Chicago:
University of Chicago Press. Mejia, A., Pizurki, H., & Royston, E. (1979). Physician and nurse migration:
Analysis and policy implications. Geneva, Switzerland: World Health Organization.
Melia, K. M. (1996). Rediscovering Glaser. Qualitative Health Research, 6(3), 368-
378. Meltzer, B. N. (1959). The social psychology of George Herbert Mead. Kalamazoo:
Center for Sociological Research, Western Michigan University. Meltzer, B. N. (1972). Mead’s social psychology. In J. G. Manis & B. N. Meltzer
(Eds.), Symbolic interaction: A reader in social psychology (pp. 5-24). Boston: Allyn & Bacon.
Meltzer, B. N., Petras, J. W., & Reynolds, L. T. (1975). Symbolic interactionism:
Genesis, varieties and criticism. London: Routledge and Kegan Paul. Menon, M. (1992). Migrant nurses: Cross-cultural understanding or
misunderstanding? Issues in Australian Nursing, 3, 321-337. Merton, R. K., & Barber, E. (1963). Sociological ambivalence. In E. Tiryakian (Ed.),
Sociological theory: Values and sociocultural change (pp. 91-115). New York: The Free Press.
Meyer, T., & Xu, Y. (2005). Academic and clinical dissonance in nursing education:
Are we guilty of failure to rescue? Nurse Educator, 30(2), 76-79.
270
Meyrick, J. (2006). What is good qualitative research? A first step towards a
comprehensive approach to judging rigour/quality. Journal of Health Psychology, 11(5), 799-808.
Miller, D. L. (1973). George Herbert Mead: Self, language, and the world. Austin:
University of Texas Press. Miller, J. M. (2000). Language use, identity, and social interaction: Migrant students
in Australia. Research on Language & Social Interaction, 33(1), 69-100. Mills, T., & Kleinman, S. (1988). Emotions, reflexivity, and action: An interactionist
analysis. Social Forces, 66(4), 1009-1027. Mintzberg, H. (1979). An emerging strategy of “direct” research. Administrative
Science Quarterly, 24, 582-589. Miraflor, C. G. (1976). The Philippine nurse: Implications for orientation and
inservice education for foreign nurses in the United States. Unpublished doctoral dissertation, Loyola University of Chicago, Illinois.
Moore, B. (2004). The Australian Oxford dictionary (2nd ed.). Melbourne, Australia:
Oxford University Press. Morse, J. M. (1995). The significance of saturation. Qualitative Health Research,
5(2), 147-149. Morse, J. M., Barrett, M., Mayan, M., Olson, K., & Spiers, J. (2002). Verification
strategies for establishing reliability and validity in qualitative research. International Journal of Qualitative Methods, 1(2), 1-19.
Murphy, S. (2008). Actualizing the dream: Experiences of internationally-educated
nurses. Unpublished doctoral dissertation, University of Calgary, Alberta, Canada.
Murphy, S., & McGuire, M. (2005). The internationally educated nurse: Well-
researched and sustainable programs are needed to introduce internationally educated nurses to the culture of nursing practice in Canada. The Canadian Nurse, 101(1), 25-29.
Musolf, G. R. (1989). The social origins of symbolic interactionism: Corporate
capitalism, progressive politics, and the nature/nurture debate. Unpublished doctoral disseration, Michigan State University, Michigan.
Musolf, G. R. (2003). The Chicago School. In L. T. Reynolds & N. J. Herman-
Kinney (Eds.), Handbook of symbolic interactionism (pp. 91-117). Walnut Creek, CA: AltaMira Press.
271
Muula, A. S., Mfutso-Bengo, J. M., Makoza, J., & Chatipwa, E. (2003). The ethics of developed nations recruiting nurses from developing countries: The case of Malawi. Nursing Ethics, 10(4), 433-438.
Nelson, R. (2004). The nurse poachers. World Report, 364, 1743-1744. Nickens, H. (1990). Health promotion and disease prevention among minorities.
Health Affairs, 9(2), 133-143. Noble, D. W. (1967). The paradox of progressive thought. Minneapolis: University
of Minnesota press. Noh, S., & Kaspar, V. (2003). Perceived discrimination and depression: Moderating
effects of coping, acculturation and ethnic support. American Journal of Public Health, 93(2), 232-238.
NSW Nurses’ Association. (2005). No fix without student nurses. Retrieved March
19, 2007 from http://www.nswnurses.asn.au/news/3036.html O’Brien, T. (2007). Overseas nurses in the National Health Service: A process of
deskilling. Journal of Clinical Nursing, 16(12), 2229-2236. Oakley, M. (2005). Come on sweetheart, up you get! British Journal of Anaesthetic
and Recovery Nursing, 6(3), 40. Olssen, M. (1996). Radical constructivism and its failings: Anti-realism and
individualism. British Journal of Educational Studies, 44(3), 275-295. Omeri, A., & Atkins, K. (2002). Lived experiences of immigrant nurses in New
South Wales, Australia: Searching for meaning. International Journal of Nursing Studies, 39, 495-505.
Oulton, J. A. (2006). The global nursing shortage: An overview of issues and actions.
Policy, Politics & Nursing Practice, 17(3), 34S-39S. Page, F. J. (2000). A reinterpretation of the influence of American pragmatism on
symbolic interactionist theory. Unpublished doctoral dissertation, University of Utah.
Pajo, E. (2008). International migration, social demotion, and imagined
advancement: An ethnography of socioglobal mobility. New York: Springer. Palese, A. D., Barba, M., Borghi, G., Mesaglio, M., & Brusaferro, S. (2007).
Competence of Romanian nurses after their first six months in Italy: A descriptive study. Journal of Clinical Nursing, 16(12), 2260-2271.
272
Pang, S., Arthur, D. G., & Wong, T. K. S. (2000). Drawing a qualitative distinction of caring practices in a professional context: The case of Chinese nursing. Holistic Nursing Practice, 15(1), 22-31.
Parliament of Australia Senate. (2002). Report on the inquiry into nursing-The
patient profession: Time for action Retrieved March 20, 2007 from http://www.aph.gov.au/Senate/committee/clac_ctte/completed_inquiries/2002-04/nursing/report/
Parrone, J., Sedrl, D., Donaubauer, C., Phillips, M., & Miller, M. (2008). Charting the 7 c’s of cultural change affecting foreign nurses: Competency, communication, consistency, cooperation, customs, conformity and courage. Journal of cultural diversity, 15(1), 3-6.
Parry, M., & Lipp, A. (2006). Implementation of an adaptation programme for
Filipino nurses in a UK adult cancer hospice. International Journal of Palliative Nursing, 12(2), 83-89.
Patton, M. Q. (1990). Qualitative evaluation and research methods (2nd ed.).
Newbury Park, Calif: Sage. Pécoud, A., & Guchteneire, P. (2007). Introduction: The migration without borders
scenario. In A. Pécoud & P. Guchteneire (Eds.), Migration without borders: Essays on the free movement of people (pp. 1-30). Paris: UNESCO.
Peerson, A., Aitken, R., Manias, E., Parker, J., & Wong, K. (2002). Agency nursing
in Melbourne, Australia: A telephone survey of hospital and agency managers. Journal of Advanced Nursing, 40(5), 504-512.
Peirce, C. S. (1955). Philosophical writings of Peirce (J. Buchler, Ed.). New York:
Dover. Pilette, P. C. (1989). Recruitment and retention of international nurses aided by
recognition of phases of the adjustment process. Jouranal of Continuing Education in Nursing, 20(6), 277-281.
Pittman, P., Aiken, L. H., & Buchan, J. (2007). International migration of nurses:
Introduction. Health Services Research, 42, 1275-1280. Polsky, D., Ross, S. J., Brush, B. L., & Sochalski, J. (2007). Trends in characteristics
and country of origin among foreign-trained nurses in the United States, 1990 and 2000. American Journal of Public Health, 97(5), 895-899.
Popay, J., Rogers, A., & Williams, G. (1998). Rationale and standards for the
systematic review of qualitative literature in health services research. Qualitative Health Research, 8(3), 341-351.
273
Porter, S. (1991). A participant observation study of power relations between nurses and doctors in a general hospital. Journal of Advanced Nursing, 16(6), 728-735.
Powell, A. (2005, September 15). Health care reform in China discussed: Vice
minister Huang details advances, problems, reforms. Retrieved March 19, 2009 from http://www.news.harvard.edu/gazette/2005/09.15/09-china.html
Preston, B. (2006). Nurse workforce futures. Retrieved March 19, 2007 from
http://www.cdnm.edu.au/pdfs/Nurseworkforcefutures.pdf. Pullen, A., & Simpson, R. (2009). Managing difference in feminized work: Men,
otherness and social practice. Human Relations, 62(4), 561-587. Queensland Nursing Council. (2006). Increase in overseas applications. Queensland
Nursing forum, 14(1), 8. Raghuram, P. (2007). Interrogating the language of integration: The case of
internationally recruited nurses. Journal of Clinical Nursing, 16(12), 2246-2251.
Rennie, D. L. (1998a). Grounded theory methodology: The pressing need for a
coherent logic of justification. Theory & Psychology, 8(1), 101-119. Rennie, D. L. (1998b). Reply to Corbin: From one interpreter to another. Theory &
Psychology, 8(1), 129-135. Rennie, D. L. (2000). Grounded theory methodology as methodical hermeneutics:
Reconciling realism and relativism. Theory & Psychology, 10(4), 481-502. Reverby, S. (1987). A caring dilemma: Womanhood and nursing in historical
perspective. Nursing Research, 36(1), 5-11. Reynolds, J., & Reynolds, L. T. (1973). Interactionism, complicity, and the
astructural bias. Catalyst, 7, 76-85. Reynolds, L. T. (1969). The sociology of symbolic interactionism. Unpublished
doctoral dissertation, Ohio State University, Columbus. Reynolds, L. T. (2003a). Early representatives. In L. T. Reynolds & N. J. Herman-
Kinney (Eds.), Handbook of symbolic interactionism (pp. 59-81). Walnut Creek, CA: AltaMira Press.
Reynolds, L. T. (2003b). Intellectual precursors. In L. T. Reynolds & N. J. Herman-
Kinney (Eds.), Handbook of symbolic interactionism (pp. 39-58). Walnut Creek, CA: AltaMira Press.
274
Rolfe, G. (2006). Validity, trustworthiness and rigour: Quality and the idea of qualitative research. Journal of Advanced Nursing, 53(3), 304-310.
Rose, G. (1995). Place and identity: A sense of place. In D. Massey & P. Jess (Eds.),
A place in the world? Places, cultures and globalization (pp. 87-132). Oxford: Oxford University Press.
Roth, J. A. (1972). Some contingencies of the moral evaluation and control of
clientele: The case of the hospital emergency service. The American Journal of Sociology, 77(5), 839-856.
Royal College of Nursing. (2003). Here to stay? International nurses in the UK.
London: Royal College of Nursing. Rubin, H. J., & Rubin, I. S. (2005). Qualitative interviewing: The art of hearing data
(2nd ed.). Thousand Oaks, CA: Sage. Rudmin, F. W. (2003). Critical history of the acculturation psychology of
assimilation, separation, integration, and marginalization. Review of General Psychology, 7(1), 3-37.
Rumbaut, R. G. (1999). Assimilation and its discontents: Ironies and paradoxes. In C.
Hirschman, P. Kasinitz & J. DeWind (Eds.), The handbook of international migration: The American experience (pp. 172–195). New York: Russell Sage Foundation.
Sandelowski, M. (1986a). The problem of rigor in quality research. Journal of
Nursing Scholarship, 23, 161–166. Sandelowski, M. (1986b). Rigor in qualitative research. Advances in Nursing
Science, 8(3), 27-37. Sandelowski, M. (1993). Rigor or rigor mortis: The problem of rigor in qualitative
research revisited. Advances in Nursing Science, 16(2), 1-8. Sarojini, Foong, M. S., Pin, C. C., Nge, T. T., & Hong, E. P. W. (2005). The
expectations and experiences of Myanmar nursing aides working in an inpatient hospice in Singapore. Singapore Nursing Journal, 32(3), 44-50.
Scheff, T. J. (1968). Negotiating reality: Notes on power in the assessment of
responsibility. Social Problems, 16(1), 3-17. Scheff, T. J. (1988). Shame and conformity: The deference-emotion system.
American Sociological Review, 53(3), 395-406. Scheff, T. J. (2005). Looking-glass self: Goffman as symbolic interactionist.
Symbolic Interaction, 28(2), 147-166.
275
Schueler, G. F. (1999). Why is modesty a virtue? Ethics, 109(4), 835-841. Searle, J. R. (1995). The construction of social reality. New York: Free Press. Seelye, H. N., & Brewer, M. B. (1970). Ethnocentrism and acculturation of North
Americans in Guatemala. Journal of social psychology, 80(2), 147-155. Shaffir, W., & Pawluch, D. (2003). Occupations and professions. In T. R. Larry & N.
J. Herman-Kinney (Eds.), Handbook of symbolic interactionism (pp. 893-913). Walnut Creek, CA: AltaMira Press.
Shah, S. K., & Corley, K. G. (2006). Building better theory by bridging the
quantitative-qualitative divide. Journal of Management Studies, 43(8), 1821-1835.
Shaw, F. J. (1966). Reconciliation: A theory of man transcending (S.M. Jourard &
D.C. Overlade Eds.). Priceton, NJ: Van Nostrand. Sherman, R. O., & Eggenberger, T. (2008). Transitioning internationally recruited
nurses into clinical settings. Journal of Continuing Education in Nursing, 39(12), 535-544.
Sherwin, S. (1992). No longer patient: Feminist ethics and health care. Philadelphia:
Temple University Press. Shott, S. (1979). Emotion and social life: A symbolic interactionist analysis. The
American Journal of Sociology, 84(6), 1317-1334. Simmel, G. (1991). Bridge and door. Theory, Culture & Society, 11(1), 5-10. Singh, J. A., Nkala, B., Amuah, E., Mehta, N., & Ahmad, A. (2003). The ethics of
nurse poaching from the developing world. Nursing Ethics, 10(6), 666-670. Skills of overseas nurses called into question. (2005, April 7). ABC News. Retrieved
March 2, 2009 from http://www.abc.net.au/news/stories/2005/04/07/1340151.htm
Smelser, N. J. (1998). The rational and the ambivalent in the social sciences: 1997
Presidential Address. American Sociological Review, 63(1), 1-16. Smith, A. D. (1991). National identity. London: Penguin. Smith, P., & Mackintosh, M. (2007). Profession, market and class: Nurse migration
and the remaking of division and disadvantage. Journal of Clinical Nursing, 16(12), 2213-2220.
Smith, S. (2004). Understanding the experience of training for overseas nurses.
Nursing Times, 100(40), 40-42.
276
Sochan, A., & Singh, M. D. (2007). Acculturation and socialization: Voices of
internationally educated nurses in Ontario. International Nursing Review, 54(2), 130-136.
Stark, O., & Bloom, D. E. (1985). The new economics of labor migration. The
American Economic Review, 75(2), 173-178. Stein, L. I. (1968). The doctor-nurse game. The American Journal of Nursing, 68(1),
101-105. Stewart, M., Anderson, J., Beiser, M., Mwakarimba, E., Neufeld, A., Simich, L., et al.
(2008). Multicultural meanings of social support among immigrants and refugees. International Migration, 46(3), 123-159.
Storti, C. (1990). The art of crossing cultures. Yarmouth, Me: Intercultural Press. Strauss, A. (1982). Interorganizational negotiation. Urban Life, 11(3), 350-367. Strauss, A. (1987). Qualitative analysis for social scientists. Cambridge, UK:
Cambridge University Press. Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory
procedures and techniques. Newbury Park, CA: Sage. Strauss, A., & Corbin, J. (1994). Grounded theroy methodology-An overview In N.
K. Denzin & Y. Lincoln (Eds.), Handbook of qualitative research (pp. 273-285). Thousand Oaks, CA: Sage.
Strauss, A., & Corbin, J. (1997). Grounded theory in practice. Thousand Oaks: Sage. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and
procedures for developing grounded theory (2nd ed.). Thousand Oaks: Sage. Strauss, A., Schatzman, L., Ehrlich, D., Bucher, R., & Sabshin, M. (1963). The
hospital and its negotiated order. In E. Freidson (Ed.), The hospital in modern society (pp. 147-169). New York: Free Press.
Stryker, S. (1980). Symbolic interactionism: A social structural version. Menlo Park,
CA: Benjamin/Cummings. Suarez-Orozco, C. (2005). Identities under siege: Immigration stress and social
mirroring among the children of immigrants. In M. M. Suárez-Orozco, C. Suárez-Orozco & D. B. Qin (Eds.), The new immigration: An interdisciplinary reader (pp. 135-156). New York: Routledge.
Suarez-Orozco, M. M. (2000). Everything you ever wanted to know about
assimilation but were afraid to ask. Daedalus, 129(4), 1-30.
277
Suárez-Orozco, M. M. (2005). Right moves? Immigration, globalization, utopia, and
dystopia. In M. M. Suárez-Orozco, C. Suárez-Orozco & D. Qin-Hilliard (Eds.), The new immigration: An interdisciplinary reader (pp. 3-20). New York: Routledge.
Suddaby, R. (2006). From the editors: What grounded theory is not. The Academy of
Management Journal, 49(4), 633-642. Sundar, P. (2008). To “brown it up” or to “bring down the brown”: Identity and
strategy in second-generation, south Asian-Canadian youth. Journal of Ethnic and Cultural Diversity in Social Work, 17(3), 251-278.
Taft, R. (1981). The role and personality of the mediator. In S. Bochner (Ed.), The
mediating person: Bridges between cultures (pp. 53-88). Boston: G.K.Hall. Taylor, B. (2005). The experiences of overseas nurses working in the NHS: Results
of a qualitative study. Diversity in Health and Social Care, 2(1), 17-27. Taylor, S. J., & Bogdan, R. (1998). Introduction to qualitative research methods: A
guidebook and resource (3rd ed.). New York: Wiley. Teschendorff, J. (1993a). Cultural factors that impinge on the success of Philippine
nurses seeking registration in Australia. Unpublished master’s thesis, La Trobe Unversity, Melbourne, Australia.
Teschendorff, J. (1993b). Culture shock: Philippine nurses in Australia. Paper
presented at the Transcultural Nursing Conference, Sydney Australia. Teschendorff, J. (1994). Intercultural communication: Philippine nurses and the
Australian nursing subculture. Australian Journal of Communication, 21(2), 31-40.
Teske, R. H. C., & Nelson, B. H. (1974). Acculturation and assimilation: A
clarification. American Ethnologist, 1(21), 351-367. Thobaben, M., Roberts, D. A., Badir, A., Wang, H., Murayama, H., Murashima, S.,
et al. (2005). Exploring nursing education in the People’s Republic of China, Japan and Turkey. Contemporary Nurse, 19, 5-16.
Thomas, W. I. (1931). The unadjusted girl: With cases and standpoint for behavior
analysis. Boston: Little Brown. Thomas, W. I., & Janowitz, M. (1966). On social organization and social
personality: Selected papers. Chicago: University of Chicago Press. Tobin, G. A., & Begley, C. M. (2004). Methodological rigour within a qualitative
framework. Journal of Advanced Nursing, 48(4), 388-396.
278
Triandis, H. C. (1989). The self and social behavior in differing cultural contexts.
Psychological Review, 96(3), 506-520. Triandis, H. C., Bontempo, R., Villareal, M. J., Asai, M., & Lucca, N. (1988).
Individualism and collectivism: Cross-cultural perspectives on self-ingroup relationships. Journal of Personality and Social Psychology, 54(2), 323-338.
Trossman, S. (2002). The global reach of nursing shortage: The ANA questions the
ethics of luring foreign-educated nurses to the United States. American Journal of Nursing, 102, 85-87.
Turrittin, J., Hagey, R., Guruge, S., Collins, E., & Mitchell, M. (2002). The
experiences of professional nurses who have migrated to Canada: Cosmopolitan citizenship or democratic racism? International Journal of Nursing Studies, 39, 655-667.
Twinn, D. S. (1998). An analysis of the effectiveness of focus groups as a method of
qualitative data collection with Chinese populations in nursing research. Journal of Advanced Nursing, 28(3), 654-661.
United Nations. (2006). Trends in total migrant stock: The 2005 revision. Retrieved
September 5, 2007 from http://www.un.org/esa/population/publications/migration/UN_Migrant_Stock_Documentation_2005.pdf
Usher, K., Baker, J. A., Holmes, C., & Stocks, B. (2009). Clinical decision-making
for ‘as needed’ medications in mental health care. Journal of Advanced Nursing, 65(5), 981-991.
Vestal, V., & Kautz, D. D. (2009). Responding to similarities and differences
between Filipino and American nurses. Journal of Nursing Administration, 39(1), 8-10.
Walker, D., & Myrick, F. (2006). Grounded theory: An exploration of process and
procedure. Qualitative Health Research, 16(4), 547-559. Wang, A. (1987). The fever of going abroad among the Shanghai youth. Urumqi:
Xinjiang Youth, 10, 9-11. Wang, G. (2001). Don’t leave home: Migration and the Chinese. Singapore: Times
Academic Press. Wang, H., Xu, T., & Xu, J. (2007). Factors contributing to high costs and inequality
in China’s health care system. The Journal of American Medical Association, 298(16), 1928-1930.
279
Wang, R. Y., & Lethbridge, D. J. (1995). Becoming Gold-Plated: Chinese Nurses Studying Abroad. Journal of Nursing Scholarship, 27(2), 131-134.
Wang, Y., & Ollendick, T. H. (2001). A cross-cultural and developmental analysis of
self-esteem in Chinese and Western children. Clinical Child and Family Psychology Review, 4(3), 253-271.
Ward, C. (2008). Thinking outside the Berry boxes: New perspectives on identity,
acculturation and intercultural relations. International Journal of Intercultural Relations, 32(2), 105-114.
Watson, J. B. (1914). Behavior: An introduction to comparative psychology. New
York: H. Holt. Weber, M. (1978). Ethnic groups. In G. Roth & C. Wittich (Eds.), Economy and
society (pp.385-398). Berkeley: University of California Press. Wee, C. (2005). Montaigne’s cannibals and multiculturalism. In S.-h. Tan (Ed.),
Challenging citizenship: Group membership and cultural identity in a global age (pp. 137-150). Aldershot, Hants, England: Ashgate.
Weinberg, S. K. (1962). Social action systems and social problems. In M. R. Arnold
(Ed.), Human behavior and social process (pp. 401-424). Boston: Houghton Mifflin.
Weiss, R. S. (1973). Loneliness: The experience of emotional and social isolation.
Cambridge, MA: MIT Press. Weiss, T., & Berger, R. (2008). Posttraumatic growth and immigration: Theory,
research, and practice implications. In S. Joseph & P. A. Linley (Eds.), Trauma, recovery, and growth: Positive psychological perspectives on posttraumatic stress (pp. 93-104). Hoboken, NJ: John Wiley & Sons.
Whittemore, R., Chase, S. K., & Mandle, C. L. (2001). Validity in qualitative
research. Qualitative Health Research, 11(4), 522-537. Wickett, D., & McCutcheon, H. (2002). Issues of qualification assessment for nurses
in a global market. Nurse Education Today, 22(1), 44-52. Wiley, S., Perkins, K., & Deaux, K. (2008). Through the looking glass: Ethnic and
generational patterns of immigrant identity. International Journal of Intercultural Relations, 32(5), 385-398.
Wilkes, G. A., & Krebs, W. A. (1998). Collins English dictionary (4th Australian
ed.). Glasgow: HarperCollins. Wilkinson, R. G. (1996). Unhealthy societies: The afflictions of inequality. London:
Routledge.
280
Willey, J. (November 27, 2008). Nurses banned from calling patients ‘dearie’ Daily
Express, Retrieved August 22, 2009 from http://www.dailyexpress.co.uk/posts/view/73086
Williams, R. (1988). Understanding Goffman’s Methods. In P. Drew & A. Wooten
(Eds.), Erving Goffman: Exploring the interaction order (pp. 64-88). Cambridge, UK: Polity Press.
Wilson, H. S., Hutchinson, S. A., & Holzemer, W. L. (2002). Reconciling
incompatibilities: A grounded theory of HIV medication adherence and symptom management. Qualitative Health Research, 12(10), 1309-1322.
Winkelmann-Gleed, A., & Seeley, J. (2005). Strangers in a British World?
Integration of international nurses. British Journal of Nursing, 14(18), 954-961.
Winnicot, D. W. (1971). Playing and reality. Middlesex, England: Penguin. Withers, J., & Snowball, J. (2003). Adapting to a new culture: A study of the
expectations and experiences of Filipino nurses in the Oxford Radcliffe Hospitals NHS Trust. NT Research, 8(4), 278-290.
Worchel, S. (2005). Culture’s role in conflict and conflict management: Some
suggestions, many questions. International Journal of Intercultural Relations, 29(6), 739-757.
Worthington, E. L., & Drinkard, D. T. (2000). Promoting reconciliation through
psychoeducational and therapeutic interventions. Journal of Marital and Family Therapy, 26(1), 93-101.
Xiao, Q. (1989). Five Waves. Beijing, China: People’s University Publishing House. Xu, Y. (2003). Are Chinese nurses a viable source to relieve the U.S. nurse shortage?
Nursing Economics, 21(6), 269-274. Xu, Y. (2004). International nurse migration. Journal of Nursing Scholarship, 36(3),
189. Xu, Y. (2005). Clinical challenges of Asian nurses in a foreign health care
environment. Home Health Care Management & Practice, 17(6), 492-494. Xu, Y. (2006). From diplomacy to national development: Evolution of Chinese
policy on the international mobility of nurses. Harvard Health Policy Review, 7(1), 121-132.
281
Xu, Y. (2007). Strangers in strange lands: A metasynthesis of lived experiences of immigrant Asian nurses working in Western countries. Advances in Nursing Science, 30(3), 246-265.
Xu, Y. (2008). Communicative competence of international nurses and patient safety
and quality of care. Home Health Care Management Practice, 20(5), 430-432.
Xu, Y., & Davidhizar, R. (2005). Intercultural communication in nursing education:
When Asian students and American faculty converge. Journal of Nursing Education, 44(5), 209-215.
Xu, Y., Gutierrez, A., & Kim, S. H. (2008). Adaptation and transformation through
(un) learning: Lived experiences of immigrant Chinese nurses in US healthcare environment. Advances in Nursing Science, 31(2), E33-E47.
Xu, Y., & Kwak, C. (2005). Characteristics of internationally educated nurses in the
United States. Nursing Economics, 23(5), 233-238. Xu, Y., & Kwak, C. (2007). Comparative trend analysis of characteristics of
internationally educated nurses and U.S. educated nurses in the United States. International Nursing Review, 54(1), 78-84.
Xu, Y., Xu, Z., & Zhang, J. (2000). The nursing education system in the People’s
Republic of China: Evolution, structure and reform. International Nursing Review, 47, 207-217.
Xu, Y., & Zhang, J. (2005). One size doesn’t fit all: Ethics of international nurse
recruitment from the conceptual framework of stakeholder interests. Nursing Ethics, 12(6), 571-581.
Xu, Z., Xu, Y., Sun, J., & zhang J. (2001). Globalization of tertiary nursing
education in post-Mao China: A preliminary qualitative assessment. Nursing and Health Science,3,179-187.
Yahes, E., & Dunn, A. K. (1996). Enculturation of foreign nurse graduates: An
integrated model. Journal of Continuing Education in Nursing, 27(3), 120-123.
Yallop, C. (2004). Macquarie concise dictionary: Australia’s national dictionary
(rev. 3rd ed.). Macquarie University, NSW, Australia: Macquarie Library. Yi, M. (1993). Adjustment of Korean nurses to United States hospital settings.
Unpublished doctoral dissertation, State University of New York, Buffalo, NY.
Yi, M., & Jezewski, M. A. (2000). Korean nurses’ adjustment to hospitals in the
United States of America. Journal of Advanced Nursing, 32(3), 721-729.
282
Zielyk, I. V. (1966). On ambiguity and ambivalence. Pacific Sociological Review,
9(1), 57-64. Zolberg, A. R. (1989). The next waves: Migration theory for a changing world.
International Migration Review, 23(3), 403-430.
283
Appendices Appendix A: Publication in the Queensland Nurse My name is Yunxian Zhou and I am a Chinese PhD student currently studying at the
School of Nursing, Queensland University of Technology. My research is focused on
Chinese nurses’ experiences of working in the Australian health care system. The
aim of this research is to analyse the experiences of Chinese nurses working in
Australia. A key objective is to determine whether existing support structures for
Chinese nurses are adequate.
This research is a qualitative study and will involve face to face interviews and focus
groups with approximately 25 participants. The interviews will of about 45-minute
duration each and will take place in locations chosen by participants. The focus
groups will be 1 hour in length and will take place in Room 601 N Block Kelvin
Grove QUT or alternatively using teleconferencing facilities. I will interview in
Chinese.
If you are a nurse born and educated in China or Taiwan and are currently registered
and working as a Registered Nurse in the Australian health care system, I would be
grateful if you would contact me through the following:
Office telephone: 07 31388211
Mobile phone: 0413554122 (Optus)
email: [email protected]
Thank you for your assistance in advance.
Kind regards
Yunxian Zhou
284
Appendix B: Publication in the Australian Nursing Journal An increased emphasis on overseas recruitment has been one response to the critical
shortage of registered nurses in Australia. Yet, while the number of overseas nurses
entering and working in Australia is increasing, relatively little is known about the
working lives of migrating nurses. In particular, little is known about those for
whom English is a second language. Yunxian Zhou is from China, a registered nurse
and currently undertaking PhD study in the School of Nursing, Queensland
University of Technology. The focus of Yunxian’s research is the experiences of
China-educated nurses who are working in the Australian health care system. The
aim of this research is to explore and come to understand the experiences of Chinese
nurses working in the Australian health care system. A key objective is to determine
the adequacy, or otherwise, of existing support structures for Chinese nurses working
in this country. The data collection for this qualitative study will involve in-depth
face to face interviews and focus groups, both of which will be conducted in Chinese.
The sample will be drawn from Queensland and NSW.
If you are a nurse born and educated in China or Taiwan and are currently registered
and working as a registered nurse in the Australian health care system, you can give
voice to your experiences by participating in this research. Yunxian will greatly
appreciate your contribution to this area of knowledge. You may contact Yunxian
through one of the following:
Office telephone: 07 31388211
Mobile phone: 0413554122 (Optus)
email: [email protected]
Appendix C: Participant Information Sheet
PARTICIPANT INFORMATION for QUT RESEARCH PROJECT
The experience of China-educated nurses working in Australia: A
symbolic interactionist perspective
Research Team Contacts Name Ms Yunxian Zhou Dr. Fiona Coyer Ms Carol Windsor Dr. Karen
Theobald Phone 31388211 31383895 31383837 31383904 Email [email protected]
.edu.au [email protected]
u.au
Description This project is being undertaken as part of a PhD project for Yunxian Zhou. The
purpose of this project is to explore how Chinese nurses construct the meaning of the
experience of working in the Australian health care system. The research team
requests your assistance because you were educated in China as a nurse and have
migrated to Australia to work as a nurse.
Participation Your participation in this project is voluntary. If you do agree to participate, you can
withdraw from participation at any time during the project without comment or
penalty. Your decision to participate will in no way impact upon your work position.
Your participation will involve a 45 minute interview, which will be done at a
location chosen by you at a mutually agreed time. Chinese will be the interview
language. The interviews will be audio-recorded digitally to ensure accuracy. Your
part in this study will be anonymously acknowledged at the end of the thesis and
subsequent publications.
Expected benefits
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This project may not benefit you personally. However, the results of this study may
be used to fully assist understanding of Chinese nurses’ experience of working in the
Australian health care system and possibly improve support services for them.
Furthermore, it may also provide some useful information to future Chinese nurses
who want to seek employment in Australia.
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Risks No physical risk to the participants is anticipated. It is possible that you may feel
emotional discomfort in reflecting upon your experiences. If this happens, the
interview will be terminated. Also, QUT provides for limited free counselling for
research participants of QUT projects, who may experience some distress as a result
of your participation in the research. Should you wish to access this service please
contact the Clinic Receptionist of the QUT Psychology Clinic on 31384578. Please
indicate to the receptionist that you are a research participant.
Confidentiality The tape recording will be destroyed after the contents have been transcribed. All the
data will only be used for research purpose. Only the researcher and her supervisors
have access to the data. No names or other identifiers such as place of employment
or geographic region will appear in the transcribed or presented data.
Consent to Participate We would like to ask you to sign a written consent form (enclosed) to confirm your
agreement to participate.
Questions / further information about the project Please contact the researcher team members named above to have any questions
answered or if you require further information about the project.
Concerns / complaints regarding the conduct of the project QUT is committed to researcher integrity and the ethical conduct of research
projects. However, if you do have any concerns or complaints about the ethical
conduct of the project you may contact the QUT Research Ethics Officer on 3138
2340 or [email protected]. The Research Ethics Officer is not connected
with the research project and can facilitate a resolution to your concern in an
impartial manner.
Appendix D: Participant Consent Form
CONSENT FORM for QUT RESEARCH PROJECT
The experience of China-educated nurses working in Australia:
A symbolic interactionist perspective
Statement of consent By signing below, you are indicating that you:
• have read and understood the information document regarding this project
• have had any questions answered to your satisfaction
• understand that if you have any additional questions you can contact the research team
• understand that you are free to withdraw at any time, without comment or penalty
• understand that you can contact the Research Ethics Officer on 3138 2340 or [email protected] if you have concerns about the ethical conduct of the project
• agree to participate in the project
• understand that the project will include audio recording
Participant Name
Signature
Date
Researcher Name
Signature
Date
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Appendix E: Demographic Information Sheet Interview number:
Date of interview:
Time of interview:
Place of interview:
Background information of participants (Please tick the right box and describe if
necessary)
Gender: Female Male
Age (years): 20-30 31-40 41-50 >51
Education: Associate Bachelor Postgraduate Others , Please describe
Marriage status: Single Married Divorced Others , Please describe
Live with family: Yes No
Work experience in China: years
Place of employment in China:
Job title and position in China:
Work experience in Australia: years
Current work place:
Type of employment: Public hospital Private hospital Nursing home
Community Agency Others
Current work department:
Current nurse level:
Current employment type: Full-time Part-time Casual
Work experience in countries other than China and Australia:
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Appendix F: Interview Checklist Arrive 15 minutes before appointed time Before the interview: Date: Time: Location:
Things to prepare: 1. Participant contact details (phone or mobile number) 2. Transportation details (bus information and timesheet) 3. Map 4. Mobile charged, with credit 5. Folder with information sheet, consent form, and demographic sheet 6. Interview questions 7. 2 digital recorders charged 8. 2 pens 9. 1 notebook
On commencement of the interview: 1. Greeting, self introduction, and casual talk 2. Find a quiet and private place for interview 3. Turn off mobile 4. Explain the aim of the study 5. Information sheet, consent form, and demographic sheet 6. Explain rules of the interview 7. Set up recorder and check its function
At conclusion of the interview: 1. Anything to add? 2. Potential for future contact? 3. Thanks
Post-interview: 1. Field notes 2. Reflexive journal 3. Transcription 4. Analysis
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Appendix G: Interview Questions for the Seventh Interview
Note to participants:
I want to know about your experiences and feelings of working in Australia as a
Chinese nurse. I want to hear the story in your own words. After you have completed
your storytelling, then if I have further questions or if something is unclear, I will
ask you. But for now just talk freely. Begin wherever you would like to tell me.
Interview questions:
1. Could you explain how you came to Australia to work as a registered nurse?
2. What were your thoughts about working in Australia before you came?
3. Tell me your early experience (concerns, thoughts, feelings, and perceptions) of
working as (being) a registered nurse in Australia, when you first came here?
4. How has that experience (concerns, thoughts, feelings, and perceptions) changed
over time? What happens next, later on?
5. What support services are available for immigrant nurses in your hospital? Do you
find them helpful?
6. What is your suggestion to further improve the support services for immigrant
nurses?
7. What are your recommendations for those future Chinese nurses who may
consider working in Australia?
8. Please tell me if there are other issues which you consider important for me to
understand the experience of Chinese nurses working in Australia.
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Appendix H: Examples of Reflexive Journal November 27th 2007 It is so hard to persuade myself that I am not looking at truth. From my quantitative background, I felt a bit uneasy when I realised that I was not searching for truth in my research but more an in-depth understanding of something. I was concerned whether my analysis would twist the experience in some ways and resulted in a distortion of reality. I mean when I did the interview, the participants tended to tell me what was significant in their mind. They would not tell me the normal part usually, but more about the problematic area. When I did the analysis, I tended to pick up what was significant in the data through my eyes and gave them meaning through my own interpretation. I mean my analysis is based on the knowledge I have of course. That is the only way it is going to work. However, it is quite possible that some parts of the experience get exaggerated and some overlooked. It is no more a neutral reality really. It is the reality filtered through my perspective. It is something real but not truth. It tells what is going on to a large extent, but it is simply not the same with the reality as it is just one perspective from one person’s point of view. March 28th 2008 I have always thought that it is important to find out what Chinese nurses’ support needs are in order to better support them in the Australian health care system. After some interviews, I found I was wrong. Many of them claimed no need for support as this may indicate them as inferior. Also, they were unwilling to reveal unknowns as they may be viewed as unqualified. Now I felt I needed to look more in-depth at this kind of issues instead of focusing only on what services they think might be good for their support. June 30th 2009 The theory emerges from the data. Is it from data, or more? To me, I feel it has to go beyond data at some stage to be abstract. So why we emphasise it emerges from data instead of somewhere else which might be as important as well? Is it theory? Not sure. Maybe it depends on how one defines a theory. Why we have to call it theory? To me, it is abstract understanding only. A neat theory, while neat, is usually too simplistic to reflect the complex reality. Is it emerged? Absolutely not in my case. To be fair, it is constructed by the researcher. Maybe Glaser would worry if it is simply constructed, it will be too subjective to be of any scientific value.
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Appendix I: Examples of Initial Coding transcript Initial code
Yes! I can experience more. When I was
at home, since I was the only child in the
family, I never did any house chores. The
hospital which I worked was also close to
my home, I never think too much. I feel I
need to learn lots of things when I am
here, away from the family, lots of stress
to face. I felt it is indeed different. Before,
I never did any house chores at home. My
mother even handed chopsticks to me
before I ate, but I still got angry
sometimes without a good reason. Now I
live away from the family, I need to take
care of myself and there is no other way.
Indicating reasons for coming
Being the only child
Being well looked after
Never thinking too much
Indicating the learning required
Being away from family
Facing stress/It is indeed different
Being well looked after
Being spoiled at home
Taking care of self
There is no other way
Since the morning, you need to take care
of patients when they have breakfast; this
is absolutely not the case in China. Then
take a shower for the patient, all these
things. Patients here are totally dependent,
you have to take care of everything,
including bathing and going to the toilet,
so many things, this is what I haven’t
thought about.
Explaining what nurses do
Being different from China
Patients being dependent
Taking care of everything
Not having thought about
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Appendix J: Examples of Focused Coding transcript focused code You have to consider the situation carefully. Ask those who can help you and keep away from those who are suspicious of or questioning you. Sometimes work is like walking on ice and you have to be extremely careful. That is true. You do have many unknowns. For example, you knew the patient got a wound, but you didn’t know the name of dressing used. Then when you read the notes, you couldn’t tell as well. As most doctors’ handwriting is not easy to recognise. If you ask other RNs too often, they would think why you always ask them since you are an RN yourself. There are also ENs there, but how can you turn to them--people who work under your supervision, for help?
Weighting up the situation Having many unknowns Explaining difficulties in seeking help
Yes, I use the Chinese name and they cannot call me by that. They feel awful as well, you know. They asked me all the time: we are so sorry to ask your name again, how should I call you? Can I call you by another name? For example, XY, or X or Y, anyway, there are all kinds really. At last I said, never mind, call me whatever you feel the easiest. I said I can have an English name, but finally my passport, my pay list or any of my documents, I still need to use my genuine name. That is to say, the name on my RN license is my official name, so I cannot use an English name to replace that.
Failing to remember my name Requesting an alternative name Questioning the adoption of an English name
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Appendix K: Examples of Memo March 20th 2008-Trust in emergence? Trust in emergence? How does it actually happen? Glaser’s criterion of emergence is too elusive and his words are misleading in some way. We need at least some demonstrations of that mysterious process. I mean he is quite voluminous in what is forcing. But what on earth is emergence? If people do not have a correct understand of this, they can easily go wrong. Probably one person’s emergence is forcing in another people’s view point. I think the concept of emergence is too soft to be useful in practice. March 21st 2008-Going abroad is like a high wall One participant mentioned to me that going abroad is like a high wall. Those people outside the wall are dreamed of going inside one day. But once they have an opportunity to be there, they start to question themselves whether it is a right choice for them to be there. They feel hesitated, confused in some way. Divided by the wall are two quite different realities and they never thought of what life would like inside the wall. Maybe it is too hard for them to have a clear idea before they go inside, the willingness to go inside make them even not bother to think of what is like being there, or there is too less information available when they are outside the wall. The high wall makes it very hard for people to observe the other side and have a clear idea early on. Once they are inside the wall, they start to face the different realities and struggling to deal with the difference. They may feel painful during the process, but they may also grow out of it. Life needs to carry on anyway so reconciling is happening day after day. May 22nd 2008-Trust in emergence? Trust in emergence? My experience is that it is not something appears automatically. It takes lots of efforts (reading, thinking, and trying) to get the core category and even after I get the tentative core, I am not so sure whether it is absolutely the case. I hesitated; I was reluctant to decide on that core; I tried to be as much open as possible to allow something else to emerge if it did prove to be significant later on. So, it is not simply emerge. Also, the articulation of the core category is a challenge as well. The idea may emerge, but its name never. I have to find the right words to best capture its imageric meaning. This is something I have to try hard, not come to me easily. And I may need to name and rename the core category if it appears not so fit. This fitting of words is like a game really and I need to learn how to play it. If I fail to name the category appropriately, what is the difference between forcing then? All of this is hard work, which is more than something emerging out of blue.
