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The Lived Experience of Non English Speaking Background The Lived Experience of Non English Speaking Background The Lived Experience of Non English Speaking Background The Lived Experience of Non English Speaking Background
Overseas Qualified Nurses Working in the Western Australian Overseas Qualified Nurses Working in the Western Australian Overseas Qualified Nurses Working in the Western Australian Overseas Qualified Nurses Working in the Western Australian
Metropolitan Metropolitan Metropolitan Metropolitan Hospital Workforce:Hospital Workforce:Hospital Workforce:Hospital Workforce:
A Transcendental Phenomenological A Transcendental Phenomenological A Transcendental Phenomenological A Transcendental Phenomenological StudyStudyStudyStudy
Christine Denise Andree Smith
This thesis is presented for the Masters of Health Professional Education at the
University of Western Australia
Education Centre, Faculty of Medicine, Dentistry and Health Sciences
May 2010
ii
iii
ABSTRACT
The purpose of this research study was to explore the lived experiences of 13
female Non English Speaking Background (NESB) Overseas Qualified Nurses
(OQNs) as they integrate into the Western Australian (WA) metropolitan
hospital workplace. The current shortage of nurses worldwide has taken its toll
on the Australian health care system. In fact nurses are at present at the top of
the ten occupations in most demand. As a result there is an increased and
ongoing migration of OQNs, some of them coming from non English speaking
countries. Studies of migrant nurses working abroad have been conducted in
countries such as the United Kingdom, Canada and the United States of
America each of which have a long history in employing OQNs. Similar studies
have also been carried out in the eastern states of Australia. However while
NESB migrant nurses are employed in the WA health care setting and are still
encouraged to come and work here, there is very little research on their
employment experiences in WA. This study was a first step in addressing this
gap in knowledge.
A qualitative design based on Husserlian transcendental phenomenology was
used to explore the lived experience of working in the WA metropolitan hospital
system of 13 female NESB OQNs from five different WA metropolitan hospitals.
Four main themes emerged from the data analysis; “the initial feelings of
professional loss”, “feelings of otherness”, “rediscovering nursing” and “it all
works out in the end”. The findings from this research highlighted the personal
and professional journey of the participants as they integrated into the WA
workforce. A feature of the outcomes of this study was the participants’
resilience and agency in terms of their willingness and determination not only to
iv
adapt and to learn from the new country and work practice, but also to maintain
their integrity as unique professional individuals practising nursing.
v
ACKNOWLEDGEMENTS
Now that I have completed the thesis I admit that while the journey has been
long and tumultuous, I have thoroughly enjoyed it and learnt immensely.
However the successful completion of this research would not have been
possible without the interest and support of the following individuals to whom I
wish to express my appreciation.
I am very grateful and would like to thank the 15 NESB OQNs who volunteered
to participate in this study. I feel very privileged that they offered to share their
experiences with me so that this project could take place. This thesis is the
result of their valuable contribution.
Special thanks go also to my two supervisors. Dr Annette Mercer’s patience
and encouragement assisted me to persevere on what I recall being a difficult
journey. Dr Colleen Fisher who came on board in the middle of last year
provided the guidance to undertake Husserl’s transcendental phenomenology to
this project. Her high competence in qualitative research and genuine
supportive approach gave me the confidence to carry out this project.
Finally I would like to express my above all appreciation of the support and
understanding provided to me by my husband Kim and my two children Jeremie
and Melanie.
vi
DECLARATION
In accordance with the regulations for presenting theses and other works for
higher degrees, I hereby declare that this thesis is entirely my own work and
that it has not been submitted as an exercise for a degree in any other
university.
Christine Denise Andree Smith
Date: / /
vii
ABBREVIATIONS
ABC Australian Bureau of Statistics
ANMC Australian Nursing and Midwifery Council
APNMF Australian Peak Nursing and Midwifery Forum
CGFNS Commission on Graduates of Foreign Nursing Schools
CN Clinical Nurse
DIAC Department of Immigration and Citizenship
EN Enrolled Nurse
ESB English Speaking Background
HPH Hollywood Private Hospital
IELTS International English Language Testing System
INC International Nursing Council
IV Intravenous
MDGs Millennium Development Goals
MODL Migration Occupation in Demand List
NESB Non English Speaking Background
NHS National Health Services
NMBWA Nurses and Midwifery Board of Western Australia
NMRAs Nursing and Midwifery Regulatory Authorities
OECD Organisation for Economic Corporation and Development
OET Occupational English Test
OQN Overseas Qualified Nurse
PCA Patient Care Assistant
QNU Queensland Nurse Unions
REOH Researching Equal Opportunities for Overseas-trained
nurses and other Healthcare professionals
RN Registered Nurse
SCGH Sir Charles Gardner Hospital
UK United Kingdom
USA United States of America
WA Western Australia
viii
TABLE OF CONTENTS
Abstract.............................................................................................................. iii
Acknowledgements............................................................................................. v
Declaration......................................................................................................... vi
Abbreviations .................................................................................................... vii
Table of Contents .............................................................................................viii
1 Chapter One – Introduction .........................................................................1
1.1 Background ..........................................................................................1
1.2 Aim of the Study ...................................................................................3
1.3 Structure of the Thesis .........................................................................3
1.4 Summary ..............................................................................................5
2 Chapter Two – Nursing in Australia .............................................................7
2.1 Introduction...........................................................................................7
2.2 The nursing profession in Australia ......................................................8
2.2.1 Foundation of nursing....................................................................8
2.2.2 The national regulatory body.........................................................9
2.2.3 Nursing education .......................................................................10
2.2.4 Regulations on OQNs coming to Australia ..................................11
2.2.5 Nurses and midwifery board of Western Australia.......................12
2.3 The mobility of nurses ........................................................................13
2.3.1 Shortage of nurses worldwide .....................................................14
2.3.2 Shortage of nurses in Australia ...................................................15
2.3.3 Strategies to alleviate the shortage .............................................17
2.3.4 Migrating to Australia...................................................................17
2.3.5 Australian migration history .........................................................18
2.3.6 Recruiting OQNs .........................................................................19
ix
2.4 Summary ............................................................................................20
3 Chapter three – Methodology ....................................................................22
3.1 Introduction.........................................................................................22
3.2 Overview of the methodology .............................................................22
3.2.1 Qualitative research.....................................................................22
3.2.2 Phenomenology - overall perspective..........................................25
3.2.3 Transcendental phenomenology .................................................26
3.2.4 Hermeneutical phenomenology...................................................28
3.2.5 Phenomenology in nursing research ...........................................30
3.2.6 Summary .....................................................................................33
3.3 Research methods..............................................................................33
3.3.1 Rationale for choosing a phenomenological approach................34
3.3.2 Moustakas’ approach to phenomenological research..................35
a Methods and procedural guidelines ................................................36
3.3.3 Personal and social foundation in the research topic ..................37
3.3.4 Research aims and questions .....................................................39
3.3.5 The author’s standpoint ...............................................................39
3.3.6 Ethical considerations..................................................................41
3.3.7 The data collection process.........................................................42
a Identifying the participants ..............................................................42
b Recruitment of participants .............................................................44
c The study sample............................................................................45
d The interview process .....................................................................46
3.3.8 Managing the data.......................................................................48
a The interviews.................................................................................48
b The transcriptions............................................................................48
x
c The analysis of the data..................................................................49
3.3.9 Rigour and trustworthiness..........................................................51
a Credibility ........................................................................................52
b Dependability ..................................................................................53
c Transferability .................................................................................53
d Confirmability ..................................................................................53
3.4 Summary ............................................................................................53
4 CHAPTER FOUR – THE INITIAL FEELINGS OF PROFESSIONAL LOSS
55
4.1 Introduction.........................................................................................55
4.2 The overwhelming differences experienced in the work environment 56
4.2.1 So many things are different........................................................56
4.2.2 Feeling a lack of trust ..................................................................59
4.2.3 Feeling self doubt ........................................................................61
4.2.4 Relationship and discussion of findings to existing literature.......62
4.3 Being like a learner again ...................................................................66
4.3.1 Acting as a learner ......................................................................66
4.3.2 Being treated like a junior/ novice nurse......................................67
4.3.3 Relationship and discussion of findings to existing literature.......68
4.4 Phenomenological explanation of the participants’ experiences.........73
5 CHAPTER FIVE – FEELING OF OTHERNESS ........................................75
5.1 Introduction.........................................................................................75
5.2 I have to speak English ......................................................................75
5.2.1 English is not my native language ...............................................76
5.2.2 What’s wrong with my English?...................................................78
5.2.3 I don’t understand their English ...................................................80
xi
5.2.4 How can I work? ..........................................................................82
5.2.5 Relationship and discussion of findings to existing literature.......86
5.3 I know that I am different ....................................................................91
5.3.1 They can be a bit off putting ........................................................92
5.3.2 Discovering the WA culture .........................................................93
5.3.3 Relationship and discussion of findings to existing literature.......95
5.4 Phenomenological explanation of the participants’ experiences.........99
6 CHAPTER SIX – REDISCOVERING NURSING .....................................103
6.1 Introduction.......................................................................................103
6.2 Preparedness to work.......................................................................103
6.2.1 It is the same .............................................................................104
6.2.2 But it is different.........................................................................104
6.2.3 The ‘other’ health services.........................................................107
6.2.4 Relationship and discussion of findings to existing literature.....107
6.3 Working with patients........................................................................113
6.3.1 A patient centred approach .......................................................113
6.3.2 The WA patients have a say......................................................114
6.3.3 Relationship and discussion of findings to existing literature.....116
6.4 Working with doctors ........................................................................118
6.4.1 The team approach ...................................................................118
6.4.2 The doctor / nurse hierarchy......................................................119
6.4.3 Relationship and discussion of findings to existing literature.....120
6.5 Let’s talk about professionalism........................................................122
6.5.1 Feeling valued? .........................................................................122
6.5.2 Etiquette and professionalism ...................................................124
6.5.3 Relationship and discussion of findings to existing literature.....126
xii
6.6 Phenomenological explanation of the participants’ experiences.......128
7 CHAPTER SEVEN – IT ALL WORKS OUT AT THE END.......................130
7.1 Introduction.......................................................................................130
7.2 I am not left alone .............................................................................131
7.2.1 There is support ........................................................................132
7.2.2 Feeling of belonging ..................................................................134
7.2.3 Relationship and discussion of findings to existing literature.....137
7.3 I can rely on myself...........................................................................140
7.3.1 I have resilience ........................................................................140
7.3.2 I have agency ............................................................................142
7.3.3 Relationship and discussion of findings to existing literature.....143
7.4 I am one of them...............................................................................144
7.4.1 Acculturation to the WA workplace............................................144
7.4.2 I am different but so what ..........................................................145
7.4.3 I am a WA Registered Nurse.....................................................147
7.4.4 Relationship and discussion of findings to existing literature.....148
7.5 Phenomenological explanation of the participants’ experiences.......151
8 CHAPTER EIGHT – OVERVIEW OF EXPERIENCES AND CONCLUSION
154
8.1 Overall Phenomenological explanation of the participants’ experiences
154
8.2 Limitations of the study.....................................................................156
8.3 Significance for nursing knowledge ..................................................157
8.4 Further research ...............................................................................158
8.5 Concluding statement.......................................................................158
9 APPENDICES .........................................................................................160
xiii
Appendix A: Information Sheet....................................................................160
Appendix B: Consent Form .........................................................................162
Appendix C: poster for SCGH .....................................................................163
Appendix E: Flyer for SCGH........................................................................165
Appendix F: Flyer for HPH...........................................................................166
Appendix G: Letter of invitation ...................................................................167
Appendix H: Demographic form ..................................................................168
Appendix I: Guiding Questions ....................................................................169
10 REFERENCE LIST ..............................................................................170
1
1 CHAPTER ONE – INTRODUCTION
1.1 Background
The persistent shortage of nursing staff reported by most industrialised
countries including Australia poses a threat to the delivery of health care.1-9
While on one hand advances in medical research continue to improve people’s
health status and life expectancy, the depletion of the nursing workforce on the
other hand has the potential to jeopardise the provision of much needed
professional health care. In an effort to alleviate this dilemma consecutive
Australian governments have, over time, developed various strategies to care
for its population. One of these strategies has been to encourage Non-English
Speaking Background (NESB) Overseas Qualified Nurses (OQNs) to enter the
Australian workforce.10, 11
While Australia has been importing individuals with nursing qualifications from
the United Kingdom (UK) since the 1980s,2 changes to the federal immigration
laws now permit nurses from other countries to migrate and enter the Australian
workforce.3, 12 In order to facilitate this process and to assist NESB OQNs to fit
within the Australian nursing standards of practice, government policies and
initiatives such as bridging courses and English tuition have been
implemented.10, 13-17
The combined shortage of nursing staff and the policy of consecutive federal
governments of multiculturalism have, therefore, opened doors for nurses from
Asia, the Philippines, Eastern Europe, Africa, South America and elsewhere to
migrate to Australia. However despite changes in immigration policy the legacy
2
of the white Australian Anglo-Saxon culture may still prevail, which could
therefore generate additional challenges for NESB OQNs trying to integrate into
the workplace. While NESB OQNs have met the Australian Nursing and
Midwifery Council (ANMC) nursing eligibility requirements for registration with
the Nurses and Midwifery Board of Western Australia (NMBWA), they
nonetheless speak with a foreign accent and display some communication and
nursing practice styles that reflect their socio-cultural inheritance. In addition,
some of them display physical characteristics, such as skin colour, that highlight
their ethnic and cultural background which may distinguish them from the
dominant Australian nursing population. These differences could potentially
impede their professional performance, job satisfaction and overall well being,
which may then affect them and result in them leaving the nursing labour
market and/or Australia.
Although the number of NESB OQNs working in Western Australian (WA)
hospitals is increasing18 there is limited documentation and evidence of their
working experiences and their level of work satisfaction. At this time no known
studies have been carried out that address this issue in Western Australia (WA).
Some recent research studies conducted by Australian scholars from the
eastern states have investigated the lived experiences of NESB OQNs, but they
are limited in their number and breadth. However international sources are
available. In fact intensive research studies from United Kingdom (UK), Canada
and in the United States of America (USA), whose long histories of ‘importing’
and employing internationally trained nurses, provide a solid background from
which the lived experiences of migrant nurses working in predominantly white
Anglo-Saxon dominant countries can be understood.
3
While valuable sources of information and knowledge are provided by overseas
scholars, their country’s history, culture, populations and societal structures
differ from those in Australia. Likewise, while Australian studies conducted in
the eastern states offer valid information, the experiences of migrant nurses
working in WA may have some parallels and/or variations. With these limitations
noted the current study should therefore provide a better understanding of
NESB OQNs working in WA.
1.2 Aim of the Study
The aim of the study was to explore the lived experiences of a small group of
NESB female OQNs working in WA metropolitan hospitals in order to extract
the essence of their experiences. The findings should increase and enhance the
current body of knowledge on this topic. The WA setting and perspective will
therefore, add to knowledge generated from other Australian contexts including
Victoria and New South Wales.
The research question for this project was:
What is the impact of NESB female OQNs’ socio-cultu ral
background on their lived experience in joining the Western
Australian metropolitan hospital workforce?
1.3 Structure of the Thesis
The thesis is divided into eight chapters which are now going to be individually
introduced.
4
Chapter One: Introduction. This chapter introduces the study and the context in
which it took place.
Chapter Two: Nursing in Australia. This chapter describes the setting of nursing
in Australia including its regulatory bodies, the shortage and mobility of nurses
and the government immigration policies.
Chapter Three: Methodology. This chapter explicates the research
methodology and describes how this study was undertaken when seeking to
understand the lived experience of NESB OQNs working in the WA
metropolitan hospital workforce. It first gives a general introductory account of
the methodology, with the emphasis placed on transcendental phenomenology
which was the framework chosen for this research project. Secondly it
elaborates on the research methods that have been utilized.
Chapters four, five, six, and seven discuss, in detail, the four themes and sub-
themes that were developed from the study. These themes and sub-themes
are:
Chapter Four: The Initial feelings of professional loss. This chapter includes two
subthemes which are:
� The overwhelming differences experienced in the work environment
� Being like a learner again.
Chapter Five: The Feelings of otherness. This chapter includes two sub-themes
which are:
� I have to speak English
� I know that I am different.
Chapter Six: Rediscovering nursing. This chapter includes four sub-themes
which are:
� Preparedness to work
5
� Working with patients
� Working with doctors
� Let’s talk about professionalism
Chapter Seven: It all works out in the end. This chapter includes three sub-
themes which are:
� I am not left alone
� I am one of them
� I am a WA Registered Nurse
At the end of each sub-theme section, the relationship of the findings of this
research are discussed within the context of the current Australian and
international body of knowledge retrieved from reviewing literature research
conducted in Australia, the UK, Canada and the USA.
Chapter Eight: Overview of experiences and conclusion. This chapter includes
the overall Phenomenological explanation of the participants’ experiences. The
limitations of the study, its significance to nursing knowledge and suggestions
for further research are elaborated upon and precede the concluding statement.
1.4 Summary
This first chapter was an introduction to the thesis. It first provided a brief
background to the topic where the current shortage of nurses in Australia and
the government strategies in employing international nurses including NESB
OQNs were introduced. An overview of the possible challenges faced by
international nurses working abroad were briefly discussed introducing the
existing Australian and international sources of information on the topic, while
establishing the lack of current data on the lived experiences of NESB OQNs
working in WA. Then a brief overview of the aim of the study, and the research
6
question were stated. Finally, an overview of each chapter was presented which
provided the framework of the structure of the thesis.
The following chapter provides the setting for the research topic as it examines
the nursing profession in Australia. It gives a brief historical background,
discusses the professional regulatory bodies, the mobility and shortage of
nurses and the migration procedures in place.
7
2 CHAPTER TWO – NURSING IN AUSTRALIA
2.1 Introduction
The need for health services to care for the sick is not a new phenomenon.
Nursing care has always been and will always be required in societies and
communities. In Australia, as in other countries in the world, the nursing
profession has evolved over time to fit the contemporary health needs of the
people. This has resulted in the education and regulations of nursing practice
becoming increasingly complex. Furthermore, the increasing number of OQNs
entering the Australian workforce 18, 19 has also given the impetus for further
regulations to be put in place.
This chapter provides an overall discussion of the nursing profession in
Australia. The first part gives a brief historical background on the foundation of
nursing, followed by a discussion of the national regulatory nursing body and its
various roles in relation to education and its authoritative role in assessing
prospective migrants. The role of the Nurses and Midwifery Board of Western
Australia (NMBWA) is also examined. The second part explores the mobility of
nurses by first discussing the shortage of nurses worldwide, and then more
specifically, the shortage of nurses in Australia. A brief account of Australian
strategies to alleviate the deficiency is also undertaken. Finally, the migration of
OQNs is explored through a historical account of migration policies, followed by
an explanation of the current recruitment processes at national and state levels.
8
2.2 The nursing profession in Australia
2.2.1 Foundation of nursing
Florence Nightingale the English founder of modern nursing20, 21 has been
highly influential in shaping the nursing profession worldwide, including
Australia. Her approach to patient care and understanding of the powerful
contribution nurses could make to the health care system revolutionised the
nursing profession. It is from the famous Nightingale Training School at St
Thomas hospital in London,22 which she established in 1860, that Lucy Osburn
and five nursing sisters originated. Their arrival in Sydney in March 1868 was
instrumental in spreading the Florence Nightingale vision and value of nursing
care delivery in Australia.21, 23 While the nursing profession has developed over
the years and adapted to the needs of societies and populations, the framework
and essence of Florence Nightingale’s teachings continue to provide a model
for nurses today in Australia and worldwide.20
The International Nursing Council (INC) which represents nurses from more
than 130 countries including Australia provides a relatively universal definition of
nursing. 24
“Nursing encompasses autonomous and collaborative care of
individuals of all ages, families, groups and communities, sick or well
and in all settings. Nursing includes the promotion of health, prevention
of illness, and the care of ill, disabled and dying people. Advocacy,
promotion of a safe environment, research, participation in shaping
health policy and in patient and health systems management, and
education are also key nursing roles.”25 (INC 2002)
9
This explanation of nursing offers a holistic understanding of what it is to be a
nurse, which applies to all nurses regardless of their ethnic or cultural
background. However nursing is a regulated profession and countries have
professional bodies which, with the best interests of the general public at heart,
ensure that practising nurses fit the professional competencies to provide
quality health care to the needed population.
2.2.2 The national regulatory body
In Australia, the Australian Nursing and Midwifery Council (ANMC) is the
leading national body that regulates nursing and midwifery. It was established in
1992 and works in partnership with the eight states and territories’ Nursing and
Midwifery Regulatory Authorities (NMRAs) to achieve a national uniformity in
regulating the profession.26 Its mission is to:
“… safeguard the healthcare interests of the community by
formulating and promoting high standards of nursing and
midwifery practice…” (ANMC).10
The ANMC therefore is responsible for developing and reviewing educational
and professional standards so that the diverse Australian population can benefit
from an optimal health care delivery.26 This is reflected by the high professional
standards it sets for nurses and midwives.27 However the nursing profession is
not practised in a vacuum. It needs to function within the dynamic Australian
setting. Economic reforms, health policies and population demographic changes
have to be taken into account by the Council in order to ensure nurses are well
prepared and supported so that they can deliver the high quality nursing care
that is expected of them.
10
2.2.3 Nursing education
In 1993 there was a shift from hospital based training to tertiary education. This
reflected the strong commitment of the ANMC to equip nurses not only with
clinical abilities but also broader knowledge and higher intellectual skills, such
as communication and critical and analytical skills, to assist them in adjusting to
the challenges of their contemporary code of practice.19, 28 It also showed the
Council’s continuous commitment to the delivery of high quality care to the
Australian community. However, in order to achieve the educational process
that would assure that competence and accountability continued to lead the
Australian domain of nursing, the ANMC does not work in isolation but “…
[collaborates] with educational institutions, the health care sector, the
community and the profession, and the nurse regulatory authorities”.28(p.4) It also
engages in international forums so that it is up to date with nursing and health
matters and developments occurring in other countries.10 Therefore the
programmes in teaching universities must be accredited and must operate
within the national and international context of the nursing profession.29
The nursing curriculum must reflect the core framework of nursing practice set
by the ANMC30 which is encapsulated in the National Competency Standards14,
the Code of ethics31 and the Professional Conducts.27 At present each
Australian state and territory has its own nursing legislation to provide the
accreditation of courses and, therefore, has the final responsibility for course
accreditation.28, 30, 32 However the Council of Australian Governments’ decision
to establish a single national registration and accreditation scheme for health
professionals by 1st July 2010,32, 33 has been welcomed by the ANMC and the
Australian elite nursing and midwifery organisations called the Australian Peak
11
Nursing and Midwifery Forum (APNMF)16. The Forum is currently working to
facilitate this transition.
It is important to note that not all nurses working in Australia have gained their
qualifications in this country. Many nurses have qualified overseas and many
more OQNs are expected to migrate to Australia in the future. However while
their profession reflects the INC definition of nursing25, their qualifications and
skills must still be evaluated in order to assess if they fit the Australian nursing
framework set by the ANMC.
2.2.4 Regulations on OQNs coming to Australia
While the ANMC holds the authority for the Department of Immigration and
Citizenship (DIAC) to assess the eligibility of OQNs for migration, it does not
grant nurses a license to work.10, 13 In order to migrate, applicants can apply as
an independent skilled migrant or under one of the sponsored visas. In both
cases they must meet specific criteria. They must be less than 45 years of age,
able to provide evidence of their nursing qualification and work experiences,
and be proficient in the English language.10 From July 2009, all internationally
qualified applicants, unless registered in New Zealand, must have successfully
completed either the Occupational English Test (OET) with a minimum of a B
pass or the International English Language Testing system (IELTS) with a
minimum score of 713, 34, 35. This requirement is to ensure that, despite their
nursing expertise, OQNs are able to communicate effectively with their clients
and their families, colleagues and other health professionals.
12
Following this thorough process the ANMC sends a ‘letter of determination’ to
the applicants detailing the outcome of their application for migration.13, 35
Depending on their country of qualification not all applicants are eligible. Some
may be required to undertake a form of competency based assessment or a
migrant bridging program which, when successfully completed, will lead the
participant to be eligible to apply for migration and registration. The current
process for registration occurs at the NMRA of the state or territory in which the
prospective nurse applies to work.15, 29 However, as mentioned before the
change towards a national registration is to take place by mid 2010.16, 32, 33
As this research is looking at OQNs working in Western Australia, the Nurses
and Midwifery Board of Western Australia (NMBWA) will be briefly discussed. In
particular the process that OQNs need to follow in order to obtain their
professional licence will be described.
2.2.5 Nurses and midwifery board of Western Austral ia
The NMBWA’s vision is to influence quality nursing and midwifery practice for
the community of Western Australia.24 It is comprised of twelve board members,
a CEO, four directors and a network advisory panel. It also has six advisory
committees that address issues related to complaints, finance, professional
practice, registration and competence, and education and research. Each
committee advises the Board on matters related to their set duties which are
carried out in accordance with the Western Australia Nurses and Midwives Act
2006 and Regulation 2007.36, 37
13
As stated on the NMBWA website,38 OQNs are encouraged to come and work
in WA. If they are eligible to work in Australia, meaning that their education
qualifications have been approved, they hold a working visa, have no criminal
record, have passed the English competency test and are physically and
mentally sound to practise then they can apply for their registration.38 However
if they have been advised to undertake a registration bridging course, there are
five accredited institutions available in Perth to provide the theoretical and
clinical practice components of the required curriculum.39
Once OQNs obtain their license they then join the pool of WA registered nurses
and, like all other nurses, must provide evidence of their continuing professional
competence.40 To do this they must maintain a professional portfolio, where
evidence is provided of annual work assessment, continuing professional
development and recency of practice.41
In Australia the nursing profession is a well regulated body and the NMBWA
aligns with the ANMC in its mission to protect the community by ensuring safe
standards of nursing and midwifery practice.10, 42 The influx of OQNs into the
Australian workforce reflects not only on the health system’s need for nurses
but also the immigration policies and ideology of the current and recent federal
governments.
2.3 The mobility of nurses
Qualified nurses like many other professionals are able to sell their skills
nationally and internationally. In fact since the late 1990s their mobility has been
more substantial, to the point of becoming a global phenomenon. There is no
14
doubt that the improvements in communication and travel have made it easier
for them to export themselves. Nevertheless, the driving forces behind their
mobility are multifaceted and complex.43 The increased demand on the health
sector, combined with the scarcity of nurses are often described as high
contributors to the current predicament of the nursing workforce.4, 44 While this
phenomenon exists for a variety of health professionals, such as doctors,
physiotherapists and occupational therapists, it is widely held that nurses are
the main professional component of the ‘front line’ staff in most health
systems.44 Through both their curative and preventative roles, nurses provide
the highest percentage of patient care.45 Among the pool of health
professionals, nurses are in high demand.4, 43, 46, 47
2.3.1 Shortage of nurses worldwide
While the 12 million nurses estimated to be in the world may seem a reasonable
number to the lay person, expert studies report that nurses are globally in short
supply. The extent of this problem is perceived to have short and long term
dramatic effects and has been termed by the ICN in 2002 to be a “global
crisis”.44, 45 In fact, its impact is believed to have the potential to jeopardize
some of the humanitarian 2015 Millennium Development Goals (MDGs) to
reduce child mortality, improve maternal health, eradicate extreme poverty and
hunger, to combat HIV/AIDS, tuberculosis and malaria epidemics.44,48
Furthermore, the nursing shortage may be exacerbated further as far reaching
research highlights increasing rates of medical and surgical complications,
cross infection rates and, therefore, increased mortality.44, 45
15
There are no universal norms in relation to the ‘right’ ratio of nurses within a
population. Some populations may be sicker than others therefore requiring
higher levels of care than others. Nevertheless, when one compares, for
example Africa with a ratio of 71 nurses per 100,000 population, with Europe
with a ratio of 663 nurses per 100,000 population (WHO, 2004)44 it is obvious
that major discrepancies between countries and regions of the world exist and
that the situation of developing countries is dramatic.29, 43-45 Nonetheless,
despite the fact that wealthy industrialized societies have an overall higher
nursing population; they are still struggling to sustain the health service
demands and expectations of their growing, ageing and sick populations.44, 45, 49
The ICN is reporting a shortage of 13,000 nurses in the Netherlands, 18,000 in
France and 3,000 in Switzerland. It is also estimated that in 2010, the United
States of America will have an alarming downfall of 1,000,000 nurses and in
2011 Canada will be short of 78,000 nurses.44, 45 Australia is not exempt with a
predicted shortfall of 40,000 nurses in 2010.18, 45, 50
2.3.2 Shortage of nurses in Australia
In 2005, the Nursing and Midwifery Labour Force Census reported an overall
national pool of 230,57817 registered nurses. However the National Health
Workforce Taskforce 2009 report is more precise as it specified that only
206,873 of these nurses were in the workforce.19 The figure is nonetheless
insufficient to provide for the fast growing Australian population, whose
increased life expectancy, burden of lifestyle diseases and chronic illnesses are
placing a huge amount of pressure on health services.18, 19
16
In Australia nurses are the largest health professional body. As a result of the
impact of new discoveries and new knowledge in medicine and public health,
their scope of practice has increased and diversified. Consequently their skills
are not only in high demand from doctors but also from the Australian public.19
In fact nurses can work in both primary health care and hospital care settings,
and while the scope of their practice has expanded it has also given room for an
increased workload.19 However, despite the growth in professionalism and
despite the greater demand for nurses, females continue to dominate this
occupation. The 2005 Census reported a male representation of only 7.9% in
the profession. It also highlighted that the average age for a nurse is 45 years.
17-19, 28, 29, 45 Therefore it seems that nursing is failing to attract young recruits
both male and female.
In Western Australia the 2005 Census results showed a total of 19,102
employed registered nurses with an average age of 46.7 years and with a male
cohort of 5.2%.17 The reasons for this gender imbalance are multifaceted.
However, a female dominated profession is affected by constant fluctuations in
its employment pool, as women in their reproductive years are more inclined to
leave the workforce or work part time while raising their children.
The nursing shortage is a real threat to the welfare of populations. Global and
national strategies to find remedies on how to tackle the crisis have been and
continue to be researched and implemented.29 Programmes to improve the
efficiency in the provision of healthcare delivery are discussed in the literature,
however they will not be elaborated upon as the main focus of this research is
on the human aspect of the shortage, therefore on nurses.44, 49
17
2.3.3 Strategies to alleviate the shortage
There are three sources to acquire registered nurses and in its search to
increase the pool of working nurses, the Australian government has been
working actively on each of these options.17 Firstly, it can try to attract more
prospective students, not only school leavers, but also mature age people44 in
order to produce more new graduates.18 This is a good long term goal. It takes
up to four years full time for a registered nurse (RN) to graduate from university.
The enrolled nurse (EN) programme takes up to 2 years; and through training
pathways ENs can upgrade their qualifications to become RNs.17, 28, 29
Secondly, it can endeavour to recruit qualified nurses who are not currently
employed. The 2005 census estimated that 41,260 RNs and ENs are not
working as nurses in Australia.17 Financial incentives and refresher courses are
made available to encourage nurses back into the workforce. 51Thirdly, it can
open its frontiers for overseas qualified nurses to come to Australia. The 2005
Australian Bureau of Statistics (ABS) census showed that in 2004-2005 a total
of 6,619 OQNs entered Australia, although not all for employment reasons.17
The common feature of these three schemes is to have long term effective
plans to sustain the existing nursing workforce and attract new nurses to the
profession either from within Australia or from overseas.29, 44, 45 For the purpose
of this study the last strategy, the employment of OQNs, will be explored further.
2.3.4 Migrating to Australia
Global migration is a growing feature of our time. In 2005 it was estimated that
3% of the world’s population were international migrants and in industrialised
countries, it was around 10%.50, 52 In 2002 the Organisation for Economic
Corporation and Development (OECD) report estimated that in Australia,
18
Canada, the UK and the USA a quarter of the medical and nursing workforces
were educated abroad.53 While the shortage of nurses is a worldwide
phenomenon, Australia like most industrialised nations, has been actively
recruiting from overseas.53, 54 55
2.3.5 Australian migration history
As a settlers’ country, Australia has a long history of migration with about 40%
of its population being immigrants or children of immigrants.56 However it is
important to highlight that various policies have been implemented over the
years that have been highly influential in setting the criteria to regulate
migration. The ‘White Australian Policy’ which was implemented between 1901
and 1966 restricted permanent settlement to Europeans, preferably those from
the British Isles.57 Arthur Calwell, the first Australian immigration minister
developed, in 1947, the first immigration programme which favoured English
Speaking Background (ESB) migrants.58 However the subsequent assimilation
and integration policies had the effect of opening the doors to a more diverse
population, including people from Asian countries.56-58 The slogan of this time
‘populate or perish’ highlighted the urgency to alleviate the massive labour
shortage. Migrant workers who were brought in primarily as cheap labour to
benefit rising capitalism, had limited access to economic growth and political
power.58
In 1972 a new policy on multiculturalism emerged whereby the welfare of non-
European migrants and the need for equal rights, similar to those of the
dominant Anglo-Celtic population, was considered.56-58 This policy has been
shaped over the years, however, in essence, it recognizes and values cultural
19
and ethnic diversity. It advocates the principles of cultural identity, social justice
and economic efficiency as prerequisites for all individuals regardless of their
background.57 This non- discriminative policy combined with the globalisation
and deregulation of the Australian economy has changed the immigration intake
towards educated people, with little emphasis on their country of origin.58 This
approach and policy are still in place today59 and therefore it is within this
ideological framework that foreign nurses entering Australia are working.
2.3.6 Recruiting OQNs
The high demand for registered nurses as per the Migration Occupation in
Demand List (MODL)60 and the Critical Skills List61 provides the impetus for the
Australian government to be proactive in its recruiting strategies to attract
registered nurses from abroad. The Department of Immigration and Citizenship
website provides extensive information for future migrants on how to apply for a
working visa.62 It also conducts national and overseas ‘Skills Expos’ to attract
potential applicants and, while nurses are not the only required workforce, they
are at the top of the ten occupations in most demand.63 64 At a state level
nurses are also on the Western Australia Occupations list.65 The State
Government migration website66 similarly provides detailed information on the
state’s regional labour needs, and visa and sponsorship processes67. It also
carries out international events to attract emigrants.
Hospitals are also actively recruiting OQNs. They can apply to the Department
of Immigration and Citizenship to sponsor OQNs who, upon selection, can apply
for a visa. This initiates the process towards gaining their working licence.62
20
In the ANMC 2005-200668 annual report, 1717 OQNs applied for a skills
assessment as required under the General Skilled Migration. In the 2007-2008
annual report,10 2274 applied. In both reports 63 countries were represented.
These statistics highlight not only the increase in the number of applicants and
therefore the success in recruiting nurses, but also the cultural and ethic
diversity of the growing cohort of registered nurses in Australia.
2.4 Summary
This chapter has provided the background of the nursing profession in Australia.
The first section started with a short history of the foundation of nursing,
followed by the ANMC responsibilities in education, and assessment of the
qualifications of OQNs wishing to migrate to Australia. The role of the NMBWA
was also discussed. The second section looked at the global mobility of nurses.
An initial general discussion of the shortage of nurses worldwide was
elaborated upon to set the background for a more specific discussion on the
shortage of nurses in Australia. A discussion of various approaches to alleviate
the problem was briefly undertaken.
The issue of migration was explored firstly through a historical description of the
migration policy processes and then through an account of the current national
and state recruitment strategies to encourage OQNs to join the Australian
health care system. The discussion of these issues provides the context for this
study, which aimed to explore how Non English Speaking Background (NESB)
Overseas Qualified Nurses (OQNs) integrate into the Western Australian (WA)
hospital workforce.
21
The following chapter will present an overview of the methodology and will
explain research methods utilised in this project.
22
3 CHAPTER THREE – METHODOLOGY
3.1 Introduction
This chapter, which is divided into two parts, describes the research
methodology utilised for this study when seeking to understand the lived
experience of NESB OQNs working in the WA metropolitan hospital workforce.
The first part provides a general overview of the methodology while the second
part elaborates on the research methods that have been used.
3.2 Overview of the methodology
This section provides a general introductory account of qualitative research.
This is followed by a discussion on phenomenology where two dominant
schools of thoughts, namely transcendental phenomenology69-73 and
hermeneutical phenomenology69, 70, 73-75 are explained. Lastly a review of the
implementation of phenomenology in nursing research is discussed.
3.2.1 Qualitative research
Qualitative research is an investigating process that is interested in
understanding the way human beings act and interact within their social world.
Utilisation of qualitative research can be traced from the beginning of the
twentieth century and has a long tradition in social sciences and
psychology.76, 77
23
In the late 19th and early 20th century the natural sciences approach to research
which was believed to be more logical, neutral and accurate became influential
and provided a shift in the way sociological and psychological research was
undertaken.77 Quantifying data was based on a positivist philosophical
viewpoint which assumes that reality and truth exist independently of people
and context. Therefore, it was argued that research should be focusing on the
discovery of natural laws that govern the functioning of the world.76, 78 This
paradigm was then applied to unravel the rules and patterns of social life.79 In
utilizing this empirical-analytical methodology, populations were sampled
randomly and standardized surveys were conducted in order to study a
particular trend. The findings were then reduced and converted into numerical,
statistical data which generated knowledge on social life that was believed to be
the universal truth.78-80 The complexity and diversity of human nature and
behaviour was simplified and generalized to frequencies and numbers.
Disenchantment with these research outcomes, which failed to explain and
understand individuals’ and groups’ subjective life experiences, was the impetus
in the 1960s for the renaissance of qualitative research in social sciences and in
psychology.76, 79, 81-84 As Flick79 argues, research should take into account
people and therefore should be analysing concrete cases, where individuals’
activities are studied within their local contexts. This approach provides a more
appropriate framework in the endeavour to understand how and why people
think and make sense of what they do. Set within the participants’ natural
surroundings, depth and intimate information are collected mostly via
interviews, focus groups and observations, which drive the researcher on a
journey of discovery, to grasp the unique life experiences of participants.
24
Through this dynamic inductive approach, knowledge can be gained. It does
not, however, claim to be the truth but an interpretative analysis of the
phenomena studied.76-79
Underpinning qualitative research are philosophical assumptions that inquirers
make. Their ontological stance is that reality is constructed and resides within
the realm of the individual. Therefore reality is subjective and multiple.73, 79
Based on their theory of knowledge, their epistemological position is to minimise
the distance between researcher and participants in an attempt to facilitate a
better understanding of the worldview of the latter.73, 78, 85 Their methodological
approach is inductive, that is, from the ground up and influenced by their
worldviews. Furthermore, data are interpreted through a theoretical lens.
Qualitative research encapsulates all these philosophical assumptions and
impacts necessarily on researchers’ selection of research methods and their
overall approach to the study. 73, 76, 79, 80
Among the most common approaches to qualitative research are narrative
research, case study, grounded theory, ethnography, participatory action
research, discourse analysis and finally phenomenology.73, 79, 80, 84-86 Each of
these approaches has a different purpose and level of complexity in addressing
the respective research question. The researcher, therefore, has to select the
approach that aligns with his/her philosophical viewpoint but also which he/she
believes is most appropriate to conduct the investigation.
As phenomenology was the chosen approach to this research, a concise
description is provided in the next section.
25
3.2.2 Phenomenology - overall perspective
Derived from the two Greek words phainomenon and logos meaning
‘appearance’ and ‘reason’, phenomenology was a term used in the 18th century
in philosophical texts.71,87,88 Franz Brentano (1838-1917) an eminent
psychologist who was interested in the internal nature of consciousness is
believed to have brought this philosophical component into the world of
science.71, 74, 88 Following his footsteps, Edmund Husserl (1859-1938) a German
mathematician who converted to philosophy, further elaborated this concept to
the point that it could be applied as a research method of inquiry.87-89 His pursuit
was to discover the structure of human consciousness and therefore to find
truth in lived experiences.84,90 He was very much interested in understanding
how people live and experience the everyday world.83, 87 He stressed that
because the mind is always directed toward objects, people are consciously
aware of what they know. Therefore the individual conscious awareness of an
object creates his/her perception of its reality. He termed this principle
‘intentionality’.69, 70, 73, 83, 84, 91, 92 His belief was that the external world does not
exist independently of people but is what people’s consciousness believes it is.
Reality is then understood as the life-world.69, 70, 83, 93, 94 Phenomenological
study, which is imbued by its philosophy, is concerned about how a group of
individuals who share a similar life experience describe and give meaning to
that particular phenomenon; how they interpret it and how they make sense of it
so that its essence can be captured.73, 90
In order to gather the information necessary to grasp people’s consciousness
informal ‘in depth’ individual interviews are conducted in a safe environment
where participants are encouraged to elaborate on their lived experience of the
26
issue being studied.73, 90, 91 The challenge nevertheless is to ensure that the
subject is comfortable so that the narrative flows naturally and spontaneously.89
The goal of the researcher is to retrieve the meanings that participants give to
their lived experience of the same phenomenon. The result of the gathered data
of individuals’ conscious recollection is not to explain or analyse it but to reduce
it to an essence, an invariant component which highlights the commonality of
the phenomenon as lived by all the participants.69, 73, 86, 90 It is interesting to note
that this approach has in a way a positivistic element as it tries to seize the
universality of the lived experience.
Nowadays there are many strands of phenomenology discussed in literature
which have all been influenced from the two traditional philosophers Husserl
(transcendental phenomenology) and Heidegger (hermeneutic phenomenology)
whose approaches to phenomenology differ quite significantly.
3.2.3 Transcendental phenomenology
According to its founder Edmund Husserl, transcendental phenomenology is the
original and the only approach to phenomenology. As the name implies,
researchers need to transcend their natural stance and beliefs about the world
when conducting research informed by transcendental phenomenology.95
Fundamental to this philosophical standpoint is that only descriptions should
arise from the lived experience of a distinctive phenomenon. In fact Husserl’s
emphasis was to return to the original things prior to any reflective thoughts and
any objectivity about humanity. He argued that in order to reach the core
meaning of an incident or an event, its context (including the time and its
environmental factors) have to be put aside.70 Husserl wanted to grasp “the
27
natural attitude as reflected in pre-reflective experiences” 89(p.310). Experiences
had to be reduced to a neutral stage for their original essence to be
uncovered.87, 92 It has been argued that, through this process, Husserl was
trying to bring objectivity and generality to the understanding of human kind.
This in a way is skewed more towards an empirical, pragmatic paradigm, and
thus, moves away from the subjectivity of people’s worlds.69, 70
With his primary focus placed on describing how participants give meanings to
their shared experience of a particular phenomenon, Husserl stressed the
importance for the researcher to set aside his/her preconceived ideas of the
situation under investigation and thus to suspend any prior knowledge of the
phenomenon. The purpose of such an approach is to gain a fresh outlook on
the phenomenon in order to unveil the essence of consciousness, the true
realm of being.69, 70, 84, 87, 88 Therefore the unique and defining feature of
transcendental phenomenology is the process of reduction.71, 72, 88, 95 This
implies that the researcher has to ‘bracket’ not only the outer world, but also
his/her beliefs and preconceptions of the undertaken inquiry, so that no
personal biases or self interest could contaminate the collected data.69, 70, 84, 89-
91, 93, 95 Husserl refers to this as ‘Epoche’ and his viewpoint was that when
‘Epoche’ is undertaken the researcher is able to return and re-examine some
taken for granted understandings and erase them so that new uncovered
meanings can emerge. The description of the findings should then be as close
as possible to the participant’s true experience not influenced by the
researcher’s viewpoint. 70, 71, 92
28
To Husserl bracketing provides the rigorous element needed to give validity and
credibility to qualitative research in the human sciences.70, 72 In keeping with this
procedure the researcher can then proceed with one on one in-depth
interviews, where broad and open ended questions are asked. The collected
information from the individuals is then reduced to significant quotes and then
synthesized into themes which would contribute to the uncovering of the
essence of the experience.70, 73, 84, 86 Whilst Husserl’s concept of bracketing
appears easy to follow and apply and a very valuable tool in trying to remain
true to the collected data and its analysis, its application and reliability in trying
to remain detached and objective during the data analysis continues to be
debated. Many scholars disputed that, as social beings, individuals cannot fully
depart from their own viewpoint and ethnocentrism and that, at best only partial
bracketing can be achieved.69, 70, 91, 95-97
3.2.4 Hermeneutical phenomenology
Hermeneutical phenomenology is also a strand of phenomenology and is
concerned with human lived experiences. This approach, however, not only
intends to describe a phenomenon but it also endeavours to interpret the
findings.73, 87, 88 Its pioneer Martin Heidegger (1889-1976) was taught and
mentored by Husserl84, 87, 90 however he expanded and departed from Husserl’s
epistemological approach to an ontological debate in search of uncovering the
meaning of being.70, 87 He refuted the dichotomy between the mind and object
and argued that consciousness was encapsulated in the world of human
existence altogether.88 He further elaborated that people’s consciousness of an
experience does not occur in a vacuum but is shaped by their personal history
and culture and by the social context in which they live. 69, 70, 84, 95 For Heidegger
29
the experience and understanding of “Being-in-the-World” was what he was
searching for.74, 87, 88 He pointed out that the ability to interpret the world was a
characteristic of human nature and that it was an essential element to the
process of understanding.70, 84, 88 Following this principle, he further expanded
that, because the researcher cannot depart from his/her inherent need for
interpretation, he/she should bring his/her own experiences and knowledge to
the study being undertaken. As a result, he refuted the ‘Epoche’ or bracketing
process.70, 87, 95 In fact he was adamant that the researcher and the participants
should be close. In his view, this partnership was legitimate and essential
because the investigator’s prior knowledge and pre-understanding of the
phenomenon under investigation would provide greater impetus and richness to
the analysis, thus facilitating depth to the interpretation of the data.70, 74, 84, 90
In order to implement this approach Heidegger developed the notion of the
‘hermeneutic circle’ to ease the journey to further research the discovery of the
essence of the studied phenomenon.69, 70, 74, 84 The hermeneutic circle allows
the researcher to go in a “… back and forth movement, of questioning and then
re-examining the text and results in an ever-expanding circle of ideas about
what it might mean to be”. 70(p.11) The purpose of this dynamic element, is to
examine the “texts” of life73 by constructing, deconstructing and reconstructing
them to arrive at a shared knowledge which Heidegger assumed represents the
true essence of the phenomenon.70, 73, 84
While both are strands of phenomenology, it is interesting to note that the
approaches of both philosophers are very different. It is, therefore, important
when conducting a study that utilizes phenomenology to specify the selected
30
approach. In this research project transcendental phenomenology was chosen
as the preferred approach.
The application of phenomenology in nursing research will now to be discussed.
3.2.5 Phenomenology in nursing research
In the search to advance and redefine its identity within the field of health, the
nursing profession has developed and evolved quite rapidly in recent years.
While initially this discipline emerged within the parameters of the natural
sciences and primarily from the domain of medicine, it has progressively
departed from the dominant biomedical model of health shifting from the
traditional physiological and pathological focus toward a more holistic approach
to patient care.89, 96, 98, 99 In recognizing and accepting individuals’ unique
understanding of the world, nurses strive to be more client focused, not only in
their practice, but also in their research.89, 100 However, with nursing research
traditionally conducted within the dominant positivist approach, some nursing
scholars became dissatisfied with this inquiry framework as it did not respond to
the knowledge they sought about the complexity of people’s behaviour. In fact
while nursing epistemology has a very strong scientific based component, it,
nonetheless, is very much interested in how people and their significant others
experience health and illness, and also how practising nurses experience
nursing.
With this in mind, nursing theorists started to seriously question the relevance of
the traditional quantitative research process.74, 91, 92, 97, 98 They disputed the
adequacy of the generalization of findings on human experiences and
31
behaviours. The importance of the subjective element of how people
experienced a particular phenomenon started to be recognized and valued. This
gave the impetus to a move towards qualitative nursing research.
Phenomenology established itself as a preferred approach to nursing research
in the late1970s and early 1980s, and continues to be the most popular method
utilized in qualitative inquiries.91, 93, 96, 98, 101
The new Theory of Humanistic Nursing (1976) developed by Paterson and
Zderad based on the humanistic principle recognizing that ”… the dignity,
rational abilities and value of all people... [influence] their own destiny...”99(p.1561)
brought a new understanding and an innovative focal point to contemporary
nursing practice.74, 99, 102 The emphasis placed upon the therapeutic relationship
nurses have with their clients and in particular the empathy they consciously
display, was believed to be strong by contributing to “the development of human
potential”. 99(p.1563) This new theory gave the impetus to search and attempt to
explain the nature of patient-nurse interactions. Nursing academics adopted
philosophical phenomenology to describe and explain people’s interaction with
the self and the environment, as it fitted well with the new ethos of nursing
practice and, therefore, their research needs.102 Nursing scholars, however,
primarily embraced and adopted the hermeneutic phenomenological approach
in their search to interpret, rather than describe, situations within the context of
health and illness that nurses and/or patients were experiencing. Hermeneutic
phenomenology, it was argued, aligned with the subjectivity and individualistic
human experience and was believed to be salient in expanding on nursing
knowledge.70, 74, 89, 96, 98, 100, 101
32
However, while phenomenology has been and continues to be widely utilized in
nursing research, critique of the thoroughness of its application has been
generated. Crotty103 in 1996 published a text which was highly critical of nurse
researchers’ poor application of phenomenology in their studies. In fact North
American nurse academics such as Benner, Turale and Garrett, who have
produced extensive studies have been condemned for their lack of rigor.96, 103
Their work has been described as highly descriptive, lacking critical analysis
and with little if no resemblance to the original European philosophical and
fundamental elements of phenomenology.103 It appears that many researchers
have conducted similar research but varied the approach and failed to
discriminate between the different philosophies.87, 91 Many of the researchers
failed to justify why they adopted phenomenology for their chosen investigation,
others offered no explanation of which philosophical strand (e.g. Husserl or
Heidegger), they were following; and others displayed a total ignorance
between philosophy and methodology.69, 74, 96, 100 Furthermore, while the
subjectivity of the human experience is highlighted in some nursing texts, it
seems that some scholars’ research findings reside with the ontology of an
objective reality. In their research findings they tend to describe their
participants’ unique perception of a phenomenon as an authoritative statement
so that it becomes a general truth.97 Such statements go totally against the
intent and underpinnings of phenomenology.
These gaps and failures to comply with the methodological framework and
philosophical theory have been detrimental not only to the research, and their
researchers, but furthermore to the body of nursing. The profession has been
33
working hard in recent times to depart from an identity of assisting medical
doctors to a professional identity and field of expertise within its own right.89
Nursing academics have responded and disputed the condemnation brought
upon their work. They have argued that phenomenology cannot only remain
within the realm of philosophy and that it has to evolve so that it can be applied
at a scientific level for nursing.104 Overall the impact of criticism within the field
of nursing has generated mixed responses. It has, however, provided an
overture for debates and for analysis and reflection on the application of
research methods. The scrutiny has been beneficial in bringing more depth in
qualitative nursing research and, therefore, at bringing the nursing profession
within the realm of its intellectual search for improvement and recognition as a
distinctive career.
3.2.6 Summary
In this first section an introduction of qualitative research has been provided and
a discussion on phenomenology with further elaborations on Husserl and
Heidegger’s distinctive approaches has been provided. Finally a review on the
implementation of phenomenology in nursing research has been included. The
following section is a description of the research methods that were utilized for
this study.
3.3 Research methods
As highlighted in the previous section, the past utilisation of phenomenology in
nursing research has had difficulties in applying Husserian or Heideggerian
frameworks. With philosophy being the core element of phenomenology,
34
challenges inevitably occur when one tries to utilize it in real life situations that
focus on human activities. The move towards an interpretive model appears to
fit well within the holistic approach of today’s nursing paradigm. However, the
intention of this study was to describe the life experiences of NESB OQNs as
they integrate into the WA metropolitan hospital workforce. Therefore the
approach utilised for this study was in line with Husserl’s epistemology.
Moustakas’71 scientific approach to transcendental phenomenology informed by
the work of Husserl and others underpinned this study.
The following section elaborates on Moustakas’ phenomenological approach
and justifies the choice of method as it was adopted in this study.
3.3.1 Rationale for choosing a phenomenological app roach
The aim of this research was to explore how NESB OQNs experienced work in
the WA metropolitan hospital workforce. The phenomenological approach is
appropriate as it allowed the gathering of information from participants who
shared the same experience. The aim of the study was not to try to seek,
understand or justify the reason for what happened, but instead to recall and
describe the meanings that all the nurse participants gave to their experience in
order to extract the essence of their conscious acknowledgement of the
phenomenon. The approach adopted was able to account for people’s
uniqueness and individuality while at the same time search for commonalities of
the pre-reflective meanings they provided of this experience.
35
3.3.2 Moustakas’ approach to phenomenological resea rch
Framed within Husserl’s’ transcendental phenomenology, Moustakas in his
book “Phenomenology Research Methods”,71 provides a thorough explanation
on how to proceed with a research project. This source informed this research.
Moustakas believes that intuition and essence precede empirical knowledge
and that one should return to her/himself in order to discover the nature of the
meaning of things. When that occurs what appears in the consciousness is the
pure phenomenon. It is, however, vital to first step aside from any judgment or
any preconceived understanding. In Husserl’s terms this is called ‘bracketing’
one’s view points of a situation. Through this transcendental phenomenological
reduction, each experience is then considered in its singularity in a fresh and
open way. A textural description of the meanings and essences of the
phenomenon and what comprises the experience is derived. A structural
description then describes the conditions that precipitate and connect with an
experience. Finally, the Imaginative Variation facilitates explication of a
structural essence. Moustakas then combines the Reduction and the
Imaginative Variation processes in order to arrive at what he calls “the
structural-textural synthesis of meanings and essences of the
phenomenon”.71(p.36)
When applying transcendental phenomenology to human science it is important
to capture the wholeness of the true things without preconceptions in order to
gain meanings resulting from intuition and reflection of conscious acts. Only the
description of the experience of what is materialized in consciousness is sought.
However, as noted previously the feasibility and the reliability of the ‘bracketing’
or ‘Epoche’ process has been disputed. As Moustakas explains “[its value] is
36
that it inspires one to examine biases and enhances one’s openness even if a
perfect and pure state is not achieved”.71(p.61) Indeed the complex process of
socialisation that shapes people’s individuality is hard to fully dissect and
identify. Therefore a pure/blank human being state of mind cannot be achieved.
Nevertheless researchers’ awareness of past experiences and understanding of
a situation, and the reflection and meditation processes that follow, not only
endeavours to set aside biases, but also contributes to expanding the body of
knowledge of the wonder of true human nature.
a Methods and procedural guidelines
In order to proceed with the research, Moustakas suggests that the following
steps be undertaken:
1. Discovering a topic and question
2. Conducting a comprehensive review of the professional and research
literature
3. Locating appropriate participants
4. Providing participants with clear instructions, obtaining informed consent,
ensuring confidentiality and applying ethical principles of research
5. Developing set questions for interview purposes
6. Conducting and recording individual interviews
7. Organising and analysing data to develop individual textural and
structural descriptions, a composite of textural and structural
descriptions, and synthesise the textural and structural meanings and
essences. 71(p.104)
37
These guidelines were followed in this research. However, a small literature
review was undertaken initially in order to develop a research proposal for this
thesis. A full review of the literature was conducted after the research had been
completed and the data analysed. The rationale for this was in line with the
bracketing process. In-depth knowledge of what previous theorists/ researchers
had found on the topic would need to be ‘bracketed’ in order not to influence the
analysis of the interviews. Pertinent findings from current research were woven
throughout chapters five, six, seven and eight that elaborated on and discussed
the themes that emerged from this research project. In fact under each sub-
theme existing and related literature are highlighted and discussed.
3.3.3 Personal and social foundation in the researc h topic
Like many other phenomenologists, Moustakas71 argues that the researcher’s
intimate interest and curiosity in a topic gives the impetus for the investigation to
take place. This phenomenological inquiry emerged out of my personal and
professional history and experience.
It first started over 20 years ago when I migrated from France to WA. As a
registered nurse I first struggled through the whole process of obtaining my
license, but afterwards, I also experienced difficulties in trying to fit into the
hospital working environment. At the time I felt that the Australian nurses were
not helpful and did not really care where I was coming from as long as I did the
work. I also experienced great difficulties with the English language. I found that
my colleagues made little effort to communicate clearly and also to listen
carefully to what I was saying. I lived this experience in isolation and worked
very hard in trying to blend in.
38
About ten years ago I was teaching and coordinating NESB OQNs students on
their clinical rotation in a Perth metropolitan hospital. This was the last
component of the university bridging programme they were undertaking so that
they could obtain their nursing registration with the NWBWA. In this role on
numerous occasions I witnessed some of the difficulties the nursing students
were faced with. They struggled with their English language skills. They also
appeared shy, especially with their nursing colleagues as they waited for
direction and support. That was surprising because I knew that all the NESB
OQNs were qualified and experienced clinicians in their own country.
Furthermore the nursing preceptors, who were working with the students and
reporting to me on the students’ performance, provided feedback that was at
times ethnocentric and even racist.
As a result of these encounters with NESB OQNs in the clinical field I
remembered some of my own experiences when I first came to WA. This is how
the interest in the topic emerged, as I started to wonder if NESB OQNs had
some commonality in their life experiences of working in WA hospital settings. I
was curious to hear their stories. I myself never had the opportunity to discuss
my experiences and feelings about the topic because I felt that it was a rather
personal matter. Furthermore the political and emotional components attached
to the experiences made it difficult to share with Australian and migrant people.
I nonetheless was very curious to find out the lived experiences of a nominated
group of NESB OQNs, but chose not to bring my personal understanding to the
topic research. I therefore did not want to follow Heidegger’s hermeneutical
39
phenomenological approach and instead tried to stand back and learnt from the
collected data.
3.3.4 Research aims and questions
The aims of the research were:
� To describe the lived experience of a small number of NESB OQNs in
order to identify commonalities that would allow the discovery of the
essence of this phenomenon.
� To disseminate the findings so that educational, organisational and
structural adjustments can be implemented at government and health
care facility levels to assist the integration of NESB OQNs into the WA
health care system and most specifically the hospital system.
The questions were:
� What is the impact of NESB female OQNs’ sociolinguistic background on
their integration into the WA metropolitan hospital workforce?
� Are there any commonalities in the participants’ experiences of the
phenomenon and if so what are they?
3.3.5 The author’s standpoint
As discussed previously I as the researcher had prior direct and indirect
exposures to the phenomenon and therefore I have developed over the years
some personal understandings on the topic. In my endeavour to bracket my
previous experiences and viewpoints on the research topic I wrote a Textural
description followed by a Structural description of my personal experiences in
40
line with Moustakas’ modification of the Van Kaam Method of analysis of
phenomenological data. 71(p120) These two descriptions were compiled into a
Composite description of the meanings of my experience, the extract of which
follows:
“The experience of being a foreigner with difficulties with the
English language generated professional doubt at a personal
level and at a ward level. In fact the language barrier was the
trigger to the difficulties to integrate into the workplace. It
gave the impetus to hesitation in taking professional tasks
which was often perceived by WA nurses as a sign of
deficiency in nursing knowledge. The professional
ethnocentrism generally displayed by the local nurses
ostracised me, as a ‘foreign nurse’. This had the effect of
jeopardising my confidence as it reinforced a sense of
otherness, causing stress at a personal and professional
level.”
I also read some journal articles on the topic so that I could compile a proposal.
Utilising Gibbs reflective framework105 I kept a journal so that I could reflect on
some past issues especially the ones with emotional connotations. I also used
this process after the interviews if I felt that I had strong feelings about what the
participant had conferred. The intention was to set a side any particular
preconceived elements I had while conducting this research. Like an artist I
wanted to start with a ‘clean canvas’ and build only on the participants’
narrative. I was curious to hear their stories and extract the foundations of their
experiences. Therefore I wanted to approach the research with no assumptions
41
or preconceived ideas about the topic. However my affinity with the participants
in relation to gender, professional background and history of being a migrant in
WA, provided a genuine interest that was utilised to encourage participants to
openly talk about their experiences.
3.3.6 Ethical considerations
In order for the study to take place, several areas of ethical review had to take
place. At an organisational level the approval from the Human Research Ethical
Committee of the University of Western Australia, where the researcher was
enrolled had to be sought and granted. Thereafter, clearance from Sir Charles
Gairdner Hospital (SCGH) and its Research and Ethic Review Committee had
to be obtained. After discussion with the director of clinical services at
Hollywood Private Hospital (HPH), no formal ethics approval was needed as the
project had received ethical approval from UWA and because the recruited
nurses were not being interviewed within the hospital setting.
At an individual level the respondents were fully informed in writing of the
purpose of the study (Appendix A), and following their choice to participate,
were asked to complete and sign a consent form (Appendix B). Discussions on
the length and process of the interview also took place. On the day of the
interview, the purpose of the project was verbally repeated and participants
were encouraged to ask any questions. Their right to terminate their
participation at anytime was also reiterated. Furthermore, they were informed
that their names would not be mentioned during the recorded interview in order
to protect their identity and that all their information would only be utilised for the
proposed research.
42
In addition, all raw data including, printed transcriptions, demographic forms and
other notes taken by the researcher were securely stored in a locked filing
cabinet and remain the property of the researcher. All verbal interviews which
had been digitally recorded, the typed transcriptions and other information
related to the research were saved on the researcher’s work computer and
laptop hard drive which were protected by passwords known only to the
researcher. After five years all research data will be erased. The verbal
interviews will be deleted from the researcher’s computer and laptop hard drive.
All written information related to the study will be professionally destroyed.
The participants were also offered the opportunity to read their transcribed
interview and if they wanted to make some changes they were assured that it
would be done. On completion of the thesis and therefore after being reviewed
and examined, the participants will be offered the opportunity to read the final
analysis of the project. They will all receive a certificate of participation in the
research to include in their professional portfolio.
3.3.7 The data collection process
a Identifying the participants
To be included in the study, participants were required to meet the following
criteria:
� Female nurses from a NESB currently registered with the NMBWA and
working in a hospital clinical setting
43
� Nurses who gained their initial nursing qualification and worked abroad
where English was not the primary language.
� Nurses who had lived in Australia for less than 20 years.
The researcher’s rationale for wanting only female nurses was that; firstly this
project was conducted at a master’s level. Therefore the number of participants
was going to be relatively small. Secondly the demographic of the nursing
population in WA is dominated by women.17-19, 45 Therefore, it was established
that it would be mostly females participating and that having one or two male
nurses may provide a perspective that might have been different. As a result the
research would not have been able to be completed within the timeframe. One
could of course question the element of gender inequality in this project but the
intention was toward generating richness of information from a sample of
female nurses. Hence, in order to eliminate the possible divergence between
male and female viewpoints, it was decided to approach females, mirroring the
dominant gender of WA nurses.
While initially the researcher was seeking participants that had lived in Australia
for a maximum of ten years, it rapidly became apparent that participants were
difficult to locate. The timeframe was therefore extended to a maximum of
twenty years. The justification for allocating the initial criterion of ten years was
due to a concern that acculturation, which inevitably occurs when people are
exposed to a new society and culture, may affect participants’ recollection of the
events. However, as Husserl highlights, people’s meanings of a particular
incident are timeless.71 The evidence of this is mirrored in the collected data.
44
b Recruitment of participants
The recruited participants came from five Perth metropolitan hospitals and one
nurse was from a nursing agency. However the active recruitment process took
place in two hospitals namely SCGH and HPH from which ethics approval was
sought and granted.
At SCGH the researcher approached the Nurse Manager Marketing and
Recruitment. At HPH she contacted the director of Clinical Services. Both
hospitals provided their full support to the project. Upon SCGH and HPH
approvals the researcher made contact with all nurse managers requesting their
assistance in placing posters (Appendix C & D), and flyers (Appendix E & F) on
their wards. However, the limited results from this strategy gave the impetus for
the researcher to call upon the nurse managers and/or nurse specialists to
identify potential participants amongst their nursing staff. As a result over ninety
individual letters of invitation indicating the purpose of the research (Appendix
F) were posted. However, only five nurses were recruited from SCGH and three
from HPH.
Despite the low number of responses from the two selected hospitals the
researcher was nevertheless able to recruit participants as a result of snowball
sampling. Migrant nurses from other metropolitan hospitals made contact with
the researcher and another seven participants meeting the criteria were
selected. Two were from Princess Margaret Hospital, three were from Royal
Perth Hospital, two were from St John of God Hospital and one was an agency
nurse.
45
All decisions by participants to take part in the project were by their own free
will. The researcher’s email address and telephone number were provided on
the posters, flyers, and letters of invitation. The researcher waited for nurses to
make contact. Their questions were answered and it was not until they agreed
to take part that an appointment was set for the interview.
c The study sample
While an initial sample of fifteen participants were interviewed, only thirteen
were included in this study.
This research project involved thirteen nurses who self-identified as being
NESB and qualified overseas. They were from eleven different countries
including four from China and two from South Africa. They all worked in a
clinical setting and had work experience abroad. They had lived in Australia
between 4 months and 20 years, and their age ranged between 25 to 55 years
old.
Two participants were excluded from the study post-interview as they did not
wholly fit the preliminary criteria entirely. One nurse while being French national,
and therefore, having English as a second language had received her nursing
education in England. Furthermore, her whole professional career prior to
coming to Australia was only in the UK. Therefore, her whole nursing training
and professional experiences had been within the UK context only. In addition,
while her intention was to discuss her nursing experience in WA, during the
course of the interview she primarily recalled her working experiences in
England. The second respondent was Dutch and she had lived in Australia for
46
22 years which was above the inclusion criterion for length of time by two years.
However, the decision to discard her input was mainly because she elaborated
on her nursing experiences in Queensland while the focus of the current
research was WA. Furthermore, another participant who did not fit the criteria
entirely, as she had been in Australia for 22 years, was nevertheless included in
the research. She was very keen to take part in the research. Her interview
revealed that she had only worked in WA and her recollection of work
experiences was rich and full of details. Thus she was included in the study.
It should be noted that the two participants who have been excluded from the
analysis were the first two nurses who made contact and who were interviewed.
Upon reflection the data collected from these two interviewees were utilised as
a pilot study as they were valuable learning tools that contributed to the
development of the interview process.
d The interview process
Only individual interviews were conducted for this research. The nurses who
chose to take part in the study made contact with the researcher and because
the interviews were conducted outside their working hours, they decided the
location and time that best suited them. The settings ranged from an office and
room for nurses working at SGCH to the researcher’s office at UWA and in the
participant’s home. The aim was to ensure that the participant was comfortable
with the environment and the time, and that privacy was provided so that they
felt at ease discussing their personal experiences. When possible, coffee, tea
and/or water were offered and provided on request. The researcher wanted to
47
create an atmosphere that was acoustically sound, relaxed and conducive for
the conversation to take place.
All participants were thanked for their interest in the project and were told how
their time and contribution were highly valued. A brief discussion on the project
was then provided. The consent form (Appendix A) and a small demographic
form (Appendix H) were given to the participant to fill in either before or after the
interview. An information sheet with some guiding questions (Appendix I) was
provided to assist the nurse in her thought process. She was also reassured
that there was no right or wrong answers and that her personal experiences and
feelings about working as an RN in WA were sought.
While the participants had already been informed of the use of a recording
device to tape the conversation to be later analysed, verbal permission was
requested prior to commencing. These preliminaries gave the impetus for small
talk to take place which eased both individuals’ interaction and
acknowledgement of their accent and mannerisms. After having answered
possible questions that might have arisen, the interviewer requested permission
to proceed.
Individual in-depth interviews were conducted. The researcher started by asking
the nurse to try to remember the first day she worked as a RN in WA in order to
capture her experiences and feelings at the time. This had the effect of starting
the participant talking. Broad open ended questions were also used to guide
and facilitate the conversations (Appendix I) allowing the participants to
elaborate and expand, at ease, on valuable information. The researcher
48
positively encouraged the participant to carry on with her narrative through
active listening, smiling, nodding the head and reassurance that the information
was very valuable to the project. It happened on several occasions that the
conversation had been concluded and the tape stopped, and that the
participants made further valuable statements that could have been useful for
the analysis. When that occurred the researcher asked if the recorder could be
restarted and the statement be repeated. In all instances agreements were
granted. Overall, the length of the interviews varied between 36 minutes to
1hour 30 minutes. After listening and transcribing the data, if the researcher felt
that more information and/or clarification was needed she sought permission
from the participant to either meet again or to clarify via email.
3.3.8 Managing the data
a The interviews
The interviews were recorded on a digital sound system and transcribed
verbatim. All data were saved under a code number on the researcher’s work
computer, on her personal laptop and on a USB drive that were accessible only
to the researcher.
b The transcriptions
All interviews were transcribed by the researcher. However, because English
was a second language for all the participants, audio recordings had to be
reviewed and listened to very carefully during transcription so that each
individual’s enunciation and, therefore, narrative could be fully understood.
While this method was lengthy, it nonetheless enabled the researcher once
49
again to become acquainted with the dynamic and content of the interview.
When clarifications were needed, participants were contacted via email and
usually responded. On one occasion an interviewee who had been contacted
several times chose not to reply, which was her right. Her information was
nonetheless utilised with the gaps unfilled. It is important to note that all the
transcriptions were true to the interviewees’ words. The English syntax errors
which were a characteristic of most of the participants were left intact. The
reason for this decision was to highlight the reality of the communication
challenges experienced by these nurses while also providing authenticity to the
narratives. Both of these are vitally important when conducting a
phenomenological study.
c The analysis of the data
It is important to reiterate that prior to undertaking data analysis the researcher
bracketed her personal experiences of the phenomenon to look anew at the
data. While this was difficult to fully achieve, the intention was nevertheless to
objectively set aside prior knowledge and possible emotion related to the topic
in order to get as close as possible to each participant’s experiences.71, 73
After reading each transcript entirely several times in order to become
immersed in the details of the data, Moustakas’ modification of the Van Kaam
method of analysis of phenomenological data71, 73 was utilized as a framework
for data analysis. The sequences of the analysis are described below:
1. Each transcription was read and every significant statement, sentence or
quote that was relevant to the experience were listed and given an equal
value. Moustakas refers to this process as Horizonalization.71, 73
50
2. In order to establish the Invariant Constituents, the list of recorded
expressions was scrutinised. Each expression was assessed to identify if
it had enough information to capture the understanding of that particular
moment of the experience. If it did, then a label was applied and the
expression constituted a horizon of the experience. However in this
process any expressions that did not meet the requirements, such as
repetitive and/or unclear statements, were eliminated. The horizons that
remained were the invariant constituents of the experience.
3. The invariant constituents of the experience were grouped together and
flagged under a theme label. Four initial broad themes emerged:
� The initial feelings of professional loss
� Feelings of otherness
� Rediscovering nursing
� It all works out in the end.
4. The Invariant Constituents and Themes were checked against the
complete record of the participant’s transcription to ensure that they were
expressed clearly or were compatible. If not, they therefore had little
relevance with the participant’ experience of the phenomenon and were
deleted.
5. In using the relevant, validated invariant constituents and themes, an
Individual Textural Description of each participant’s story of the
experience was written including verbatim examples.
6. Following this an Individual Structural Description of each participant’s
experience was constructed using the previously written Individual
Textural Description and use of Imaginative Variation. The aim of the
Imaginative Variation is to identify possible meanings through the
51
imagination where the phenomenon is tackled from different
perspectives, to reach a structural description of the experience. As
described by Descartes71 the Imaginative Variation which allows a free
fantasy variation occurs when: “…the intellect ought to use every
assistance of the imagination, sense and memory: to intuit distinctly …”
and to correctly unite what is sought after with what is known in order
that the former may be distinguished”. 71(p35) The Imaginative Variation
process allows extracting from the description of the event the “how”
therefore trying to make sense of how a particular incident occurred.
Describing the essential structures is the primary task of the Imaginative
Variation. Nevertheless a reflective process is necessary to examine and
explain the many possibilities provided. The Imaginative Variation
process then permits the researcher to identify structural themes which
guide the analysis toward the essence of the phenomenon, which in itself
is not a linear path.
7. Finally a Textural-Structural Description of the meanings and essences
of the experience for each participant was written.
8. After having completed each participant’s Textural-Structural
Descriptions (a total of thirteen) a Composite Description of the
meanings and essences of the experience, encompassing all thirteen
Textural-Structural Descriptions, and representing the whole group, was
written.
3.3.9 Rigour and trustworthiness
Rigour is paramount when undertaking any research to ensure the findings bear
the truth of the participants’ lived experiences and, while they cannot be
52
generalised, they should also shed light on understanding of the phenomenon.
There is no consensus on a check list to ensure rigour applies to qualitative
studies. Nevertheless Lincoln and Guba106 who suggest four criteria in
establishing trustworthiness of a study and they were used for this study. The
criteria are further explained below.
a Credibility
This refers to the accuracy of the description of the phenomenon. The portrayal
of the reality must be faithful to those who experienced it. This was established
by the following actions
� A prolonged engagement where mutual trust and respect between
the participants and the researcher was always established. Time
was spent to explain the purpose of the study, answer questions
and articulate a preferred venue that would be conducive to the
interview. The length of the interviews was open and guided by
the context and depended on the reporting style and the richness
of the participant’s story.
� Triangulation. In order to gain a deeper understanding of the
phenomenon was established, data were collected from
participants who were diverse in their ethnicity, age and time
spent in Australia. Furthermore they did not meet or know each
other so no collaboration occurred when they recalled their
events.
� Participants were offered the opportunity to read the transcription
of their interviews for verification.
53
b Dependability
Sufficient details have been provided in the thesis to enable examiners to
appraise the process and analysis of the data.
c Transferability
Sufficient details in this study report should allow readers to assess the
appropriateness of the results to other NESB OQNs working in a Perth
metropolitan hospital. It is however not the intention to generalise but to provide
a deep awareness of the phenomenon.
d Confirmability
This reflects the plausibility of the meanings, the discovered essence. The
researcher strongly believes that independent colleagues would have arrived at
similar results if they had followed the same steps of this research, included the
same participants, context and setting and had the same level of rapport with
them.
3.4 Summary
This chapter was concerned with the research methodology employed in the
research project. The goal was to develop an understanding of the lived
experience of NESB OQN’s working in the WA metropolitan hospital setting. In
the first section an overview of qualitative research was reviewed with emphasis
placed on phenomenology and its implementation in nursing research. In the
54
second section the application of transcendental phenomenology and the
methods utilised in this research were fully described.
In the next chapter the first theme of the research titled “the initial feelings of
professional loss” is presented.
55
4 CHAPTER FOUR – THE INITIAL FEELINGS OF PROFESSION AL LOSS
4.1 Introduction
To start working in a Perth metropolitan hospital as a RN was a daunting and
challenging experience for the participants who had overseas work experiences
and qualifications. However, it is important to reiterate that, in order to gain
employment in WA all participants had successfully met the NMBWA
registration requirements which provided them with a licence to work. It was
therefore expected that both the state nursing governing body and the employer
had evidence that these nurses met the nursing competency standards.
Furthermore, at an individual level, because of their past professional
experiences and their success in gaining their WA nursing registration and
employment, each participant had a sense of self worth and believed they were
professionally competent.
This chapter explores the experiences of the NESB OQNs in relation to their
sense of professional worth as they entered the WA hospital workforce. It
describes how all the participants experienced a deep sense of professional
loss when they started to work, which was accompanied with feelings of self
doubt. The way these were experienced, however, varied between nurses. This
had the effect of them feeling once again like ‘learners’ while being treated by
their WA colleagues like junior/novice nurses.
56
4.2 The overwhelming differences experienced in the work environment
4.2.1 So many things are different
The participants felt a sense of professional loss as they entered the WA
workforce. They experienced the new working environment as unexpected and
unfamiliar in comparison with their home country. They experienced
multifaceted workplace differences which they felt jeopardised their ability to
fully perform at the professional level they were used to. The different names
used for equipment and medication, the unfamiliar ward settings and work
dynamics, the multiple communication difficulties and even the patients that
they perceived as ‘different’ left them professionally fragile. They felt lost,
confused and out of place as they experienced great difficulty in identifying with
their new work environment. Their perceived loss of professional aptitude was
further enhanced by some staff members and patients openly displaying signs
of doubt towards the participants’ nursing knowledge.
The participants felt overwhelmed with the unfamiliarity of the work place. The
ward setting, the equipment and the medications were troublesome at times.
The use of different names for equipment and medication generated some
confusion: Eileen, Julie, Lucy and Ines were puzzled as they did not recognise
the names of the drugs. With the delivery of medication being an integral
element of nursing, they felt disturbed and realised that additionally they needed
to re-educate themselves.
The system and the work setting felt unfamiliar to the nurses: Fleur felt that so
many things were different that she could not ‘get her head around it all’.
Melissa felt totally overwhelmed: “… I work in the largest private hospital… it
57
has got 18 theatres… I’m getting lost… there is so much equipment so many
manpower (sic)… everything is in large amount…The hospital where I worked,
we did not have X-ray vision table, X-ray lining no high technology like that…”.
Some of the nursing tasks they were expected to perform were also different
which surprised and sometimes shocked the participants. They were unfamiliar
with some of the nursing duties because they had never performed them in their
home country as they were not part of their nursing responsibilities. For
example Georgie felt overwhelmed by the amount of paper work she had to do.
Alice was surprised because:
”…a senior nurse who said to me ‘oh Alice would you mind help
me to bath this baby’ all I said was (SILENCE) how I do it… I
never bathed a baby before; I never fed a baby before... I’ve got
no idea about this basic nursing care…”.
These variations generated a sense of loss of professional power because the
nurses were not able to work at the standards to which they were accustomed
and were confused about expectations. Helen said: “… I don’t really know what
registered nurse is supposed to do … it was a big shock…. [in my home
country] we do things together… we all look after 70 to 80 patients... the
relatives… do their showering, washing, feeding all this kind of thing… us, we
don’t do it…”.
However they recognised that when working within the WA nursing context
these tasks were not out of the ordinary. They were in fact part of the everyday
nursing routine. Therefore they were disturbed and stressed because of their
58
lack of skills and the realisation that, as RNs, they were expected to be able to
perform these tasks on a daily basis.
For others, however difference and professional loss was experienced through
not being allowed to apply their clinical skills: Both Lucy and Julie realised that
some of the clinical and nursing skills they used routinely in their home country
were not part of the WA nursing requirements which frustrated them. Thus Julie
and Lucy felt underutilised.
Difference and its impact on professional nurses was also experienced through
multiple layers of communication difficulties. Participants were unfamiliar with
some of the abbreviations and some of the nursing and medical terminology
used. They therefore did not fully understand what was said and written about
their patients. For example Alice and Kerry could not understand the words
used in the handover notes. Julie was astonished by the extensive use of
abbreviations that she did not understand. When working in the operating
theatre Melissa, despite knowing all the procedures found that:
”… everything was different even the surgical names that we
had learnt before had different names than in my own country…
we call tetra for the pack here it is just called pack… everything
has a different name…”
The nurses found verbal communication very difficult and they struggled to
understand and to be understood. They felt that these additional difficulties
were detrimental to their ability to perform their professional duties in a
comfortable and customary manner.
59
Fleur felt sad and she stepped back emotionally because she thought that her
English was terrible. Georgie was frustrated as she struggled to understand the
people she was working with and she felt compelled to ask them to repeat. Julie
had great difficulties understanding the speaker on the orientation day which
was a concern to her because: “… you only catch every fourth or so word, so
it’s not necessarily that I’ve interpreted correctly what they’re implying to bring
across …”. Cathy found it extremely hard: “… I think for the first three months
about 50% I could understand…”.
Patients in WA were also ‘different’ to the ones they cared for in their home
country. This was also contributed element to their feelings of differences and
unfamiliarity in their new workplace. Helen felt that the way patients talked and
the things they wanted done were different. The nature of their illnesses also
felt unfamiliar at times especially the ones related to social issues such as
alcohol and drug abuse and family neglect. Julie was also taken back as: “…
there was a heck of a lot of old patients…”.
4.2.2 Feeling a lack of trust
A perceived lack of trust displayed by their colleagues and by some of the
patients they attended to, enhanced the participants feeling of fear and self
doubt in their ability to fully function as a registered nurse. This also left them
with feelings of professional loss, and was perceived as detrimental to their
ability to work in the comfortable manner they were used to in their home
country.
60
The nurses felt observed by their colleagues who they believed expected them
to do something wrong. As Lucy notes: “… you can see that staff they don’t
trust you they feel like what you’re doing is going to go wrong… ”. Similarly
Cathy said: “…[I] could see by my colleagues’ eyes that they are a little bit
worried about me…that I would be unsafe… ”. Debbie felt taken aback: “… I
usually ask some of the things just to be sure I do the right thing… she
[preceptor] looks at me like ‘you don’t know that’…”.
Participants felt that because of their colleagues’ lack of trust they were at times
not able to fully perform their professional duties. For example when Debbie
asked the Patient Care Assistants (PCAs), who are employed to help RNs to
assist her she was shocked at their refusal. In refusing to work with her she felt
that they disapproved of her status of a RN. Likewise when Eileen first started
to work she was not permitted to give medication to the patients which she felt
reflected the expectation of other nurses.
In addition, participants felt that some of their patients had little faith in their
nursing abilities. This further contributed to their sense of professional loss.
Lucy noted:
“… few of the patients… they don’t trust you even though you are
doing the right thing, they want to find out’ where did you do your
nursing’… they say ‘no don’t touch this, you are not allowed to
touch this’ which turn out to be a little bit bizarre…”.
61
4.2.3 Feeling self doubt
The participants’ sense of professional loss had the effect of generating feelings
of self doubt and fear. Their confidence level dropped and they became scared
as they were very conscious of their professional limitations. This is paradoxical,
but in itself highlights their high level of professionalism as they were aware of
the potential harm their lack of understanding could have on patients’ health.
This left Alice feeling confused and frustrated. She did not know what she
should be doing. She did not know where things were. She felt pressured to
take a patient load but she did not feel ready and safe to do so.
The result was also a loss of confidence by the participants in their professional
abilities. For example Georgie was scared and felt that she did not know much
and did not want to go beyond her scope. Fleur felt that she could not give
educational sessions even though she presented them in her home country.
They felt physically stressed and apprehensive. Helen notes: “… I was
nervous… it’s a bit challenging, not sure you do right or wrong things… bit
scary, butterflies in heart… “.
The recognition that they were lacking some knowledge and understanding left
them scared of making mistakes. Julie noted:
“… I felt like nothing because I didn’t know the drugs… you are
not sure of what is expected of you… you were immediately
expected to take responsibility for patients although ... I don’t
believe in giving a drug if I don’t exactly know what it is…”.
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Melissa was quick to tell the staff who she had not met before that she was a
new staff member, in fear of being asked to perform procedures she did not feel
confident to do and Kerry felt like a student.
4.2.4 Relationship and discussion of findings to ex isting literature
The initial feeling of professional loss experienced by NESB OQNs as they
started working in the WA health care setting is congruent with the existing
research and literature from Australia and other international sources. Reports
of unfamiliarity and strangeness with the workplace, associated with multiple
differences in communication, medication, equipment, procedures and even
patients are broadly reported and associated with feelings of stress and culture
shock. 1, 5, 9, 11, 107-110
In the UK, Alexis and Vydelingum’s107 investigation of the lived experiences of
twelve overseas black nurses reported their unfamiliarity with the National
Health Services (NHS) setting resulted in feelings of being displaced. They
commented that the busy ward situation, the multiplicity of staff wearing
different uniforms and the jargon spoken left them confused.
Difficulties have been also reported in Teschendorff’s108 qualitative research of
twenty one Filipino nurses working in Victoria, Australia where she described
how the participants experienced culture shock in their initial exposure to their
new working environment. They felt totally unfamiliar with the hospital
environment and the nursing work patterns. As a participant stated she felt
frightened because the hospital was big, all the people were white, the patients
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were large in size and she had to shower them108(p.149); something she never
had to do in her home country. The participants reported that their initial inability
to attend to patient hygiene was understood by their Australian nursing
colleagues as a sign of incompetence in their nursing practice. The study also
mentioned how, as newcomers, the Filipino migrant nurses felt ‘ashamed [and]
backward’108(p.152) at their struggle with the English language to understand and
be understood at work.
Similarly, the concept of culture shock was also reported in Yi’s9 grounded
theory study of twelve Korean nurses working in the USA. Yi described it as a
severe psychological stress experienced by the participants when they
commenced working in the hospitals. They were confused and anxious about
their poor American/English language skills and furthermore they were puzzled
and frustrated to have to fulfil patients’ basic physical care, something that was
not part of the nursing role in their home country.
The feminist approach to Jackson’s phenomenology study109 of nine NESB
OQNs working in acute care in New South Wales, Australia recalled their
feelings of displacement associated with their initial experiences in nursing in
an ‘uncomfortable and culturally hazardous work environment’109(p.122). They
experienced stress; mainly because of communication difficulties, loneliness
and fear as they worked in isolation struggling to make sense of the medical
jargon, the Australian slang, and the abbreviations that were utilised while being
confronted with new equipment. As a participant mentioned the overall
experience crippled her ability to work effectively. Jackson’s participants’
feelings of stress and isolation in the workplace were detrimental to them
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functioning at the nursing level they were used to in their home country
therefore reiterating the concept of initial professional loss experienced by
migrant nurses.
Omeri and Atkins’5 qualitative study of five NESB OQNs from five different
countries practicing in New South Wales, Australia also included data on their
pre employment phase. They reported that their experience as newcomers was
primarily gloomy. The participants expressed feelings of loneliness and of great
difficulties in finding employment. A participant described her struggles to meet
the interview standards and while she had a translator assisting her she could
not understand what was going on. In this study, the migrant nurses’
experiences in looking for employment highlighted difficulties with
communication skills. They also commented on the lack of trust displayed by
employers who failed in offering them a job and in assisting them to find one.
As a result feelings of alienation and professional loss were conveyed by the
participating nurses.
In the literature, migrant nurses often expressed that because of their hesitation
in performing some nursing tasks, they were often perceived by their nursing
peers and/or their patients as professionally incompetent. As a result they lost
their confidence in performing their nursing duties and therefore their
professional power. 2, 3, 5, 107, 110-113
Furthermore, the concept of deskilling, where migrant nurses are not allowed to
practise some of their prior learnt nursing skills in the host country is well
reported in the literature and mentioned as a high contributor to migrant nurses’
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loss of professional confidence and power. 110, 114-116 Respondents in Withers
and Snowball117 study of Filipino nurses working in the UK reported feeling
more like care assistants than nurses as they could not utilise their clinical skills
and extensive past nursing experiences in the new workplace. As a
consequence, they felt professionally diminished.
Matiti and Taylor’s112 phenomenological approach to studying twelve NESB
OQNs in the UK revealed how the participants expected to be able to perform
the nursing skills they were used to in their home country. However when they
were told that they could not do some tasks they felt that the local nurses did
not trust that they were competent enough. Furthermore, as an interviewee
from Matiti and Taylor’s study stated she was confused with what task she
could and/or could not do, which resulted in her being hesitant and therefore
giving the impression that she lacked confidence and/or knowledge.
Similarly findings in the UK of Alexis, Vydelingum and Robbins’110
phenomenological study using four focus groups of six non-white migrant
nurses revealed that they were not allowed to demonstrate some of their
managerial skills. They did not feel trusted as they were constantly being
scrutinised by their colleagues. Subsequently they expressed some self doubt
and a loss of confidence. The experience of being watched suspiciously while
performing nursing duties along with encounters of hostility in the work place
towards overseas nurses have also been stated in the Queensland Nurse
Unions’ (QNU)113 response to the Federal government review into the 457 Visa.
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The literature shows that migrant nurses feel overwhelmed and shocked by the
host country’s overall clinical / hospital settings, and while one might expect to
feel that way as a result of a new environment the reports of not feeling trusted
by their colleagues and the subsequent sense of professional self doubt had
detrimental effect on their ability to work effectively. While the sub-theme of ‘the
overwhelming differences experienced in the work environment’ in this research
study is describing the participants’ initial phase as they entered the new
workforce, the literature often elaborates on the difficulties experienced by
overseas nurses without depicting specifically their first encounters. Despite the
specificity of the time frame where the respondents in this study described their
‘initial’ difficulties, their experiences are nevertheless a reality widely reported in
the literature.
4.3 Being like a learner again
4.3.1 Acting as a learner
Feelings of professional inadequacy positioned participants as learners and
they started to consciously act as such. All participants were determined to be
safe in their practice and, regardless of their past professional experience and
status, they felt that it was important for them to step back and actively enter a
learner’s role so they could search for information and clarification in order to
remain safe with their patients. As Cathy explains: “…I don’t pretend I
understand… never pretend you understand… just ask someone you don’t
want to make mistakes… you don’t have to worry to show people your
weakness… you need the courage to do that…”.
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They continually asked for help. Barbara carried a note pad to take note of
things she did not know and could check out later. Eileen felt comfortable
because she was lucky enough to work as a supernumerary so she had
someone to look after her and to show her the ward setting. She received lots of
information and learnt a lot. “...if I don’t know or don’t understand I query I don’t
feel bad to ask…”. They were not afraid to say they did not know. Julie admitted
that she:”… had never done a bladder scan … if someone asked me to do [one]
I’d say ‘yes I will if you’ll show me how’…I needed to figure out how the whole
system works first… “.
The nurses felt professionally vulnerable because they realised that there were
a lot of things they did not know and they had so much to learn. Melissa had
three orientation days: ”… but it felt like sort of orientation went together with
learning…it’s new for me and so big to learn…”. She had to repeatedly ask
questions: “… I feel some embarrassing feeling asking the same thing again
and again…”
4.3.2 Being treated like a junior/ novice nurse
However in acting as learners in a quest to adjust their nursing knowledge to
the WA hospital workplace, the participants had high expectations that the
induction programmes would be conducive to their learning. Unfortunately it
appeared that some of their preceptors did not always respond and/or
understand their needs. In fact some participants’ feelings of vulnerability were
heightened by experiencing a lack of empathy from some of their assigned
supporting colleagues. They felt that, at times, their colleagues’ authoritative
and power oriented behaviour towards them contributed to further undermine
their already shattered nursing identity.
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Debbie and Georgie had been paired with an RN to assist and orientate them.
However they felt let down. Debbie’s nurse was too busy and could not give her
much time while Georgie felt that her nurse was too harsh with her. Both
Debbie and Georgie felt that, because of their perceived novice status and,
therefore, their lack of professional assertiveness, they were an easy target to
be ‘picked on.’ They felt upset and unhappy to be openly accused and put down
by some of their colleagues. They resented being treated unfairly and as a
result they felt intimidated. Kerry explains:
”… I feel uncomfortable, unhappy to work with… my coordinate
[who] said … why didn’t you put the monitor? You have to leave
the monitor on… look at this you forgot to pick up patient’s
clothes and the patient’s bag… you left all his medications... she
[the coordinator] tell me in front of the other patient… and the
other patients all listen… I feel very like inferior… “.
Helen was self conscious, shy and quiet and lost her confidence when people
were watching her too closely: “… one patient’s daughter reported… they call
the bell for a long time nobody answer… the manager assumed it was me…
[however] the patient is not mine… she thought it was me because I am the
junior one… “.
4.3.3 Relationship and discussion of findings to ex isting literature
The current literature reflects the participants’ willingness to learn their new role
in an attempt to adjust to the new work setting. Their nursing aptitude was the
element that they were keen to develop so that they could work effectively
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within the new work setting. 108, 109 7, 112 However the literature reports that many
migrant nurses experienced an overall lack of and/or inadequate support from
their local colleagues.
Omeri and Atkins’5 phenomenological research elaborates on how they
experienced an initial stage of loneliness from the lack of overall support in the
workplace. They argued that given the concept of caring to be the essence of
nursing, migrant nurses should be cared for at work and more widely in
multicultural Australia. Teschendorff’s108 study explained how having to work
alone without help from their Australian colleagues made the work transition
slow and very hard for the Filipino participants in her study. The Queensland
Nurses’ Union (QNU)113 response to the Federal government review into the
457 Visa argues that migrant nurses are vulnerable and often left to their own
discretion as sponsoring employers rarely offered them comprehensive
orientation programs and support. The expectation was for new recruits to fit in
and to be ‘operational’ from day one. In the UK the lack of social support,
empathy and care from local colleagues and managers in the workplace is also
reported and described as contributing to OQNs feelings of professional
isolation, unhappiness and homesickness.118 Alexis and Vydelingum’s107
investigation of the lived experience of twelve overseas black and minority
ethnic nurses detailed how most of the participants received very minimal
support from their local colleagues while practicing nursing in the NHS in the
South of England. The participants expressed how the new working
environment was daunting and how the lack of guidance left them feeling
anxious which often resulted in a loss of confidence in their ability to practise
nursing.
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The feeling of loneliness in the work place experienced by international nursing
recruits is mentioned as an issue that should be considered by their employers
and nursing colleagues. The literature describes how the use of preceptors,
‘buddy nurses’ and induction sessions are essential in guiding and facilitating
the migrant nurse’s initial entrance into the new work environment. 119-121 In
Gonda et al’s119 report, the use of nursing preceptors to assist the integration of
foreign nurses into the Australian health workplace is suggested and put
forward as a recommendation. It stated that preceptorship provides an
immediate support for the new international recruits and an ‘Australian’ nursing
role model for them to follow. Similarly in the USA, Bieski’s121 literature review
on the impact of nursing migration in countries describes the need to have
mentorship and orientation programmes to assist the integration of overseas
nurses into the culture and in this instance the value system of the American
nursing setting.
However while some supporting programmes have been put in place to
accommodate NESB OQNs the literature highlights difficulties between
appointed support nurses and migrant nurses. A lack of understanding and
empathy displayed by some of the percepting nursing staff towards their
overseas colleagues have left the latter feeling professionally vulnerable.114, 122
Some English studies 2,122 recommend a mentorship system where migrant
nurses should work alongside local nurses to provide support and orientation to
new OQNs in adjusting into the work place. Nevertheless disappointment in the
support provided by their mentors was a recurrent issue in the “We need
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respect”122 UK study involving a diverse cohort of sixty seven internationally
trained nurses. Comments provided by participants stated they experienced
multiple relationship problems with their appointed mentors who they explained,
lacked the motivation and overall collegial approach to assist migrant nurses.
Similarly Smith, Allan, Henry, Larsen and Mackintosh’s114 report which
encompassed the experiences of overseas trained nurses working in the UK,
detailed participants’ dissatisfaction with their mentors. They perceived that the
poor assistance they obtained from the local nurses who were acting as their
mentors was related to their negative attitudes towards ‘foreigners’ and their
ethnocentrism. As a result the participants felt bullied.114 However the reported
difficulties in working with mentors who did not fulfil the learning requirements of
overseas nurses provided the impetus to appoint local nurses who were more
suitable to this role.122
Current literature imparts some recommendations to provide effective
assistance to overseas nurses. It highlights the need for mentors, preceptors
and the overall orientation programmes to have a culturally sensitive approach
that could be effective in catering for the unique needs of NESB OQNs in the
initial stage of entering the workforce.122-125 Jeon and Chenoweth’s120 article
which critically discussed the employment of internationally trained nurses in
Australia, suggests implementing support programmes comparable to that
currently undertaken in the UK and USA. Their recommendations include
induction programmes where the culturally diverse backgrounds of migrants
nurses are acknowledged and ‘buddy nurse’ programmes, where local nurses
work alongside new OQNs. These strategies are discussed in depth and are
72
understood to be valuable strategies that assist the transition of migrant nurses
into the new workplace.
Guttman’s 126 article which looked at ways to assist NESB nurses in the USA,
and in particular with their English language deficiency, reinforced the
importance of appointing mentors and preceptors who are culturally aware and
sensitive to supporting foreign nurses. She argued that in order to ease the
transition of foreign nurses’ into the USA, socialisation into the workplace as
well as socialisation with their nursing colleagues should be part of the
orientation programmes. Findings in Matiti and Taylor’s112 phenomenological
study of twelve NESB OQNs in the UK mirror the need for a cultural awareness
syllabus to be incorporated in the migrant nurses’ induction agenda. It
mentioned that their need to learn and adapt culturally was also made possible
through informal interaction with local nurses.
Chambers125 argues that induction sessions for migrant nurses should
incorporate the cultural norms and values of the country they are now living in.
Furthermore, the local nurses should be informed about their international
colleagues’ cultural background. With this in mind, a reciprocal mentorship
would take place, as both parties would develop professional rapport that would
include a mutual understanding of their respective cultural values and norms.
These views resonate with Alexis’ model123, 124 that describes how to help
recruit and retain different nationality OQNs in the UK. This model provides
strategies in assisting and valuing the integration of overseas nurses and
reinforces the need for them to feel valued in the workplace. It also suggests
that migrant nurses should self-select their mentor and/or buddy nurse and that
73
they should evaluate the induction programmes so that they could be adjusted
accordingly.
The literature therefore emphasizes the need to accommodate NESB OQNs in
a non-patronising manner. It explains how reciprocal dynamisms between the
migrant nurse and the local nurse should occur so that their nursing and cultural
backgrounds could be shared and understood, therefore, enriching for both
nurses.
4.4 Phenomenological explanation of the participant s’ experiences
The participants involved in this research project were all overseas qualified
nurses with clinical experience. They were all registered with the NMBWA and
they all had successfully gained a position with a Perth metropolitan hospital.
They were, therefore, not novices but experienced capable registered nurses.
However when they first entered the WA hospital workforce they experienced
professional loss.
The nurses were shocked as the work environment was so overwhelmingly
different to what they were used to. The disparities were at multiple levels; the
ward setting, the equipment and the medication, familiar things had different
names and generally the way nursing was practised was ‘different’. The use of
unfamiliar abbreviations and terminology combined with the struggle to
understand and to be understood, were extremely challenging. The patients
were also perceived as different. Because of these differences the participants
felt that their ability to function effectively and at the professional level they were
used to in their home country was undermined.
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This was manifest in many ways. Some hesitation and lack of fluidity to
undertake the nursing tasks was felt to result in a loss of trust from patients and
colleagues. As a result, all participants were fearful, confused and frustrated
about their inability to apply their knowledge and skills. They developed self
doubt and feelings of powerlessness through realisation that they were unable
to function at the professional level they were used to and therefore they felt
they were failing in their employment commitment. Participants thus, actively
sought information and help. They assumed a learner’s role searching for the
answers to the specific difficulties they were experiencing. Therefore they were
unique learners with unique needs. However, in adopting this perceived more
novice status, some participants felt vulnerable, and more dissatisfied with the
lack of support the WA staff provided to them.
In the next chapter the second theme of the research titled “feeling of
otherness” is presented.
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5 CHAPTER FIVE – FEELING OF OTHERNESS
5.1 Introduction
This theme describes the broad spectrum of communication difficulties
experienced by participants as they endeavoured to work as English speaking
registered nurses. In migrating to WA they were culturally displaced from their
home country and thus, felt a sense of ‘otherness’. The cultural shift
experienced was heightened as it involved major communication changes.
Their sense of otherness became visible through interactions with colleagues
and patients. Their professional lives, however, revolved around communicating
with and responding to others in English at a professional level, but this was not
their first language.
Feelings of otherness occurred at two levels. Their colleagues made comments
that highlighted the participants’ cultural differences, and secondly, as a result
of their own personal experiences, the participants themselves were aware of
being different from other WA nurses.
5.2 I have to speak English
Whilst no participant was a native English speaker and there were differences in
their linguistic proficiency, they had all successfully passed the compulsory
English examination test, namely the OET or the IELTS, required by the ANC
for NESB OQNs. This was a prerequisite for them to gain their nursing
76
registration with the NMBWA. They were, therefore, judged and deemed
competent in English.
5.2.1 English is not my native language
All participants had learned English and they knew that they had to speak
English at work. However as they entered the WA hospital workplace they
struggled and experienced multiple communication difficulties. They were
conscious that they were not as fluent in English as in their first language, and
therefore not as fluent as the WA and other English speaking nurses. This
concerned them and they continually tried to understand why they were
experiencing communication deficiencies. It also gave impetus to feeling a
sense of otherness.
Alice, Eileen and Melissa had minimal opportunities to practise and use English
before coming to WA resulting in them feeling that their command of English
was deficient. Alice explained: “…I came from a totally different background and
the first language was not English… ”. Eileen said: “… we learn English but we
don’t use it…“. Melissa also commented that: “… my mother tongue is not
English we don’t learn English in the school…”.
The nurses did not feel well prepared for a high level communication in English.
They felt that the language course they undertook had been too short to be able
to prepare them well. Kerry admitted that: “…English is the second language…
before I came to Australia actually I did a short … English course they
undertook which is all the basic things…”. Hence, they justified and rationalised
their communication inadequacy, but still experienced stress from their
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language limitations. They also found it difficult to fully grasp English and it did
not come naturally. Fleur’s English teacher had given her warnings and advice:
”… you have to think in English and then talk in English or you’re going to
suffer…” However, Fleur struggled as her shift in thinking did not translate into
more fluid and easier communication.
The concern they felt was exacerbated because their communication difficulties
happened at a variety of levels. They had trouble understanding people; they
struggled with their pronunciation of words and felt that their patients and
colleagues found it hard to make sense of what they said. Georgie was taken
aback by the speed of the conversation delivery: “… they talked very fast and
this is one thing that I struggled with… talking fast there is so many words that I
could not understand…”. Ines was at times unable to understand simple
English words and it was not because she did not know the concept, rather, it
was just the words she did not understand.
They also experienced trouble in being understood. Cathy was trying to speak
but: ”… I have difficulties to pronounce the sound… I need more time - I can’t
make my tongue turn different way…”. Kerry said that: “… when I say ‘have you
finished your breakfast’, they say ‘what is breakfirst?’ They can’t understand
and I say ‘are you feel comfortable?’ ‘What the football?’...”. Even Lucy who felt
confident with her spoken English which she started to learn in primary school
was not always understood: “… you feel like what you are saying is fluent but to
them [patients and nurses] they say, ‘oh we didn’t even hear a word …can you
repeat’…”.
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5.2.2 What’s wrong with my English?
For the participants, the English they learned at school and at university differed
from spoken English in their workplace. They felt they were more or less
prepared for the nursing and medical jargon, but their sense of otherness once
again was visible through what they experienced as unpreparedness for the WA
‘real world’ with ‘real’ people whose means of communication was different from
the textbook English they learned. The participants experienced English as a
medium of communication which was unreliable.
Eileen did not understand her patients. Alice felt that she had been taught
‘proper’ English and struggled to understand her patients. Fleur felt confident
talking to her colleagues but when she talked to her patients she experienced
difficulties, as she did not understand their everyday expressions and ways of
talking.
The participants felt that their English was at a foundation level and that they
had a lot more to learn. For them learning English was a continuous process.
Kerry stated: “… You can’t learn from the basic English schools... you have to
do all yourself …”. Helen revealed that: “… I keep learning my English
because... when you meet lay people… from the community … certain words
they use you don’t learn them from uni…“. Cathy encapsulated what most of the
participants felt about their lack of preparedness for professional communication
in the workplace:
”… I am working in a real world the people communicate is
quite different, the language, the vocabulary… that is used…
at school… it is more academic…The teachers they are fully
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aware those overseas students… English is not your first
language… but in the hospital who cares… I am sick… I am
suffering… you just have to understand me… you work with
colleagues - who care about your language? I need help, you
need to come to help me… [At work]… they have less
toleration (sic) than for me at the school…”.
Communication difficulties were also experienced by participants who felt that
they were fluent in English because of living in an English speaking country or
because, in their home country, English was a commonly used second
language. For example, some commonly used words and acronyms did not
make sense to participants. Ines had not heard the acronym “BO” which meant
bowels open. Despite it being regularly used and understood by WA nurses,
she did not know the word ‘bowel’ because it was not a word commonly used in
ordinary conversation.
Participants also experienced misunderstanding and confusion because of the
lack of consistency given to the meaning of some words. Debbie was surprised
when her preceptor felt offended when she said that she ‘reported’ to her
manager how they both worked together on her first working day:
”… if you say [to me reporting] it is more like feedback but to her
[preceptor] if you say ‘reporting’ it sounds like a big thing… she
makes it a big thing like legal thing… But to myself it …is giving
feedback...”.
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Lucy was confused: “… when they [patients] say they are sick, I’m used to
nauseous and they say I’m feeling sick I’m guessing they’re feeling sick they’re
not well not that they want to throw up…”.
5.2.3 I don’t understand their English
As Melissa said: “… the way I speak English it’s different for them…”. Slang,
local sayings, accent and the pronunciation of words - the ‘Western
Australianity’ spoken English - did not make sense to participants like Melissa.
Communication challenges occurred with patients and significant others as well
as co-workers and participants experienced this as affecting their ability to work,
placing a great burden on them and further contributing to their feelings of
otherness.
Attempting to ’interpret’ slang, local sayings and unfamiliar words left
participants surprised and confused as they were trying to make sense of what
was said from the words they knew. This emphasised the complexity of the
English language, as words in isolation were understood but when placed in a
sentence and within the WA cultural setting, they acquired meanings that
participants could not comprehend. It was like a different language for them.
Alice commented: ”… they say nappy and I was trained to say diaper, or a
pacifier and they call it dummy…”. Julie stated:
”… people would say ‘hi guys there’s lollies for you’ and I’m
thinking ‘what the heck a lolly is’… there’s a lot of words like that
that they’ll say that I’m thinking ‘what did they just say?’…”.
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Barbara and Fleur were bewildered:”… arvo this arvo what are you talking
about…”. “… You don’t understand… [Like] cool bananas... I just get meaning
from the words which doesn’t make any sense…”. Eileen became totally
puzzled when a colleague talked about a patient who was on oxygen: ”… she
said something about second set of wind… I never heard that… I said ‘what
kind of wind?’… wind can mean flatulence…”. Similarly Kerry did not have a
clue about what her patient was talking about: “… oh I had a very good sleep
even don’t know who’s Arthur who’s Martha and I say to my colleague ‘who’s
Arthur or Martha?’ - they were laughing to me…”.
Their inability to understand what was said to them interrupted the normal flow
of their care delivery and placed them in uncomfortable, stressful and at times
embarrassing predicaments. One of Fleur’s patients asked for some ice but she
could not understand:
”… he says ACE I stare blankly at him… I don’t know what
ACE is can you describe? I spent about 5 good minutes to find
out what that patient was asking for … I felt like “gee I can’t
understand him… “
Georgie observed that:”… When they say NO they say it with a ‘I’… they say it
differently so when they say NO they say NI…”.
While understanding the Australian accent was hard, NESB OQNs face
additional hurdles given the range of ethnicities, and thus, language diversity,
among their patients and colleagues. Cathy acknowledged: “… Australia is a
multicultural society… and when they speak English they all got different
82
accents it really make it hard very hard…”. Debbie remarked: “… there are
some foreigners… like from my country or India or Malaysia…it’s difficult to
communicate with them for the accents for me is difficult…”. Eileen was
overwhelmed:
“… you are not only talking to English speaking people you
talk to people who speak Irish, Scottish, Greek, Italian,
French you’ve got Malaysian, Indonesia, Mandarin,
Cantonese, all difference (sic)…”.
Alice stated: ”… [Aboriginal people] …I don’t understand what they are talking
about…like nappy lets say… they call it kimbee???”.
5.2.4 How can I work?
Because participants interact dynamically with colleagues, patients and their
significant others, each had their own personal sense of English proficiency.
Therefore, cognizant of their communication, they developed some strategies
and behavioural patterns in order to be able to function at their expected
professional level. For some participants, addressing the question “How can I
work?” meant concentrating very hard to capture what was said. Barbara
revealed:
”… I had to concentrate on what they are talking about, what the
background of what they are talking about and, you know, you
have to be 100% aware…in a medical situation if they pointed, I
immediately understood what it means…”.
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Similarly Cathy said that she needed to: ”… be very alert, very sharp not only
listen… but… see their body language…I guess 50% from their body language”.
They felt that they had to stay highly focused right through their working shift.
The handover of patients’ information, an intrinsic component of nurses’ duty
was particularly worrying for the participants. They felt very anxious as they
feared missing important details that would jeopardise their ability to provide
safe care to the patients they were responsible for. Helen’s statement
encapsulated how all professionals felt about their professional duties: “… I
think I made it really clear to myself, if I don’t know something I’m not going to
do it until I find out exactly what to do...”.
Verbal or taped handovers were experienced as particularly stressful. Once
again they remained attentive and asked for clarifications when possible.
Checking the patients’ written notes, however, was most helpful. While these
measures were difficult, time consuming and tiring, they nonetheless felt
compelled that they could not start their working shift until they had fully
grasped the essential information relevant to their patients.
Cathy stated: ”… when I listen to the handover I try to concentrate… later I’ll
find the patients’ notes… to pick up what I have missed …”. Fleur said: ”… it’s
hard to keep on asking them to repeat…you still cannot get it… I prefer to read
the writing rather than asking them to repeat… you have more time to look at
words…”. Helen disclosed that: ”… often I came to work early so I can ask the
coordinator what patient load I have got so then I am going through the patients’
notes myself before the handover…”. Kerry also revealed: ”… I have to take
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time to check the patients notes first…I just read the night shift notes and the
previous day … I get there 15 minutes before and then [go to] the handover…”.
Similarly doing the handover was not easy. Cathy felt that: ”…it is a very scary
thing to talk to the tape… I write everything that I am going to say… and read
everything…”. Kerry disclosed that: “... before I do a handover sheet I just
prepare first and I will make small list what I’m going to talk about. I prepare it
and read it out...”.
Tea breaks were not experienced as relaxing. While they mostly sat quietly,
participants tried to comprehend the random unstructured topics discussed by
their colleagues. Barbara stated: ”… I did not talk much… I was more listen to
what other say trying to figure out what they are talking about…”. Fleur said:
”… the people will be talking about their day life their casual life… there be
slang…the way they describe things I don’t understand… it’s hard for me to get
the words… ”.
All participants endeavoured to improve their English and they tackled their
quest in ways that best suited their needs. Eileen followed the news reader and
read the newspaper, talked to a recorder and listen back to her own voice.
Helen asked her children to teach her the ‘Aussie slang’. Kerry said:
”… [I] bring my dictionary… check out from the dictionary and
then find out and then do it… I always ask my colleagues…”
Also:”... When I’ve got time I will put some words or some
sentence how you pronounce this or how do you read this and
my colleagues... will help me”.
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At work they would gather help from their colleagues, patients and would take
some notes. Melissa asked people to repeat and wrote things down phonetically
or in her own language.
They also found ways to obtain their clients’ cooperation so that they could
understand them. When Cathy did not understand she made a little joke, telling
her patients that English was not her first language and then asked them to
speak slowly. Lucy explained that she would go out of the room and come back
in asking the same query again.
They all knew that they had to communicate in a manner that best suited their
client’s understanding. They became aware if people did not understand them.
Julie knew when to slow down her speech delivery: ”… if you get that sort of a
vague look from the patient you already know they don’t understand...”. They
made conscious effort to slow down their speech delivery and to repeat when
asked. Debbie had been alerted during the bridging course to speak slowly, to
articulate and to repeat when asked. She implemented these strategies and
found them useful and valuable as her patients understood her. Eileen spoke
slowly to let people get used to her accent.
Answering the phone was another dilemma faced by the participants. They
dreaded the telephone; they felt highly stressed because they could not fully
capture what the caller was saying. This reinforced how much they relied on full
conversation dynamic including body language, facial expressions and
surroundings to understand. Helen said:
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”… when the phone rung if it is possible I try not to pick it up to
start with …other people [nurses] who are conscious about it
… they would pick it up to help you…”.
Melissa described that:
”…I wait for someone to answer… if nobody answer then I go…
because … we cannot read the lips… it is difficult to
understand… I don’t see the person...” Often the caller would
say:”… sorry I didn’t understand you and I also ask… I don’t
understand anything”.
She would write messages and asked the caller to ring again. They were also
conscious that they could misunderstand some vital pieces of information. Alice
said that she: ”… was scared to pick up the phone … in case it was from the lab
and took some wrong information…”. Cathy explained: ”… if it is an important
message and I can’t understand … I would be in big trouble or I
misunderstood… it was a very stressful time…”. Furthermore to make a phone
call was also not easy. They wrote things down and practiced before hand.
Cathy stated: ”…I prepare[d]… this new vocabulary I don’t really know how to
say, I find someone… ask her to pronunciate (sic) first I am practising in front of
her until she says it’s OK…”.
5.2.5 Relationship and discussion of findings to ex isting literature
The participants’ responses in this research project are congruent with existing
literature from Australia, Canada, the USA and the UK. Communication and
language difficulties are widely reported as one of the major barriers faced by
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NESB OQNs in their endeavour to work effectively in a dominant English
speaking country. 1, 5, 119, 127 3, 7-9, 107, 109, 112, 114, 117, 122, 128-132
Such difficulties have been described as highly detrimental to the ability of
migrant nurses to practice their professional roles.107As a result, frustration from
all parties involved in the communication process: staff, patients and the
migrant nurse, is broadly highlighted and misunderstanding is mentioned as
potentially increasing the risk of error to occur within the health care setting.131
Therefore, even migrant nurses with outstanding nursing knowledge lose their
professional credibility if they are unable to communicate effectively in the
health workforce in which they are employed.
Communication is an integral component of nursing. Therefore language
competency within the clinical setting is an important asset to have in order to
be able to function professionally. Gonda, Hussin, Gaston and Balckman119 in
their chapter on migrant nurses in Australia argue that NESB difficulties with
English are complex as it encompasses speaking, listening, clinical writing and
reading combined altogether. They further explained that a lack of language
competency can affect a person’s ability to work effectively, which can
unfortunately be perceived by colleagues as being professionally incompetent.
This then affects one’s confidence at work and is therefore detrimental to
integrating into the Australian workforce. 127 These viewpoints are reflected in
Omeri and Atkins5 phenomenological research. The participants described how
their experience of professional setback was primarily related to the semantic
and accent differences between them and the local nurses that resulted in
misunderstanding. Similarly in New South Wales, Australia, Jackson’s109
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research study of nine NESB nurses revealed how they commented that their
high level of stress was due to unpleasant encounters with their colleagues who
made little effort in trying to understand their accent. The diverse ethnic
backgrounds of the participants in these two Australian phenomenological
studies provide credibility on the commonality of the migrant nurses’
experiences. However, the small number of participants limits the richness of
the data.
Two other Australian research studies where all participants migrated from Asia
also emphasise communication as a major issue to the participants. Walters’8
narrative analysis of sixteen South Asian nurses who had successfully passed
the OET or IELT and were working in an Australian public mental health facility
in Victoria complained of major language problems. In his grounded theory
research with twenty Filipino nurses working in Victoria, Teschendorff128
discovered that the idiomatic Australian, the accent, the slang, the abbreviation
and the delivery mode made their comprehension very difficult. They often did
not understand or misunderstood what was happening. This was a major
concern to them especially during the handover. They were also scared to
answer the telephone. While they struggled with professional English they also
had problems making sense of the more casual conversations that took place
during break time. This therefore reinforced the fact that their English deficiency
was not purely related to the medical and nursing jargon but to the overall
English language spoken in Victoria, Australia. While Teschendorff’s128 results
are valuable, his analysis was nevertheless conducted with a homogeneous
ethnic group which fails to address the diversity of migrant nurses working in
Australia. As a result his grounded theory might not be applicable to other
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cultural groups. Language barriers were also integral to Johnstone and
Kanitsaki’s study.130 They argued that, as a result of the participants’ foreign
accent and their difficulties in expressing themselves fluently, migrant nurses
were vulnerable to being perceived as incompetent professionals.
The plethora of language barriers experienced by migrant nurses in Australia is
congruent with findings conducted in other English speaking countries. A
thematic analysis study132 of thirty internationally educated nurses from twenty
countries working in Ontario Canada outlines how the nurses were confused,
stressed and embarrassed by the language challenges they experienced in the
healthcare setting. They had great difficulties trying to understand people and to
be understood; therefore constant repetitions of what was said had to occur.
They had to remain attentive at all times and found this to be tiresome and to
slow down their work. They also found the whole experience emotionally
draining as it emphasized their communication incompetency.
In parallel, similar findings from a thematic analysis conducted by the
Commission on Graduates of Foreign Nursing Schools (CGFNS) of a large
focus group study including participants from eight cities in the USA and
Canada revealed that difference in language was one of the obstacles faced by
foreign educated nurses. They reported feeling linguistically unprepared,
especially with colloquial expressions and medical abbreviations. This was
testified in their difficulty using the telephone, communicating effectively with
their colleagues, their patients and the patients’ relatives. As a result they felt
disadvantaged and inadequate in their professional role.
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Yi’s9 grounded theory study of twelve Korean nurses working in the USA,
described how the language barrier was detrimental in achieving their work
duties. Participants expressed their particular difficulties with the use of the
telephone because they were not able to rely on the non-verbal communication
‘codes’ that they highly relied on in face to face communication to assist their
understanding of what was said. While this finding could once again reflect the
specific cultural group studied, it nonetheless coincides with previous study
reports.
In the UK as well, the extended body of research reports communication as a
major problem of NESB migrant nurses. Withers and Snowball’s study117 which
encompassed collecting data from forty five questionnaires and eight semi-
structured interviews with Filipino nurses working in the UK, reports of their
bafflement with the UK English slang, colloquial words and medical
abbreviations. Equally Matiti and Taylor’s phenomenological study112 of twelve
nurses from four NESB countries described how the accent, the colloquial
English and the fast speech delivery of colleagues and patients were barriers to
the participants’ understanding. At the same time they experienced great
difficulties in being understood. In the extensive report titled “We need
respect”122 where the year 2001 existing research demographic and statistics
were utilised to approach possible participants, sixty seven internationally
trained nurses working in the UK from eighteen different countries took part in
focus group interviews. NESB participants expressed their surprise and
disappointment at the lack of “Oxford English” spoken by British people. Their
unfamiliarity of the local spoken English was reported as a major difficulty.
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The consistency in the voluminous international research findings of the
differences between the English learnt and spoken by the overseas nurses and
the English spoken in the host country provide evidence on the commonality of
communication problems experienced by international nurses irrespective of
their NESB country of origin. In fact the verbal interaction which is primarily
used in the daily routine of nurses at work was stated as the most troublesome
element of their communication difficulties.
It is also important to note that Australian nurses, like their counterparts living in
Canada and in the USA, care for multi ethnic patients who display a broader
variety of accents. These have been reported in the literature as further
challenges for NESB international nurses.132, 133
The overall literature illustrates the multifaceted communication predicament
and its effect on the professional experiences of NESB OQNs working in
dominant English speaking countries.
5.3 I know that I am different
While the nurses’ communication difficulties contributed largely to their feeling
of otherness, this feeling was also reinforced by the way some of their
colleagues behaved towards them which brought, at times, a rather negative
tone to their existing feelings of otherness.
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5.3.1 They can be a bit off putting
The directness and openness of some of their colleagues have left participants
at times feeling offended and hurt. Cathy’s colleagues joked about her accent
and her pronunciation. Eileen felt that it was hard because people laughed at
the way she spoke. Fleur has encapsulated how participants felt when their WA
colleagues looked down at their accent, pronunciation and/or their country.
Fleur said:
”… they still think that [my home country] is poor… they will
ask me silly questions; do you have tall buildings… you don’t
have lifts…” Fleur felt offended “…’cause like you look down at
my country you look down at me…”.
When told by their WA nursing colleagues to alter some of their working habits
both Debbie and Lucy were surprised and offended. Debbie was told that her
handover was too long and that she was wasting people’s time:
”… I am not trying to use the other words because [she] said
worse things… [She] was too harsh… it could get said in a nice
way… I’ve not spoken to them before and to talk to me like that
it doesn’t sound good…”.
Lucy was told that her greeting etiquette was not necessary:
“…I say good morning and everyone was quiet …they said
‘here in Australia you are not forced to say good morning and
we are not forced to answer’… it sounds very bizarre to me
because I believe you need to say good morning to people
especially when you arrive at work… that’s how I grew up…”.
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The participants knew that they were different and somehow anticipated that
they might have difficulties in integrating into the WA system: Georgie said that
her supervisor was very harsh but commented that it was quite natural because
overseas nurses looked different, therefore reinforcing her sense of otherness.
Helen explained:
”… [some] people they are not nice to you, they pick on you...
you find that you different from most of the people, so that’s
really the things that really gets me, you are different, you are
mature age, you speak a different language, you eat
differently, you cook differently... you feel you are an alien. You
are really self conscious”.
5.3.2 Discovering the WA culture
The participants’ sense of otherness was further highlighted for them as they
did not feel that they could make ‘small talk’ with the patients. They missed the
‘WA touch’ that they felt their WA colleagues displayed at all times in the very
fluid manner they interacted with their patients. Interaction with patients for
participants was characterised by caution.
Kerry was not fully satisfied with her delivery of care as she was self conscious
of her lack of skills in initiating small talk with her patients:
”… the only problem if the patient will feel very boring under
my care… for me I feel like I’m very... boring person...I’m not
making any joke when I do the bath to the patient like wash in
bed I just wash and then ask them how you feeling, how’s
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that...if I’m working with the other colleagues they will say lots
of stuff they talking to patients a lot... I don’t know what I
should talk about ...”.
Similarly Debbie struggled to initiate stories that were relevant to her patients’
world. Fleur stated: ”… the way they [her colleagues] describe things is so nice
and so natural… I want to be able to describe things like that…”.
Etiquette was also of concern to the participants with comparisons between
their communication style and that of their WA colleagues. Kerry has observed
that her WA colleagues’ work etiquette was different to hers and she was
concerned that she might give them the wrong impression:
”… they’re all very polite, they always say please… thank
you… sorry…every time when you helping … they all [say]
thank you Kerry or Kerry could you please do that…”.
However in her home country it is:
“… not quite often to say thank you or sorry… we don’t say
thank you quite often…and [if] say thank you… we never put
the [person] name… we’ll say can you do this can you do that
if I say in this way [in WA] … well seem like you’re so bossy…
that means I’m not polite, it’s just the culture thing”.
They realised that the WA people’s tone and body language were also different
to their own. This had the effect of reinforcing their feeling of otherness as they
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felt that their culture had shaped their current communication style and they all
felt they should change to fit within the WA norms. Julie said: ”…Aussies …
they’re a very mellow type of culture… a monotonic type of voice…”. She felt
that people perceived her as abrupt or bombastic. However, she said that it was
not her intention but a reflection of her culture. Another cultural issue that left
Fleur puzzled, unsure of what to do next and that highlighted a sense of being
different occurred one morning when she greeted one of her colleagues. ”… I
just say … ‘good morning are you alright?’ … and she said ‘I’m not’. I was stuck
… and she says ‘oh my husband left’…”. Fleur did not know what to say
because in her home country: ”… you only tell the (sic) story to the very close
friend…”.
The participants desired their communication style to become closer to their WA
nursing colleagues. However they realised that it might not be an easy and fast
process. Lucy disclosed that:
“… with my culture I can’t maintain eye contact it is not an easy
thing because we grow up you know doing … eye contact that is
disrespect so it’s not easy to change suddenly…”.
5.3.3 Relationship and discussion of findings to ex isting literature
The responses of the participants in this research of their conscious awareness
of being different as well as being perceived by the local people as different is
similar to the current literature. Some variations however are also noted.
In the literature communication difference has been described as conducive in
highlighting migrant nurses’ sense of being different from the dominant group.
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In the UK report titled “We need respect”122 participants described, that while
over time they became accustomed to the English accent, it was not the case
for their patients and colleagues who continued to experience difficulty in
understanding their accent. Furthermore, they reported that often their local
colleagues would use the participant’s ‘difficult’ accent as an excuse to not
bother to make any effort to try to understand them. Comments on feeling
stigmatised because of their communication style and elocution, which at times
generated mockery among their co-workers, were also mentioned. The element
of ridicule was also reported in Likupe’s literature review131 of nineteen
research articles which studied most specifically the lived experiences of
African nurses in the UK NHS. Migrant nurses’ pronunciation of English being
laughed at openly by some of their UK colleagues resulted in feeling of
frustration and anxiety.
In Taylor’s thematic analysis7 of eleven overseas nurses from six different
countries working in the UK NHS, language difficulty was of great concern to
NESB participants. However, while some of the UK nurses made various efforts
when communicating with the migrant nurses in order to assist their
understanding; in trying to help they nevertheless treated them differently and
as a result many participants felt ‘belittled’ by their local colleagues’ approach
towards them.
International studies also emphasize how NESB migrant nurses have been
perceived and treated differently. They have been made aware by some of their
colleagues of the differences in their spoken English in ways that were at times
unsympathetic and hurtful. The literature also reveals that migrant nurses were
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self conscious about their communication deficiency7, 107, 132, 133 and their overall
communication differences was commented and associated with feelings of
embarrassment about their limited verbal and non-verbal skills.107, 122, 132 In the
UK Alexis and Vydelingam’s’107 investigation on the lived experiences of twelve
overseas black and minority ethnic nurses reported that the unfamiliarity with
the local English made them feel like “being thrown into a different world”107(p.16)
where they juggled with the English they knew leaving them at times feeling
embarrassed and shamed by their poor language skills in front of their patients
and colleagues.
Furthermore, the concept and the use of non verbal communication methods
characterised by the use of body language, eye contact, smile, speech delivery
and the tone of voice have been reported as additional challenges for
international nurses. In fact their communication norms and values often varied
from the country in which they were born and the country to which they have
migrated.1, 9, 107, 111, 123 As a result of these unfamiliar culturally shaped
communication techniques, studies conducted in Australia report of the
difficulties international nurses experience in trying to participate and to fit in the
everyday informal conversation.120, 126 An example of that is provided in
comments made by some Filipino participants in Teschendorff’s research108
who were unable to contribute in the casual talk about “cricket” which was a
recurrent conversation topic occurring in the hospital environment.
Furthermore, in 2006 the Researching Equal Opportunities for Overseas-trained
nurses and other Healthcare professionals (REOH)114 report which
encompassed the experiences of overseas trained nurses working in the UK
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health system reported on their difficulties and concerns in relation to career
mobility. The migrant nurses felt that communication skills and ability to fit into
mainstream English were paramount in applying for and gaining promotion. This
was something they found themselves less able to do, compared with their
English Speaking Background counterparts.
Migrant nurses’ sense of being different from their local colleagues is very often
correlated with participants feeling of being discriminated against in the
Australian and international literature.2, 7, 107, 114, 122, 131, 132, 134-136 In Australia
Omeri and Atkins’5 study participants describe how migrant nurses felt
discrimination and prejudice on the basis of their differences in ethnicity and
experiences. Their Australian colleagues’ cultural ignorance left most
participants feeling as if they were ‘stupid’. Gonda et al119 argue that in Australia
there is a ‘common belief that foreign educated nurses are actually incompetent
and possibly a danger to clients’.119(p.130) Jackson’s109 report also described how
migrant nurses experience what she called ‘horizontal violence’ where some
Australians nurses displayed discouragement stratagems and unhelpful and
hostile behaviours, to avoid assisting migrant nurses. Teschendorff’s108
investigation of Filipinas working in Victoria describes cases of racism and
ethnocentrism experienced by the participants and he believes that their
vulnerability to discrimination and, therefore, feelings of inferiority was
enhanced by the legacy of their history under the influence of the Spanish and
American colonialism. As a result Teschendorff argues that they view ‘white’
Australians as superior to them. Furthermore he explained that the participants’
understanding of some of Australia’s anti-Asian attitudes made them believe
that they were a potential target for discrimination. Avoiding conflict and
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remaining silent were thus their preferred coping mechanism. Finally
Hawthorne’s report3 on the barriers confronting overseas qualified nurses
working in Australia using surveys and interviews of OQNs including fifty NESB
nurses, revealed that prejudicial attitudes toward migrant nurses in the form of
hidden and direct discrimination, ‘back stabbing’ and blunt racial behaviours
occurred. Consequently participants commented on losing their confidence
while feeling generally ostracised. While these findings could not be applied
across the whole nursing migrant community it nonetheless highlights how
participants might interpret and feel about their cultural otherness status in the
host country.
However, while reported in Australia and internationally the evidence of
extensive data on ethnocentrism and racism do not reflect the experiences of
the WA NESB OQNs interviewed in this research project. In fact, while a few
examples of difficulties related to their ethnic otherness status have been
mentioned, the overall report of their experiences at work did not emphasise
feelings of being discriminated against in the workplace.
5.4 Phenomenological explanation of the participant s’ experiences
The participants involved in this research project were non English speakers
who migrated to Australia. However, they met the national English requirements
so that they were able to gain their WA nursing registration and be employed
within the WA health care system. They knew that the use of their mother
tongue would become redundant as they entered the WA hospital setting. They
had to speak English. However, this process was not easy and many difficulties
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in communicating with their colleagues and patients were experienced. This
cultural and linguistic shift resulted in their feeling of otherness.
The nurses were very well aware that their English would be different from the
WA native speakers and that they might experience some difficulties. They all
explained that, while they learnt English, it was not a language they commonly
used before coming to Australia. They were conscious it would be different
because, as Fleur said, the fluidity of the language did not come naturally and
easily. The difficulties they experienced were multiple and they were
overwhelmed and taken aback by their struggle to converse and the impact it
had on their work. They wondered what was wrong with their English. They felt
that their textbook English did not reflect the way the people around them
spoke. They felt ill prepared by their ability to speak at work. While all
participants experienced communication difficulties most of them believed that
their basic knowledge of English was responsible for their predicament. Others
who were more confident about their English proficiency also remained
confused.
Their English was different than the English spoken in WA. In fact they felt that
WA English was ‘a language of its own’. Some of the words were different, and
they did not understand the local slang. Furthermore some words they knew,
when placed within the local context, did not make any sense at all. In addition
the local accent and pronunciation, combined with the multitude of accents that
characterises multicultural WA, left the participants frustrated and confused.
Their ability to work in a smooth and efficient manner was negatively impacted.
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In searching to bridge the communication gap, developing strategies was
central to overcoming their feeling of otherness resulting from communication
difficulties. As they felt they could not simply rely on their listening skills to
understand what was discussed, they concentrated at all times, even during the
tea breaks, in a holistic manner and observed people’s facial expressions, body
language and the surroundings in order to capture what was said.
The handover process, which is central to nursing, was a source of anxiety.
Participants felt that they could not fully understand their colleagues’ verbal or
taped handover and feared missing vital information which could jeopardise
their delivery of care. Therefore, they all felt compelled to access their patients’
written notes before or after the handover to supplement the information
provided. They also found the experience of handing over scary and would write
everything down first and then read it out. The nurses made enormous
sacrifices of their time and effort to overcome their language deficiency and felt
more comfortable with written information.
Improving their English was important for the participants. They were self
directed learners, and developed skills and strategies so that cooperation
between themselves and their colleagues and patients would occur and mutual
understanding would result. They all feared and stressed about answering the
telephone. This somehow reflected the important component that visual clues
had in their ability to communicate. They were afraid of possible
misunderstandings and were highly conscious of the potential harm to their
patients’ welfare.
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The participants feeling of otherness was further enhanced through some of
their WA colleague’s verbal remarks on their accent, country of origin, and/or
ways of working. They experienced their colleagues’ comments as rather abrupt
and direct leaving them feeling negative and ‘different’. Furthermore, their
exposure to the hospital setting resulted in them becoming self aware of the
cultural difference between them and their WA colleagues. They compared their
communication style and etiquette with the WA nurses and realised that their
culture had shaped their professional communication style, which at times
differed from their WA colleagues. They all felt the need to change and to
become closer to the norms and standards of the WA nursing culture but
realised that the process might present challenges and will take time.
In the next chapter the third theme of the research titled “rediscovering nursing”
is presented.
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6 CHAPTER SIX – REDISCOVERING NURSING
6.1 Introduction
While the participants were qualified and experienced registered nurses in their
own country, working in a WA hospital required some adjustment to their
practice. The new work environment, the patients and their colleagues were
different to that of their home country and while they recognised that nursing
was similar they also highlighted that it was at the same time ‘different’.
This chapter explores the lived experience of NESB OQNs in relation to their
professional self. As they started working in a Perth metropolitan hospital they
revealed their feelings and understanding of nursing in WA.
6.2 Preparedness to work
Nursing practice as experienced by the participants was ‘the same, but it was
different’. The participants found that they were partially prepared to work. While
they recognised the core and foundation of nursing practice was universal, they
were taken aback by the way nursing was practised. They realised that they
had better clinical skills that their WA counterparts and felt that some of their
skills were redundant. However the WA holistic approach to patients’ care that
included high level communication skills, much paperwork and a plethora of
allied health services and professionals left them overwhelmed.
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6.2.1 It is the same
Participants felt reassured about the practice of nursing because they could
recognise the essence of nursing in their colleagues’ practice. Julie explains:
“…if you’re a nurse you’re caring person so… I find that the relationship with the
nurses here with the patients … in general …it’s pretty much the same…”.
Alice commented that: “… at the end of the day all we do is we look after sick
[people]. That’s the whole purpose or the goal is the same… my guess in terms
of everyday nursing practice…. I could not see much huge difference…”.
Melissa was working in the operating theatre:”…although [the surgeons] do
different ways... the procedures you are familiarised (sic) they do the same
thing…the profession by definition is similar, nursing and caring…”. Eileen felt
that: “... medication it is basically almost the same ... I understand what the
theories were because I can put into action... I have that knowledge...“.
6.2.2 But it is different
While the nurses were able to recognise the sameness within the WA nursing
practice they all identified multiple differences. Some differences were minor:
Cathy acknowledged that: ”…there is not much difference… it is just the
different culture the way that we do the things they are a bit different…”. Ines
did not: ”… actually come across anything that hugely different…the practice in
itself is not very different…”. As Barbara stated: ”… nursing is slightly
different... basically we are doing the same things here… [I] did not have any
problem to do nursing practice…”.
Other differences were experienced as more pronounced. Participants felt that
they had more nursing scope with a broader range of clinical skills than their
105
WA colleagues. This reflected the task oriented nursing care that was intrinsic
to their past work experiences in their home country.
In Kerry’s home country:
“…what we have to do ... is like doing the medication,
administrate (sic) the new patient coming and the discharge
patient and then pre-op and post-op all nursing care we focus
on the treatment...nurses here [are] not as good as us … we
did lots of things ....if emergency happen we have to do it
ourselves not like here ... the medical emergency team ... they
will help but we all do ourselves.”.
In Cathy’s home country: “… we only do the technical skills, nursing care,
medical care…here we look after the patient holistic care... we look at
everything, eating, drinking, showering, hygiene...”. Eileen realised that: “…I
have better clinical experience that some of the nurses who work with me [in
Perth]. At home I can take blood... do cannulation... I can do stitch, suture ...”.
In Helen’s home country the nurses’ tasks: ”... is quite different [they] focus
more on their skills ... they are really excellent with skills... they do quite a lot of
things... [In WA] most of nurses can’t do cannulation... they can’t put urinary
catheter…”. Lucy was adamant:
“… our nursing is more advanced that Australian nursing …we
are more independent we do things ourselves …our scope of
practice is 50 pages …When you do your second year you
need to know how to cannulate … no one’s going to come to
your rescue……Here… Australian nurses, they know much of
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the theory; they are good in theory but … when they come to
clinical nursing area they don’t know nothing…”,
However, the realisation that in WA they were not allowed to implement all their
clinical skills left them feeling frustrated; Julie felt:”…totally underutilised… I
can’t tell you in how many positions I’ve put up an IV line in my life before…it is
like giving a bedpan that’s a normal part of my life…”.
They also felt that communication and holistic patient care was fundamental to
the practice of nursing in WA, something with which they were not familiar.
Helen’s statement described how she perceived nursing care in WA and this left
her feeling overwhelmed:
“…the work is not much ... the nursing skills... they emphasize
our communication skills, how you are going to help patients to
overcome their concerns and help them in transitional like from
hospital to the community...”
”... you have to do everything... you need to keep all this
medication and go to doctors round and listen to the phone all
these things... organise everybody’s treatment has to be done
properly and in time and then you have all the showering,
bathing all these other things to do and then communicate with
patients about their social problems, organising their physio,
the social worker, or occupation(al) therapists regarding their
discharge. I find it is physically and mentally challenging...”.
107
6.2.3 The ‘other’ health services
The availability of extended and specialised health services available to assist
with their patients’ health needs was also unfamiliar to the participants as they
did not exist in their home country.
Alice was surprised: “… sometime you would refer a patient to …Silver Chain
or …the baby one the Ngala … I was not aware of all these…”. In Fleur’s home
country: ”... there isn’t any social worker, so if patient have any social problem
well too bad,... you never bother [to] ask a patient... there’s no ... resources that
you can use to help your ...patients …”. Similarly in Helen’s home country:
”... society doesn’t have the resources to help people so it’s not
part of the care... Family looks after them... you don’t have these
responsibilities to go to talk to them You don’t have time, you
don’t pay attention to their psych(o)- social issues, here it’s a
large part of your duty... the system is so different ... so you just
have to know the health system working all these kind of
things...”.
6.2.4 Relationship and discussion of findings to ex isting literature
Some of the participant responses in this study are congruent with the existing
body of research. In fact, current international literature acknowledges the
culture of a country influences how nursing is practiced within the existing
health care system. This concept of diversity within the world of nursing is a
reality that affects nurses as they go and work abroad. 5, 9, 11, 118, 132
108
In New South Wales, Australia, Omeri and Atkins’5 qualitative study of five
migrant nurses elaborated on how culture highly influences nursing practice.
They argued that in some countries nurses do not attend to basic nursing care
such as bathing and feeding patients, as it is attended to by their family. In other
countries nursing is tackled holistically. Therefore all patients’ needs are
performed by the nurse. Nursing care can vary from a bedside approach to a
more scientific, task oriented approach. Furthermore Josipovic’s118 research
which reinforces the concept of diversity in nursing argues that nursing practice
is influenced by the social status placed on the profession. She explained that If
migrant nurses come from a country where the nursing profession is ranked
lowly they will tend to be more submissive in their practice than nurses who
came from countries where nurses are almost equivalent to a doctor. With this
in mind, Omeri and Atkins5 stated that their participants who were from varied
countries of origin had difficulties in adjusting to Australian nursing practice.
In the USA, Yi’s9 study of twelve Korean nurses describes how participants did
not anticipate differences in nursing practice. They were shocked to have to
attend to patient’s bedside nursing care and baffled by the little emphasis their
new role had on the management of their patients’ medical care. Another
important difference the Korean nurses discovered was that they lacked the
communication problem-solving skills displayed by their American co-workers.
Unfamiliarity was noted in Bola et al’s107 study describing the wide range of
confusion faced by foreign educated nurses. This included unfamiliarity with
documentation, medication, equipment and technology, patient education and
psychological support. Patient’s health problems, which can vary from country
109
to country, were also elements that migrant nurses felt could, at times,
undermine their nursing practice.
In relation to the holistic nursing care approach, the current literature highlights
the shock experienced by migrant nurses when they came to the realisation that
their practice was to include the feeding, showering and the overall hygiene
care of their patients, something that most of them did not have to do in their
home country. As a result they felt a sense of belittlement in their professional
status. 9, 107, 108, 112, 118, 128 In addition the complexity in individualised and holistic
patient care was also described as challenging for migrant nurses who
previously worked in a task oriented fashion together with their nursing
colleagues. They missed the team approach and the camaraderie and support
associated with it. 2, 7, 108, 112, 122, 128
In the UK, Gerrish and Griffith’s evaluation research project of seventeen
female OSQNs report how they also commented on holistic care. This
understanding of it was that they had to manage their time, prioritise their
delivery of care and liaise with the diverse health team, something that they
found challenging especially for the participants who were used to task oriented,
team approach nursing practice.2 In Taylor’s7 report of eleven nurses working in
the UK NHS, holistic care was also mentioned as a challenge for most
participants. The complexity in organising their patients’ discharge planning was
a major concern to them. In Matati and Taylor’s112 paper and in the “We need
respect”122 report, the amount of paper work which made up part of the nursing
daily routine was unfamiliar to the participants, who found the process
overwhelming and left little time for patient care.
110
In Melbourne, Australia, Josipovic’s118 paper based on a descriptive
ethnographic study of NESB OQNs commented on their surprise in discovering
that Australian nurses were engaged in patients’ hygiene needs and how much
paper work and signing they had to do. Teschendorff’s108 account of Filipino
nurses showed similar results. It describes how overwhelmed the participants
were at having to shower patients and attend to their intimate care. It was
something they did not have to do in the Philippines. Consequently they felt that
the social status of the Australian nurse was low.
Furthermore Jackson’s11 research study describes how the participants’
account of varied nursing practices was framed within the national wealth and
health politics. For example in some countries it was not part of the nursing
practice to take patients’ blood pressure because of the shortage of equipment
such as stethoscopes which were only used by doctors. In Australian hospitals
the extensive use and reliance on technology and sophisticated pieces of
equipment did not always fit with the prior practice of migrant nurses. This
applied especially the nurses who migrated from poorer and less industrialised
countries where public health tasks, such as checking the communal source of
water, dominated their daily work activities. For these particular migrant nurses
the lack of technical proficiency left them feeling estranged from the Australian
nursing workplace. On the other hand, migrant nurses whose past nursing
practice included a high reliance on technology felt more at ease to utilise and
learn about the equipment available in Australia. However these technically
skilled nurses felt that it was a waste of their knowledge and a decline in their
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professional nursing status to have to attend to patient’s hygiene and feeding
needs.
The other concerns experienced by the WA participants in this research project,
which reflects the current literature, is the inability of migrant nurses to perform
the clinical skills they learnt and practised in their home country. While the
literature suggests and comments that migrant nurses’ prior knowledge and
skills are assets that should be valued and utilised by the host country, it
nonetheless appears that this concept has not been followed.118, 119, 136, 137 In
fact research data commonly highlights that most migrant nurses report their
wide range of clinical skills and extensive clinical knowledge are not recognised.
As a consequence, participants in these research studies explained how their
inability to utilise their prior knowledge left them feeling undervalued and
disempowered as professional nurses.5, 11, 109, 117, 122
In the Omeri and Aktins’5 study, feelings of being undervalued because their
past professional knowledge and skills had not been recognised was stated.
Some nurses who came from countries where doctors were scarce and who
had extensive clinical skills, felt very offended that in Australia their professional
expertise was totally ignored and therefore could not be used. Similarly
Jackson 3, 11 reports migrant nurses experiencing professional disempowerment
when attending to patient care. They complained of their inability to perform and
to share with their WA colleagues their clinical skills and prior knowledge.
Respondents in Withers and Snowball’s117 study of Filipino nurses working in
the UK reported that their supervisors were oblivious to their skills,
competences and extensive past nursing experiences. They were annoyed to
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not be allowed to insert intravenous (IV) cannula and to take blood, which was
commonly part of their former nursing duties. As a consequence, they
expressed great concern at losing these very valuable clinical skills. Similarly
Matiti and Taylor’s112 investigation pointed out that all participants were
surprised at not being allowed to practise the range of nursing skills they
acquired during their nursing training in their home country. They thought that
these skills were universally taught and therefore part of nursing education and
practice.
In the REOH study,114 results confirmed the extensive deskilling and devaluing
process migrant nurses entering the UK health system go through. Their
nursing aptitudes and competences gained overseas were appreciated by
neither their employer nor their colleagues. They were perceived not as skilled
nurses, but as learners to be trained to fit the British nursing system. Therefore
the report highlighted that placing migrant nurses as learners resulted in major
skills wastage. Similarly in the “We need respect” report122 participants
expressed their dissatisfaction at not being able to apply their prior nursing skills
so that they could fit within the British nursing standards. As a participant
mentioned, putting an IV infusion could save a patient’s life but they are not
permitted to do it until they completed the specific courses. In shaping migrant
nurses into British nurses, migrant nurses felt it was a professional step down
and an unfair lack of appreciation of their nursing proficiency.
In a descriptive survey sent to one hundred and fifty migrant nurses in a Sydney
hospital127 participants complained of having to be reassessed for professional
competencies such as IV cannulation and venupunction. They claimed that
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these skills were essential components of their nursing training and daily
nursing duties in their home country and that they were fully competent in them.
6.3 Working with patients
The nurses’ approach to patient care and the patients themselves were both
very different for the participants. Their initial surprise of being allocated a low
patient load was followed by the realisation that the purpose of it was to
facilitate and implement patient centred care.
6.3.1 A patient centred approach
Initially participants did appreciate having fewer patients to look after. Alice
described:
“…Here you take patients, lets say you’re only one to four
sometimes one to five but you’ll look after them as a person
rather than a task so you look after everything together so this
is very different… in [her home country] you are dealing with
the whole ward … five of you … with 48 patients…we only do
the medication and the documentation…”.
Barbara felt: “… that you are doing nursing to the patients...”. in her home
country: ”…there is too many patients, too much to do... ”. With nursing in WA
being about patients and not instrumental tasks, they could now devote more
quality time to each patient. Eileen was astounded: “…I only look after 4
patients instead of looking after 40 patients ... in fact I love it at the first sight...”.
In her home country nursing was: ”…like a factory …you don’t have time to see
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the [patient’s] face ... you don’t talk... you just do the task ...”. Fleur felt that the
patients were treated more: ”...like a friend... [you] make your patient feel
comfortable ...they are willing to trust you... they do it automatically.... we have
primary nursing... so you get more chance to talk to your patient....”. In her
home country: ”… we treat patients … as patients… it’s not closer than that…
you just focused on medical things… I’m the nurse… so they are forced to trust
you…”. Barbara was surprised that patients were treated as customers and that
nurses respected their wishes and tried to make them happy. Eileen felt the
impact of patient centred care is that:”…the patient is your patient... I have more
time to have contact with my patients and assess [them]...”.
They were amazed that nursing agency staff were employed to cover nursing
shortages. Melissa could not believe that: “…for this many persons [patients]
there should be this many nurses...here [patients] get enough time from … the
nurses”. In her home country: “…they don’t have agency system… and nurses
workload was very high... it’s like more than 40 persons and 2 nurses…”.
6.3.2 The WA patients have a say
The participants felt that the patient centred approach to nursing care
empowered patients to communicate. They found that patients liked to talk and
discuss their care, something that was also new to them. Julie described how
they were quite eager to give information and talk about themselves. Similarly
Helen found them very assertive in the way they talk, ask questions and request
for things to be done for them.
115
It was also new to them that patients wanted to be informed about their health
condition and that it was in their right to refuse treatment. Fleur noted:”… here if
the patient ...says no I don’t want that treatment you can’t carry on that
treatment... ”. Fleur came from a background where patients were not given
options:”... a doctor make the decision for the patient…”.
They felt that their patients were mostly friendly and fun. Kerry described her
patients as very funny, and liking to make jokes. Lucy explained how she
enjoyed looking after her patients as they were appreciative of her work and
liking to have a good laugh. She felt valued when a patient who she looked
after in hospital recognised her in the city and greeted her. However patients
could also be direct and abrupt. Barbara and Georgie were staggered at how
freely their patients expressed their feelings:
“…Here you can see what they want ...and when they say no
it means no…they show their anger without any hesitance
(sic), anger or many different emotions... they don’t hide.
Sometimes I thought “oh oua, why you are angry? “Are you
angry with me?” But no they are just showing their
emotions…”. (Barbara)
”…people here …..don’t beat around the bush - they tell you
what’s in their mind... they are very straight forward people …
they curse a lot and they swear a lot...” “... This morning I
heard a lot of swearing that’s the way it is here… [when]…they
are experiencing pain ... they will say the S word of the F
word... which I am not used to…”. (Georgie)
116
Lucy had been particularly offended by one of her patients who said to her that
she did not want a black nurse to look after her. However she was even more
offended by the response of her colleagues who said: ”…‘that person is a
patient… they don’t mean it’ … if someone do something wrong to you ‘no she
didn’t mean it… I don’t think it was her intention’…“ .
6.3.3 Relationship and discussion of findings to ex isting literature
The current literature reflects the experiences of the participants in this study
where the holistic nursing approach which encompasses the empowering of
patients in the delivering of healthcare, is reported as different for many
international nurses to what they were accustomed in their home country.
The concept of informed consent, where patients are given an explanation and
educated on their current health status so that they can actively make choices
in relation to their treatment and procedures, is broadly reported in the literature.
However such practice is stated as unfamiliar with the previous nursing practice
of many international nurses.5, 7, 118, 132, 138 In research conducted in Ontario132
participants were challenged by some aspects of the Canadian nursing practice
as it differed from their own. They pointed out that their Canadian colleagues
were assertive and pro-active in clinical decision making and more accountable
to their patients. For most of the participants the concept of informed consent,
where patients have to be fully informed and had to consent to treatment and
procedures, was new to their practice. They also reported that patients and their
families had more knowledge and control about the care and treatment that was
delivered to them and they generally had more rights than the patients in their
country. They also felt that they were valued and respected by health
117
professionals. Similarly in the UK, a participant in Taylor’s7 research stated how
surprised she was that patients and their family were involved in the decision to
resuscitate or not resuscitate, which in her country was the doctors’ sole
decision.
Josipovic’s118 report highlights that migrant nurses felt their Australian
colleagues were more legally and ethically aware of their duties toward their
patients and therefore of the legal implications of their actions. The participants
reported that in Australia patients were more medically aware and had more
rights than the patients they attended in their home countries. Therefore the
concept and respect to inform patients was new to them.
However while participants in this WA research commented on the extensive
amount of paper work nurses had to do, the literature showed similar findings
but further elaborated on this aspect. In fact the results of international studies
commented how migrant nurses viewed the extensive nursing documentation to
be directly related to the professional responsibility and accountability nurses
have towards their patients as well as their patients’ right to be informed.
Nurses’ fear of the possible legal litigation placed upon them by their patients
and/or their family was stated as constraining their practice, as well as the
driving force to keeping diligent records on their patients’ progress. 114, 115, 118,
122, 132 Furthermore in Allan’s 115 analysis of two qualitative studies investigating
overseas nurses working in the UK (one study looking at the lived experiences
of migrant nurses and the second study looking at equal opportunities and
career progression for migrant nurses) revealed that participants in these
studies believed that the emphasis on patient’s rights contributed to UK nurses’
118
fear of lawsuits and that a shift had occurred from nurses giving care to nurses
documenting care. These findings mirrored the RCN122 report where migrant
nurses in the British health system complained that their scope of practice was
restricted by the British nursing legal framework and that the rights of patients
constrained nurses from performing their duties, as they feared litigation.
In the USA Yi’s study revealed that patients were perceived by Filipino nurses
as demanding and self centred, which they believed was a reflection of the high
value Americans placed on individualism. This was not the emphasis in their
home country .9 Furthermore patients have also been stated in literature as
vocal in relation to their like and dislike of nurses attending to their care, leaving
many ethnic minority and/or ‘dark skin’ nurses feeling at times hurt and
discriminated against.1, 107, 114, 131, 132 These findings could be related to either
the empowerment of patients in their choice of care and therefore of health care
professionals or to their racism / ethnocentrism viewpoints or to both.
6.4 Working with doctors
The participants appreciated the team approach in working with doctors. They
found that their interactions with doctors made them feel part of the team and
found the doctors polite and approachable.
6.4.1 The team approach
Because of the lack of medical doctors on the wards they had to regularly
contact them to seek the medical advice they needed for their patients. Alice felt
that she had to use her own professional judgement to decide whether she
119
needed to contact the resident to review her patient, while in her home country,
residents were on the ward 24 hours everyday. Similarly Helen stated that here
she had to contact the doctors. This made her feel more like she was working
within a team because in her home country nurses did not have a voice and
they were subordinate to doctors; their main task was to help them.
Georgie recognised that: “... Here you use your critical thinking more... you can
even argue with the doctor ...”. But in her home country nurses only do what the
doctors said. She felt like they were more like little a robot. Melissa, who
worked in the operating theatre, valued the surgeons’ professional interactions
with the nurses as they spoke nicely and introduced themselves. She felt that it
was like working in a family. Nurses could express their satisfaction or
dissatisfaction which was unlike in her home country where all that mattered
was the surgeons’ satisfaction. Likewise, Lucy found doctors nice, and happy to
listen to and respond to her queries. However, they were shocked that in WA
doctors were called by their first name as they were accustomed to a more
formal way of addressing them. In her home country Barbara would have never
have called consultants by their first name; she could not even talk back to them
as the rules were very strict.
6.4.2 The doctor / nurse hierarchy
That being said, despite what seems to be a more casual professional
interaction between nurses and doctors, some participants still felt that doctors
dominated the health structure.
120
Fleur felt that the WA doctors did have authority over the nurses while in her
home country there was not much difference. Patients would sometimes call
nurses doctors. Julie found that:
”… it’s a lot of doctors and nurses here; doctors superior
nurses inferior… basically the relationship between doctors
and nurses are way different …We were highly seen by our
co-doctors…here you are just seen as the one to clean the
bed pans … so don’t expect too much of nurses cause they
might not know..”.
Lucy stated: “…You don’t make any decision … without doctor’s consent… You
ring the doctor for guidance and to have patients reviewed...”. In her home
country Lucy contacted the doctor after having initiated a plan of action. That
way she felt that the patient obtained their treatment quicker. Participants’
viewpoints on working with WA doctors thus varied depending on their past
practice of nursing in their home country.
6.4.3 Relationship and discussion of findings to ex isting literature
The current literature while limited in exploring the relationship between nurses
and medical doctors describes some similarity in findings which correlate with
this research.
In Teschendorff’s128 study of twenty Filipino nurses in Victoria, the Australian
informal way in addressing everybody by their first name including doctors has
been stated by the Filipino migrant nurses as different to the more rigid and
hierarchical system they were used to.128 In Allan’s paper ‘The rhetoric of
121
caring’115 international nurses in the UK complained that their inability to
perform the nursing skills and knowledge narrow their scope of practice. They
strongly believed that the high number of doctors available in the health system
was responsible for diminishing the scope of nursing practice. They felt
disfranchised as they had to follow doctors’ orders. As a result they believed
that their local colleagues and themselves were disempowered in attending to
their patients. This was reflected in the RCN results122 where international
nurses stated that in the UK, doctor’s professional power over nurses restricted
their nursing scope of practice. They expressed frustration at having to wait for
doctors orders, especially in situations where they knew and were capable of
initiating the care that would benefit their patient. They felt that being restricted
was detrimental to patient care.
It is nonetheless interesting to note that, as mentioned in this WA study,
depending on the migrant nurse background country, their appreciation of the
doctor nurse relationship differed. Taylor’s7 research study reports that Filipino
nurses who used to follow doctor’s orders in their home country, expressed a
view on their professional status that differed from nurses who migrated from
Finland and African countries. The Finish and African nurses who were
accustomed to work more independently felt that doctors undermined their
profession.
Furthermore in a research study conducted in Ontario Canada, participants
reported having a more egalitarian relationship with doctors. This finding does
not reflect the experience of the WA participants in this project and might
suggest that physicians’ status in Australia and Canada is different.132
122
6.5 Let’s talk about professionalism
The participants expressed their liking of the good WA working conditions
which, for most of them, was better that in their home country.
6.5.1 Feeling valued?
The nurses felt valued: they were satisfied with their working hours and the
financial compensation for overtime work. They also felt respected and trusted
as a professional body. Barbara liked having seven weeks holidays plus 10
days sick leave a year. She felt the WA system respected her personal life. In
her home country she worked harder and only received 20 days annual leave
including sick leave. Furthermore, she never received payment for overtime
work. Similarly in Eileen’s home country:
”... it is a monthly wage doesn’t matter you worked week day or
weekend everybody earn exactly the same amount but here ...
you get penalties [penalty rates] you sacrifice you social life: you
get compensation, fair is fair…”
The participants felt that the nursing profession was valued by Australian
society. Julie who came from a country where nursing was one of the lowest
paid professions was overwhelmed that in WA nurses were allowed to be a
‘Commissioner of Oath’. She felt Australian society truly trusted and respected
nurses. She also received some positive comments about nurses when she
spoke to her neighbours and some of the mothers at her children’s school.
123
However in relation to working with patients and health professional colleagues
their sense of appreciation differed. Fleur explained: “... people don’t look down
on nurses ... here I don’t think that they look up on you as well it’s like a
moderate... “. Cathy believed that the social label for nurses was quite low in
Australia and she felt less respect from her patients: “…here we look after the
patient holistic care... we look at everything, eating, drinking, showering,
hygiene... and mainly because of these you don’t [get] much respect”.
The participants expressed that, as a professional body, nursing in WA lacked
unity and political power. Ines’ statement below encapsulated that, while nurses
might be valued by society as a profession with decent working conditions and
wages, it was believed to be weak as a professional body and the participants
did not feel highly valued at work. In Ines’ home country:
”… a nurse it’s regarded much more as a profession and
you’re much more a professional group of people actually
trying to sort of develop the profession…they’re much stronger
in their unity and their union…In Australia … it’s not so much a
profession…. Nurses aren’t united in their speech… that’s
probably changing a little bit… you are sort of standing on the
same spot …[but in WA] … nurses in the profession… it’s
highly valued but there’s not actually a value put on it…
professionalism is sort of less here compared to [home
country]”.
124
6.5.2 Etiquette and professionalism
The participants were surprised at some of their WA colleagues’ poor etiquette
and lack of professionalism. Alice was accustomed to working in a nursing
setting where the dress code was relatively rigid. In Perth however, she saw
nurses as being relaxed in their approach to work and in their dress code where
some have long hair hanging, jewellery and/or very bright nail polish. Cathy
found her colleagues less motivated:
“… at home we take more serious our responsibilities….here…
the environment the culture people are less motivated they are
… more relaxed… it more relaxed they don’t take things more
seriously… cannulation [for example]... if the doctor is there
they just ask the doctor ...they are supposed to learn but they
think that if there is a way they can get out why not…”.
In her home country nursing was much more competitive:
” …if you don’t do it [cannulation] if you try to get out of it you
will be the one left behind…”.
Most of the participants called their patients by their surname and therefore they
felt very uncomfortable with the closeness displayed by WA nurses towards
their patients. Debbie was shocked: “People [colleagues], they are calling
patients darling, love, whatever, it’s very difficult for me... “.
Participants also felt that the way nurses interacted amongst themselves did not
always meet their expectations of professional standards. Julie was surprised:
“… nurses they don’t respect themselves that much here… how they present …
125
the coarse language that they use…”. She finds a lot of nurses very
unprofessional with:
“… the way that they communicate amongst each other,
talking over patients to themselves… ignoring the patient in
the meantime, swearing in front of patients… it’s totally
unprofessional… I don’t do things like that … ‘cause I see
myself as a professional...Here… there’s a lot of back
stabbing… there’s a huge turn around of staff … there is a lot
of turn around…”.
The participants observed that conflicts between nurses occurring within the
workplace were not uncommon. Kerry explained: “… [nurses] will say if they
feel unhappy…as I know there’s one nurse just going to the manager and the
clinical nurse specialist and tell them I feel unhappy with the who… or she’s
being not good to me I feel upset or something …”. Even nurse managers did
not always present themselves as highly professional. Kerry’s coordinator
spoke harshly to her in front of patients: ”…she uses… very strong words, big
voice… she tell me in front of the patient… and the other patients all listen…”.
The professional standards in relation to senior position and promotion were
experienced as unprofessional. When Lucy asked for assistance from a young
clinical nurse (CN) she was taken aback by her lack of knowledge:
”… oh I don’t know I’ll check, I don’t know I will ask and you
start to wonder the things she knows but she’s a CN… they’ve
got no experience to help so what is the use of giving that
position whereas you can’t utilize them properly…” In her
126
home country:”… you get a position according to your years of
experience here … if you are in good mood with the CNS you
can end up getting a CN position… I believed in Australia they
were doing it according to their experience … if you got four
years experience of practice you qualify for certain position like
they do in HC and England, I think that’s … much better.”
6.5.3 Relationship and discussion of findings to ex isting literature
The current literature reports some similarities with some of the findings of the
WA participants’ experiences. The economic aspect of working abroad has
been mentioned in the literature as a driving force for many migrant nurses
whose economic and social status was quite low in their home country. 114, 118,
119, 122, 136, 139 Larsen136 uses his phenomenological analysis of two overseas
qualified African nurses to illustrate how the difficult economic and political
situation in their home country was the driving force to migrate to the UK. His
report was taken from the more extensive study of overseas-trained healthcare
workers’ experiences in the UK122 where for most migrant nurses’ economic
recession in their home country was the impetus in moving to the UK. Similar
findings were reported in Aboderin’s139 qualitative research on Nigerian nurses
where the deteriorating work situation in their home country provided the
incentive to migrate. Therefore the expectations to find better working
conditions and financial reward in the host country have been reported. Withers
and Snowball’s117 qualitative research of 120 Filipino nurses working in the UK
described how the respondents enjoyed having free email access at work and
also how they valued receiving annual leave and penalty rates for working
weekends and night duty. They said that their overall earning capacity was
127
greater than in the Philippines. The study undertaken by the Commission on
Graduates of Foreign Nursing Schools (CGFNS)133 revealed that applicants
found the nurses in the USA and Canada had higher social status than in their
home country.
However it is important to note that while most nurses search for better
economic gain, and for professional and social recognition might be the driving
force to migrate to first world English speaking countries, it does not necessarily
mean that they are valued by the host society. In fact O’Brien’s116 case study
work on three hospital trusts in the UK reported that migrant nurses felt the
provision of basic nursing care was contributing to lowering the social status of
nurses. Drawing on the British study; ‘Researching Equal Opportunities for
International Recruited Nurses’ Allan, Tschudin and Horton135 argued the lack
of recognition of nursing as a profession by government and policy makers had
a negative effect on all nurses. However the emphasis of the paper was
primarily on the lack of respect, empathy and equity experienced by overseas
nurses working in the UK. The lack of political power and unity within the
nursing profession could be detrimental to not only migrant nurses but to the
body of nursing all together.
In Teschendorff’s128 research the participants found the Australian nurses to be:
“… assertive and aggressive; regardless if they are right or wrong, they have to
speak out…”.128(p38) This statement resonates with the experiences of WA
migrant nurses in this study. Furthermore participants also expressed that in
their home country the nursing profession has social status, and they were
proud to be nurses. However they found it was not the case in Australia: “… the
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nurses here… are not thinking of it as a profession. It’s just a means of
livelihood…”.108(p154) While there is not enough data to back up Teschendorff’s
findings on Australian nurses, it is nonetheless interesting to discover that it
was also mentioned by the participants in this WA research.
6.6 Phenomenological explanation of the participant s’ experiences
The participants involved in this research were all qualified and experienced
registered nurses in their own country. They had nursing skills and a sense of
professionalism that reflected their past working experiences. When they
entered the WA hospital workforce they recognised that while their past
knowledge and experiences were highly valuable, in order to function as
registered nurses they also realised that they had to adjust their nursing
practice to fit within the WA nursing environment. The NESB OQNs felt that,
while the practice of nursing in WA was not exactly the same as what they were
used to, they could however understand what was happening. They felt
reassured by their ability to identify that the core components and ultimate goal
of nursing was consistent with their own knowledge and experience.
They felt surprised that their WA colleagues did not have the range of clinical
skills they had, because for them this was an intrinsic part of their nursing
career. They were, furthermore, disappointed that they were not allowed to
utilise some of these skills and, as a consequence, felt that their scope of
practice had lessened. However, they soon discovered that the practice of
nursing in WA did not focus on tasks but was holistic and centred on the patient.
As a result they felt overwhelmed by the medico psycho social aspect of nursing
care which included holistic care, required extensive communication skills and
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paperwork and the varied health services available to their patients that they
had to know about.
They enjoyed the low patient to nurse ratio and the time they had to care for
their patients. As a result of this patient-centred care they felt that their patients
had a say. They were talkative, asked questions about their health and
treatment and expressed their feelings relatively freely as well as their likes and
dislikes. They felt that their patients had power and had to be treated like
‘customers’ with unique rights.
In working with doctors they welcomed their professional interaction and the
less formal way to address them by their first names. They found the doctors to
be polite and respectful. Nevertheless they realised that doctors had power and
authority over nurses and that they were very much controlling what nurses
could and could not do.
Finally the participants were satisfied with their working hours and financial gain
and felt trusted as a professional body. However, they experienced a sense of
professional loss as they did not feel as valued by their patients and society in
general. They believed that a WA RN did not have professional power. They felt
that their colleagues lacked professional motivation, that they demonstrated
poor professional etiquette and lacked unity as a professional body.
In the next chapter the fourth and last theme of the research titled “It all works
out in the end” is presented.
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7 CHAPTER SEVEN – IT ALL WORKS OUT AT THE END
7.1 Introduction
As discussed in Chapter Four, the participants experienced a deep sense of
professional loss when they first entered the WA hospital environment. They
were overwhelmed by the unfamiliarity of the clinical setting that was so
different from their home country. The ward surroundings, the work dynamic,
some of the equipment and medication, and various tasks they had to do, left
them feeling very confused. They also experienced multi-layers of
communication difficulties and failures that jeopardised their abilities to perform
their nursing duties at the level of competency at which they were accustomed.
Furthermore they felt that some of their WA colleagues and even some of their
patients did not trust that they were safe clinicians. As a result of all these
combinations of difficulties, the participants themselves started to develop self
doubt on their abilities to perform their nursing duties in a safe and professional
manner.
Following their initial sense of professional loss the participants experienced
persistent difficulties and work challenges related to their English language
skills and their cultural differences which, as discussed in Chapter Five, resulted
in feelings of otherness. Furthermore as described in Chapter Six differences in
the way they practised nursing in their home country and the way it is
implemented in WA was a recurrent feature of their difficulties in working
comfortably and effectively.
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Therefore after the initial shock in trying to function as registered nurses in a
new working environment, the participants soon realised that they had to learn
to adjust their communication skills and their nursing practice to fit within the
WA nursing context. It was, they recalled, a difficult journey. However, with time,
perseverance and a lot of effort they overcame some of these difficulties. In fact
they found support in their professional journey and as a consequence they
started to integrate and to feel more at ease working in the WA hospital system.
While support was available the participants’ self determination was a major
contributor to their success in adjusting to nursing in WA. In looking back at
their professional journey in Perth, the participants expressed that they still felt
‘different’ from their WA nursing colleagues, but they also recognized that they
have changed and, therefore, expressed how much more comfortable they
were in working as registered nurses in WA.
This chapter explores the lived experiences of the NESB OQNs as they
progressed into their WA registered nurse role. It describes how they did feel
supported, but also how they relied on themselves to find the strength to
persevere. Finally it explains how the participants progressed and became
acculturated to fit into a WA RN.
7.2 I am not left alone
In their quest to integrate into the WA hospital workplace the participants felt that
they were not left alone. They were appreciative of the overall multiple layers of
help and camaraderie present to assist and support their needs.
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7.2.1 There is support
All the participants described in great length how the WA nurses were very
approachable, helpful, and very reliable in providing the professional assistance
they required to carry out their professional duties. They felt the support was
available at all times.
Alice explained how: “… they guide you … even they don’t have time to do it…
they might find someone else to help you … they would sort of direct you to the
right resource…”. Similarly Barbara stated that: ”[they are] always ready to help
me out …they always say ‘come to me if you need some help’, so I never felt...
neglected…”. Julie found the people very eager to help: ”… if you asked
questions they were very keen to answer, if they didn’t know the answer they
would go find it…”. Debbie valued how, when she asked the nursing staff for
some clarifications they would always answer her questions in a professional
manner. Helen commented: ”… they make an approach to me to say ‘do you
need this book or do you know what to do’... and when you ask them for help
they are quite helpful...”.
The participants also felt that their nurse manager was looking after them.
Helen knew that her manager gave her relatively easy patients when she
started working on the ward. Melissa was very grateful that: “… every week the
nurse in charge ask me how I’m feeling things … she try to help me …the time
I said that I’m lost … she try to give me the regular [theatre] list…”.
When the participants experienced difficulties at work they went to their
manager who listened to them and took their concerns into consideration. They
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felt that they were genuinely concerned with their welfare and tried to help
resolve the issues at stake. After Georgie explained to her manager some of
the difficulties she encountered with her preceptor, she found afterwards that
the nurse had been relocated to another department and felt that they must
have talked to her and found out about what happened. Cathy, who was
struggling to integrate in the WA team, felt supported by her manager who
would ask her into her office to discuss any problems she had. In addition they
also found that their managers were an excellent source of information. Julie
found her direct line manager unbelievably ‘human’ and understanding and she
could go to her and asked her about anything.
However, at times some Australian nurses were not sympathetic in helping the
participants. Most of the participants found their colleagues supportive however
as Lucy mentioned: “the majority were…”. She felt however that unity in
support was not universal. The participants revealed that a small minority of
their colleagues were not keen on providing guidance. They nevertheless learnt
quickly who they could and could not approach for assistance. For example
Helen explained that while most of the senior nurses were obliging she
nonetheless had to be careful who she asked. She would always make sure
she asked a nurse who she knew was approachable. Similarly Cathy said that
she was quick at identifying the nurses who would be agreeable to help her.
The participants were highly appreciative of the hospital’s overall organisation
and the structures in place which they believed were conducive to their learning
and adjustment. Georgie was peered with a RN who was very helpful so she
was able to ask lots of questions that were answered immediately. As Julie
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described: “There is a lot of clinical staff on the floor … a lot the clinical
guidance …What I enjoyed was there’s a lot of systems in place… there was a
lot of education on hospital things …training and all sorts of stuff…”. Melissa
liked the established competency criteria forms because she could work
through them with the staff development nurse and learn through practising the
skills until she became perfect. She also valued the in-service education and
direct education sessions because she could learn a lot.
7.2.2 Feeling of belonging
In integrating into their new workplace the participants felt they needed to
belong. They liked the social and human interactions with others and described
how comforting it was for them to socialise with friends from their home country
and to develop new friendships. They expressed their strong need to feel part of
the team. They felt accepted by their co-workers but nonetheless they also
articulated their conscious effort in trying to fit in with the team.
The participants acknowledged their need to develop some friendships. Many
had friends from their home country and some valued the advice they provided.
Alice stated that when: “… living here … [it] is important that you have to have
friends… you are happy or sad you share with them… I had a good bunch of
[home country] friends and at the meantime I build up friendship here…”. Kerry
obtained some useful advice:
”... my manager ... she introduced some [home country]
colleagues to me…they …say ‘well Kerry don’t worry about it,
the first three months you will find very hard’ [so] that’s what I
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expect…’the only problem is the language barrier’…I realise my
English is going like improve a lot at the first three months ….’.
The participants expressed their overall satisfaction with the social dynamic at
work. The WA nurses were experienced as friendly and the participants felt
included in the nursing team. Julie commented: “…I found people extremely
friendly…the managers and everybody was extremely nice ...There’s a lot of
people that always ask me how you going and how you doing and how you
settling …”. Kerry was satisfied:
”... I didn’t feel isolated… They talk to you they make you feel
like you’re one of them… they were talking to me, … they did
not say anything special as such but I think talking to me was
the most important thing…”.
Melissa felt happy that during the tea breaks everybody in the team went
together, she thought that it was good that they always included her in the
group. Alice felt that: “… I’ve got sort of merge into the team very well… I am
part of the big family… the ward is part of my family...”. Likewise Ines reported:
“… I am happy where I am now [working]… [I’m]…more comfortable … all the
time…overall I love it here and I love the people…”.
However this feeling of belonging was something that the participants played an
active role in securing. They wanted to be part of the team and consciously
worked towards it. Barbara always wanted to have her tea breaks with her
colleagues because she did not want to be isolated or be a stranger to them.
She wanted to be part of the team. Socialising with their colleagues outside the
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workplace, however, was not necessarily something the participants liked doing.
Some felt that their dislike of alcohol contributed to their unwillingness to see
their colleagues outside the workplace. Julie felt that drinking:
”… is a cultural thing… ‘cause we’re not used to drinking …
indulgently… here the most things that they can talk about is how
knackered… how drunk they got… I just don’t find that
interesting… but… I don’t have to be social with them outside …”.
Fleur also expressed her dislike of going to the ‘pub’. She said that she was too
conservative to go to such places. However she felt that it was not a problem if
she did not socialise outside work as she was still part of the team. Similarly
Lucy had some difficulties:
”… with the staff sometimes it’s not easy to socialize with the
Australian people… … I don’t drink, I don’t smoke so it end up like
I don’t have anything in common with them, when they go out I
can’t go out cause I can’t stand noise…so I think that end up
making me distance myself because I won’t manage to go to the
pub...”.
However Lucy just like Fleur did not feel that her dislike of socialising outside
work jeopardised her sense of belonging to the team. She described how every
Friday after the ward round the team would have a communal lunch where
everyone brought a plate of food to share. There she would join the group and
eat, talk and laugh with her colleagues enjoying being part of the team.
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7.2.3 Relationship and discussion of findings to ex isting literature
The existing literature illustrates the loneliness experienced by overseas nurses
in the workplace. It also highlights the lack of support offered to them which is
unfortunately too often correlated with the ethnocentrism and racism displayed
by some of their colleagues and managers. The limited support available to
migrant nurses is described as detrimental to their integration into the
workplace.5, 107, 110, 122, 127, 134, 135, 139
Omeri and Atkins’5 report recalls the lonely path the participants working in New
South Wales went through following their migration. They missed their family
and friends which was intensified by the lack of support networks available in
their new working and living environment. Similarly, Brunero et al127 report on
homesickness experienced by migrant nurses where the support of family and
friends was lacking in their everyday living. In her research Jackson109 also
found that the participants felt lonely in the workplace and, as one migrant nurse
recalled:”… I was totally alone… [and] when you did approach, if the person
was too busy… it was like… a slap in the face...”.109(p123) Furthermore the need
to belong and to develop collegial relationships at work was stated as
paramount as participants felt that, despite their network support outside the
work environment, it did not ease their feeling of solitude within the working
place. Walters’8 also describes how participants having left their family in their
home country felt lonely and, in order to compensate for this loss, felt compelled
to develop a sense of belonging within the workplace. Matiti and Taylor112
reinforce this need as they describe how the nurses in their study valued the
supporting ward environment and felt like it was like a family as they always had
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somebody they could talk to. This had the effect of assisting their cultural
adaptation at work and in the overall UK way of life.
In the report titled “We need respect”, Allan and Larsen122 found that most
participants experienced feeling of loneliness and home sickness with limited
support available from both their colleagues and their nurse managers. It
however also reported that they obtain valuable support from other OQNs which
was very helpful professionally and morally to new migrant nurses. Smith et
al’s114 REOH report reflects this finding. They explained how what they called
‘batch recruitment style’, where overseas nurses are acquainted with other
migrant nurses, to be most appreciated and helpful. In sharing their analogous
circumstances in the workplace and in the host country migrants nurses are
seen as an excellent resource to ease new migrant recruits’ adjustment to the
UK way of life and hospital setting.
Support to migrant nurses has however also been acknowledged in the
literature. Teschendorff’s108 research reveals that, despite having to take charge
of a patient load and therefore having to work alone, the Filipino participant
nurses felt accepted and supported by their Australian colleagues who were
nice to them and helpful when they needed help. Under the theme ‘Pastoral
support’ Taylor7 discussed how local UK nurses, aware of their overseas
colleagues loneliness, offered support with transportation after work.
Furthermore, as mentioned before, newly employed NESB nurses’ affinity with
overseas nurses who had been in the system for a while was stated as a
valuable source of support.
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In the literature the role of the nurse manager in providing the support and tools
in assisting migrant nurses is often discussed in the negative. Reports highlight
that they do not fulfil their duties as an ethical and effective manager in
accommodating and valuing their overseas nursing staff. In O’Brien’s116
research results, line managers were reported to stop migrant nurses access to
short courses favouring local nurses. The RCN report122 detailed how ward
managers should actively facilitate the transition of new migrant recruits on their
ward. It explained that managers should welcome them and should make sure
that they were understood by the local staff and the patients as competent
nurses. However in reality the report stated it did not occur. These findings are
also in accordance with Aboderin’s139 recorded statement of one of his
participants when recalling difficulties experienced by ‘dark skin’ migrant nurses
in working and managing white skin carers that: ”…the tacit support or lack of
intervention of ‘white managers’, who inevitably ‘side with their own’ along
colour lines”.139(p2243)
The results from the review of the literature do not reflect the findings of the
current WA research reported in this thesis. However, positive accounts with
nurse managers have also been expressed in research findings. Gerrish and
Griffith2 have commented how their participants who hesitated at first to
approach their manager for assistance, were happily surprised, after they finally
gained the courage to talk to them, by their very supportive and encouraging
manners. There is, therefore, evidence in the literature that some nurse
managers are instrumental at providing assistance. This is despite the bulk of
the literature putting the emphasis on their negative impact, in slowing and/or
limiting the professional growth and integration of migrant nurses. Nurse
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managers are, as mentioned by Aboderin,139 in the hierarchal nursing position
not only to guide and support their nursing staff but also to make sure that the
dynamic amongst them is functional and equitable. They can trouble shoot and
lead by example. In fact the work dynamic on their ward is a reflection of their
leadership style.
7.3 I can rely on myself
While the participants recognised that the multiple layers of external support
had provided them with immense assistance, they also realised that they were
very active participants in adjusting to their new work environment. They felt
that they had resilience and agency over the integration process they went
through or were still going through.
7.3.1 I have resilience
The participants were determined, strong and confident they would overcome
the difficulties and stress they experienced at work. They worked very hard to
integrate into their WA RN role and to regain a full professional status. Barbara
wanted to overcome her work problems as soon as possible, but it was not
easy. All the new things she had to learn were hard and tiring. It nonetheless
motivated her because she could see the ‘gaps’ and she set her goals and
wanted to achieve them. She pushed herself hard but she said that she also
enjoyed it.
The participants often felt that they had to prove that they were a good nurse.
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Cathy sensed that her patients did not value her professionalism and skills so
she felt that she had to show them that she was a good nurse: ”… I do nursing
stuff and I’ll be very very particularly careful... I make sure they see it... they feel
comfortable with you... once you have proved yourself to them they just like you
so much.”
Fleur felt that she had to prove herself to her colleagues:
”... I want to impress them to tell them ... you’re OK... you feel
like that person looking down on me.... you want to do
something to impress...I don’t feel like I’m forced ... I’m willing to
do it... you do things a little bit faster..., do some extra work... I
always helped others I just quickly finish... I won’t sit at a
counter even though I feel... tired...”.
They learnt to reflect following some difficult and stressful situations and to
move forward. Debbie realised that:
” … it is not that they [PCA ] don’t want to work with you but
when you just started you might feel like that because you don’t
know what there is... I do sometimes get scared and then I go
back and pick myself up and say well I have to get used to it...”.
Lucy displayed strength and acceptance of self and others by the way she
reacted to one of her patient’s racial statement:
“… ‘I don’t want that black nurse to look after me’…if they give
me the patient the next day I just say ‘I can’t look after him or
her’ I am not going to apologize I just want a peace of mind for
myself... I respect that I don’t force myself onto the patient…”.
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Melissa noted: “…I believe that everyone is not born with skills... everybody
learnt so I can learn …it is taking me lot of work to learn... I don’t want to give it
up”. Overall Eileen’s statement highlighted participants’ feeling that hard work
and determination were the ingredients to success;
“...When you work in a different country from your mother
country you have to be prepared to work hard and work smart...
When the local people input 100% you have to put 200%... yes
more than 200%... you... use initiative learning… the more you
do the more knowledge, experience, skills... the more confident
you are”.
7.3.2 I have agency
The participants at times felt intimidated by the WA nursing milieu.
Nevertheless, they exhibited agency, as they did not change their whole
practice to fit the WA nursing setting. They assessed their current work setting
against their nursing knowledge and personal values and adjusted their practice
accordingly. They were assertive, they felt they had power and overall a deep
sense of professionalism which did not impinge on their ability to practice
nursing in WA.
Debbie liked the practice of nursing in WA; however she did not agree with the
familiarity of language displayed by the staff and therefore chose not to call her
patients ‘love’, but call them by their names. Similarly Cathy did not want to call
her patients ‘love’ or ‘darling’ she decided to continue to address them like in
her home country Mr and Mrs:
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”… I’m feeling lot more comfortable …I know I am doing the
correct thing… I have seen something different before I come
here so I keep the good things... [And] I pick up the good things
from here ... and you tell yourself that what you are doing is
right...”.
Julie and Lucy did not want to do the compulsory IV cannulation course
because they already had the skills so they contacted their nurse manager,
demonstrated their skills, and therefore were exempted. Likewise, Melissa who
worked in the operating suite indicated to her preceptor her preference not to do
orthopaedic surgery because she had a bad experience in her home country.
Lucy felt that she had something to contribute as she explained: “…[I] had a
research suggestion that we’ve been actually trying to get off in [home country]
… so I suggested it here … they were quite interested in listening… it’s a
project now going… so that was quite nice…“.
7.3.3 Relationship and discussion of findings to ex isting literature
There is little evidence in the current literature on the resilience and agency
displayed by NESB OQNs when working in Australia and/or other Western
dominated English speaking countries. This current research is thus able to
make an original contribution to extending knowledge.
In “We need respect” document Allan and Larsen122 report statements of
migrant nurses who explained how they had to consciously remain strong,
display self control and show self-confidence in order to survive the UK
workplace. However these were made in the context of a coping mechanism in
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order to alleviate the hurdles and discrimination they experienced. This was
made evident as they first described how their initial reaction to the difficulties
they were faced with in the workplace was to go back to their home country;
something that they soon realised they could not do. However Larsen’s136
recount of two African black migrants working in a nursing home in the UK could
be understood as a sign of resilience and agency. Both participants felt
unhappy with their first work assignment in aged care facilities and eventually
had the courage to apply for and acquire employment within the NHS system.
Nevertheless these accounts do not provide sufficient strength in the argument
of resilience and agency displayed by nurses as they migrate overseas. The
current lack of evidence on resilience and agency may be due to the fact that
research has primarily been focusing and elaborating on the discrimination and
on the vulnerability experienced by overseas nurses. Once again this has been
regularly reported in the literature but it has been at a relatively low level in the
account of WA participants in this research.
7.4 I am one of them
7.4.1 Acculturation to the WA workplace
As participants became acculturated to the WA workplace, the changes they
experienced were relatively smooth. They felt that they had adapted some
elements of their previous practice to the new working environment and they
liked it. The changes that occurred were relatively smooth as they were not
necessarily conscious of their acculturation process
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They felt positive and satisfied with working in WA and expressed how it
became easier over time. Alice commented: “…I like the WA way… delivery
nursing because you treat [patients] as a single person… I quite like this
communication sort of time…I must say that overall I had a positive
experience…”. Georgie’s experience was similar: ”… [I’m] exposed to people
everyday so I am beginning to understand how they pronounce the words… [I]
enjoy nursing here ... the ward I am working at now I am very satisfied...”.
Some participants were surprised how much they had changed. When Barbara
went back to her home country, she felt that she was different:” … it was a
reverse culture shock… I feel more comfortable here [Perth] than when I go
[home]…”. Comparing her home country with WA, Fleur chose and valued the
WA nursing care approach: ”... here it is more friendly ... that’s really touched
me a lot and actually changed my working attitude...”. When she went back
home: ”… I went gosh I couldn’t fit in... that environment or the way they work...
no I have to go out...”.
7.4.2 I am different but so what
The adaptation process that the participants went through encompassed a
general and self acceptance of their ethnicity and culture. They felt that their
ethnicity was acknowledged and accepted by their co-workers. Barbara felt
embraced by the team and felt that she belonged: “…it happens quite naturally
because everybody get used to being with someone from a different culture
because it is a multicultural country... Australian means people have different
backgrounds…”. Georgie sensed that her otherness was valued: ”…my
colleagues have started to accept now my American accent … they like the
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accent… I am very encouraged by that… people tell me that my accent is like
music to their ears…”.
Helen found her colleagues very encouraging:
“... during presentation... they smile even if they don’t
understand you, they don’t upset you... they always encourage
you and try to understand you and say how good you are, I think
it is very good…they don’t try to embarrass you always say
good things about you. …”.
Melissa’s ethnic background was acknowledged and discussed during the tea
breaks: “… they talk like ‘how is things in your country’… most of the people
know [home country] that there are murders and things and they also know
there are some problems, lots of problems…”.
Participants knew that they were different from the dominant Anglo-Saxon
population however they also realised that their differences were similar to
some of the people living in Perth. In fact they felt that their ethnic, cultural and
language differences were congruent with the WA multi-ethnic population. With
this in mind they started to accept and to be more comfortable with their
‘otherness status’ because it fitted within the multicultural context of Australia
they migrated to. As a result they developed a sense of belonging. Kerry felt
accepted by her patients but she also accepted herself when she said: ”… they
all understand me, the only things I not explain in the Australian way I explain in
Chinglish, I mean Chinese English…’ Barbara was: ” always aware ... and
focusing on the language but I know I don’t have to be perfect”. Cathy was
adamant:”... even 10 years, 20 years, 30 years later I would still have the same
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accent you know ... I am comfortable now with my English...”. Similarly Georgie
stated: “…I could never speak Australian English... [But] they [staff] are used to
multicultural staff...”. Assertively Eileen said: “... They talk the language; I can
talk the language, so it’s good…”. Melissa affirmed: “…most of the people
migrated so [if] they can understand, I can understand [too]”.
7.4.3 I am a WA Registered Nurse
Since their arrival in WA some of the participants had developed professionally,
others expressed their desire to further their career with growth. Overall the
participants felt that they had the same opportunity as their WA nursing
colleagues to progress professionally. They experienced continuity in their
career path and were comfortable and secure in their role as WA RN.
Since migrating to WA Helen has studied midwifery and she was currently doing
a health education diploma. She wanted to start teaching nursing students.
Eileen had been promoted to a level two; she was an active member of the
Head and Neck Association. She went to regular seminars. She was: ”
...interested to do a wound management course, some counselling course or
some clinical... teaching...Yes I’m a good nurse... I am still learning... ”. Fleur
was also a level two: “... you have equity [here] and the chances are open to
everybody if you say yeah... go ahead it’s yours...”. After working 5 years in WA
Alice applied to become a clinical nurse last year and was promoted: “… I
definitely gained the confidence… it made a huge difference on my life … I felt
very satisfied and also felt that it is all worth it…”. Ines, while working was
studying part time to become a nurse practitioner. Cathy noted: “…I am doing
good, quite well. I think I have been through all the difficult time... I would like to
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be more in a management position to make a change…”. Georgie discussed:”...
I don’t want to be a bedside nurse for the rest of my life; I would like to improve
myself ... to advance my career... [Be] promoted to a much higher level...”.
7.4.4 Relationship and discussion of findings to ex isting literature
The current literature provides limited information on the progress and
adjustment migrant nurses go through in their endeavour to work in their new
host country. It discusses the acculturation process within the context of time
where participants slowly found their feet within the new health and work
environment. Furthermore access to professional development is elaborated
upon as a contributing factor for migrant nurses as they search to develop and
expand their nursing career path in the host country.
Teschendorff108 explained how the Filipino nurses’ initial setback in their ability
and lack of confidence in performing their nursing duties adapted over time.
They observed and chose to learn from their local colleagues, thereby adopting
the Australian way of nursing. However they nonetheless described how the
whole process was slow and painful. Similarly Yi9 described also how the
Korean nurses in the USA study adjusted to their new nursing environment. In
relation to nursing tasks the participants expressed satisfaction in achieving the
USA nurses standards, however they continue to express great difficulties with
communication skills, in particular with arguing and problem-solving strategies
when dealing with their patients. Participants explained that even after more
than ten years of working in the USA they found they still had great difficulties
in dealing with these issues. However over time they adopted styles of
individualistic behaviour that mirrors the American nurses. They felt more at
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ease to express their personal feelings and emotions. They became more
confident in using the pronoun ‘I’ and also learnt to say ‘no’. They recognised
that their non-assertive behaviours, which were the legacy of their home
country cultural background, were perceived by their American colleagues and
patients as a sign of weakness which was, therefore, detrimental to their
professional status as nurses.
The process of acculturation discussed above appears to occur over time more
or less naturally as migrant nurses are immersed within their new workplace.
They have access to professional development and promotion, which assist
migrant nurses to adapt, to progress and to develop into their new nurse’s
identity. These finding are also examined in the literature. In the UK, Withers
and Snowball’s117 study found that their Filipino respondents believed they
could access professional training enhancement. They felt supported by their
nurse manager and also found the strong Filipino nurses’ network highly
valuable. They nonetheless explained that it was their own responsibility to first
search for information and to make the application. Interestingly, Taylor’s140
research on Filipino nurses in the UK argues that overseas nurses are
progressing well in the NHS Trust in London. She provided the example of a
respondent who took advantage of a nursing training course in ophthalmology
which, as a result, facilitated her appointment to a higher nursing grade and,
therefore, better work status and higher income.
However, the REOH study report114 highlights that despite the UK equal
opportunity policies, the chances of minority ethnic nurses gaining promotion
within the NHS were very slim. In fact the findings reveal how the standards
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and measures for promotional advancement lack transparency especially for
managerial nursing positions, where patronage and sponsorship are based on
subjective and cultural criteria which gave impetus to exclude minority nurses.
These procedures are perceived to contribute to racial and ethnic discrimination
against migrant nurses. Respondents have explained how the interview
process linked to promotion was difficult and biased as it encompassed the
dominant group’s communication skills and cultural knowledge that the
respondents were unfamiliar with. The overall structural format was described
as prejudiced against migrant nurses. This understanding was reinforced
through Henry’s141 analysis of twenty older Ghanaian nurses working in the
NHS who encountered difficulties in accessing managerial positions. Their
dilemma was related to a system of promotion that did not value meritocracy as
such but, instead, was blurred and based on patronage, leaving little hope for
their prospect of nursing advancement.
It seems that once again the issues of racial discrimination and ethnocentrism
described in the literature jeopardise migrant nurses’ progression on the
professional ladder bringing to a halt their journey towards feeling and
functioning on the same path as their local nursing colleagues. This is
highlighted in Gerrish’s2 study which recounts the concept of equality of
opportunity in accessing nursing courses and further education for overseas
nurses in the UK. Participants expressed their willingness and need for
professional development. As mentioned by Alexis142, migrant nurses ought to
be given the same opportunity for professional training and development and
promotion as the UK nurses. However the research shows that these
recommendations are not actively applied in the health care system.
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The current literature explicates some of the lived experiences of migrant
nurses in their search to accommodate and fit into their new country and work
place. While an acculturation process seems to happen, the ability of migrant
nurses to fully feel part of the new society and fulfil their new nursing identity
requires a need for their nursing status to become close to that of the local
nurses. This appears to be jeopardised by the difficulties they have in
accessing the same professional growth as their counterparts. However while
broadly reported these findings do not reflect the experience of the WA
informants from this research. In fact they stated and felt that access to
education and courses was available to them regardless of their ‘otherness’
ethnic background.
7.5 Phenomenological explanation of the participant s’ experiences
When the participants in this research first entered the WA workforce they
experienced difficulties and were overwhelmed by the amount of learning and
adjusting they had to do so that they could function professionally and
comfortably as WA RN’s. They nonetheless were able to over time identify that
they were not alone and that support was available to them. The hospital setting
had multiple layers of support available to assist their integration and while
education sessions and extra clinical and education staff were available to
guide their learning into the new system, they found their colleagues highly
supportive, which they valued. While some did not want to help, the participants
were always able to find nurses that would happily guide them, answer their
questions and/or direct them towards the resources to answer their queries.
Even the few nurses who declined to help were not detrimental to their
integration because they knew that nurses as a group were always very
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supportive. The odd one did not matter as they were somehow absorbed within
the larger group and there was always somebody available to help them.
They received extensive professional and emotional support from their ward
managers. They felt safe in approaching them as they were encouraged to
discuss their concerns and feelings. The ward managers would listen and
respond in a genuine and helpful manner and the respondents recognized that
they were not only interested in their professional integration but also in their
personal welfare.
The participants craved to have their need of belonging fulfilled and while some
of them had friends from their home country, they also wanted to develop some
new friendships. It was very important to them to be accepted by their work
colleagues. They happily described how they sensed that they belonged and
how friendly the WA nurses were towards them. They also emphasised that
they did not want to be left out and that they consciously wanted to be with their
colleagues especially during the tea breaks and other social times. However,
while they would have liked to take part in the out-of-work socialising, they
found the ‘pub’ sessions off putting. Nevertheless they did not believe that
socialising outside work was detrimental to them being accepted by the team.
In fact the participants, in their search to integrate, recognised that they put in a
lot of effort to fit into the system. They were resilient because while the system
and the nurses were supportive, they nonetheless had to rely on themselves to
deal with the everyday difficulties they encountered. They had to be strong,
confident and self reflective to move forward and to feel respected and valued.
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They acknowledged that they had to work very hard to sustain their integrity as
nurses. They realised that despite their initial emotional and professional turmoil
they had agency and came forward in their own time in bringing forward their
professional values and assertiveness in what they believed was right.
Finally the participants felt that they successfully adapted to their new
workplace which was expressed through professional contentment in relation to
their nursing practice and their work environment. They were surprised
however, how much they changed without realising it. It appeared that the
support, their hard work and their everyday work dynamic had shaped them
progressively into a WA nurse. They also believed that their cultural and ethnic
differences, while still present and acknowledged by others were not seen as
detrimental to their integration anymore. People adapted to them, but most
importantly the participants themselves believed that they were an integral part
of the WA population. Their ethnic and cultural status was in fact a major
contributor to their feeling of belonging as it matched the larger multi ethnic WA
community. They, therefore, believed that they integrated in their WA RN status
and were able to progress professionally. They realised that they had
reintegrated their role and professional status of RN and they had a vision for
their professional journey and growth similar to that of their WA colleagues.
In the next chapter an overview of experiences and conclusion to this research
project is presented. It includes the overall phenomenological explanation of the
lived experience of WA NESB OQNs interviewed for this research study.
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8 CHAPTER EIGHT – OVERVIEW OF EXPERIENCES AND CONCL USION
8.1 Overall Phenomenological explanation of the par ticipants’
experiences
The NESB OQNs who participated in this research study experienced a journey
as they tried to settle into their role and status as registered nurses in WA. It
was a journey of discovery into a work environment in which they had to learn to
find their way so that they could work and fulfil the professional requirements of
their employment. Furthermore, it was a journey of self discovery as they had to
adjust their own sense of self as unique individuals as well as their nursing
identity to fit within the WA hospital context.
At the beginning the journey was characterised by feelings of being
overwhelmed by multiple layers of differences experienced in the workplace.
Participants struggled to work; they felt fearful, confused and frustrated and
developed self doubts which gave impetus to feelings of professional loss. As a
result they resumed a ‘learner’s’ role, which left them feeling vulnerable and
powerless.
As their journey progressed further they identified two major challenges within
the WA workplace; namely the culture and language, and the practice of
nursing. With English not being their first language the participants knew that a
cultural and linguistic shift had to occur. However, the multiple communication
difficulties they experienced resulted in ‘Feelings of Otherness’. They could not
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understand local people and could not be understood. They had to concentrate
at all times focussing on body language and surroundings to make sense of
what was said. Verbal handovers and answering the telephone were very
stressful. Their sense of otherness was also at times reinforced by some of
their WA colleagues’ remarks about their accents and/or ways of working.
In addition they were set back by some the differences in nursing practice they
encountered in WA. They could not apply all their clinical skills; they had to
implement holistic care and treat patients like customers which was new to most
of them. They felt that doctors had power over nurses and that WA nurses’
lacked unity as a professional body. The result was feelings of professional loss
when working in WA.
However as their journey continued participants identified their difficulties, and
realised that they were not alone and that multiple layers of support were
available in the hospital setting in forms of education sessions, nursing staff and
the ward managers. However they also displayed resilience and agency in their
search to overcome their difficulties. Over time ‘It all worked out in the end’ as
participants changed and acculturated. While they realised they did not belong
to the dominant Anglo Saxon population they could, however, identify
themselves with the multi-cultural nature of the WA population. As their journey
of discovery eased they felt integrated into their WA RN status and developed a
similar vision of professional growth as their local colleagues.
The lived experiences of the thirteen NESB OQNs in this study appears to be in
line with ‘les rites de passage’, a concept that was coined and elaborated upon
by Arnold van Gennep.143 The three major phases that correlate with van
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Gennep elaboration of a rite of passage can be found in the participants’
experiences. These phases are separation, transition and incorporation. The
separation phase was their migration to Australia and their initial acquaintance
with the WA hospital workforce, where their nursing identity and sense of worth
were in turmoil. The transition phase reflects the struggles they endured and the
learning and adaptation processes they went through in their search to regain
their full professional identity as RNs. Finally the incorporation phase was, as
stated by them, their success and ability to work comfortably as WA RN’s.
8.2 Limitations of the study
While the findings from this study and the themes that were developed are
instructive, it nonetheless has its limitations. Firstly the number of respondents
was small and whilst this enabled an in depth exploration of their experiences,
the findings cannot be generalised to all NESB OQNs working in WA. Secondly,
the positive outcomes for the participants in this study may not reflect the
experiences of the NESB OQNs who, because of the difficulties experienced in
working in Western Australia, might have left the nursing workforce or returned
to their home country.
The results from this study are, however, important because they are consistent
with some of the current knowledge in relation to communication and cultural
issues experienced by overseas nurses. The study also reiterates how nursing
practice is not universal and reflects current social, economic and power
structures. However, unlike the findings of other research, this study did not find
experiences of discrimination, ethnocentrism and racism in the workplace.
While difficulties with patients and colleagues were spoken about, it was
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described as minor. In fact all participants felt that they were equal to their local
colleagues with regard to opportunities for promotion and access to further
education. This is further highlighted as all participants worked on different
wards and came from five different hospitals.
8.3 Significance for nursing knowledge
This thesis highlights the experiences of NESB OQNs and explores their
experiences of nursing in WA. It provides a perspective on their inner feelings
and sense of self but also shows how nursing practice is not universal but rather
is shaped within the social context of the setting. Therefore, this knowledge
should be incorporated to assist migrant nurses to integrate into the workplace.
A culturally sensitive approach is necessary and could start with an introduction
to the WA culture and nursing culture, where communication skills and the
practice of nursing would be emphasised. This information would provide a
framework for them to understand the new social and work environment. They
could then evaluate and compare this against their own values, norms and
nursing practice. Local nurses should also be educated on cultural diversity, so
that they could display empathy and be aware of their own possible
ethnocentrism. In addressing these two broad concepts, agencies and
employers might ease the integration of migrant nurses, into the work
environment. This could assist with work satisfaction and/or sustainability of the
workplace.
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8.4 Further research
The persistent nursing shortage and the Australian initiative to actively recruit
overseas qualified nurses should give impetus for further research. In fact the
experiences of other NESB OQNs working in Western Australia should be
studied to enhance knowledge on the topic. It would, however, be valuable to
obtain perspectives from local nurses and nurse managers working with migrant
nurses. This would provide richness and depth in understanding the
interpersonal and work dynamics between migrant nurses and their colleagues.
However NESB OQNs are not confined to working in WA metropolitan
hospitals, they also work in regional, rural and remote areas. It would therefore
be valuable to conduct research that would investigate their experiences, given
the need for health professionals in rural and remote WA.
8.5 Concluding statement
The global shortage of nurses has given impetus to nurse mobility. In Australia
the need for nurses and the changes in immigration laws in the 1980s, has
facilitated the migration of overseas qualified nurses including Non English
Speaking Background nurses to Australia. While research on migrant nurses
working in Australia has been conducted in the Eastern states of Australia,
there is very little research about the experiences of NESB OQNs working in the
Western Australian hospital system. This thesis was a first step in addressing
this gap in knowledge.
159
The findings from this research highlight the personal and professional journey
of the participants and differences from current knowledge where migrant
nurses have often been reported as vulnerable and discriminated against by the
host country nurses. This study emphasised the participants’ resilience and
agency in terms of their willingness and determination not only to adapt and to
learn from the new country and work practice but also to maintain their integrity
as unique professional individuals practising nursing.
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9 APPENDICES
Appendix A: Information Sheet
How do Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) Experience Nursing in Western Australia?
PARTICIPANT INFORMATION SHEET
Introduction Thank you for expressing interest in participating in a research study that will review how Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience working in WA. Before you make your decision, it is important for you to understand why the research is being done and what it would involve for you. Please take as much time as you need to read the following information carefully and discuss it with friends and colleagues if you wish. Do not hesitate to contact me if there is anything that is not clear or if you would like more information. What is the purpose of the study? This study is to look at how NESB OQNs’ socio-linguistic background influences their working experience in the WA hospital environment. The aim is to gain a better understanding of potential difficulties that may be detrimental to their smooth integration into the nursing workforce. Do I have to take part? Your participation in this study is voluntary and you can withdraw at any time. If you decide not to participate, or decide later to withdraw, it is your right and you do not have to give a reason for your decision. However if you decide to take part you will be asked to sign a consent form. You will be given this information sheet to keep and you will receive a copy of your signed consent form. Your participation in this study will not prejudice any right to compensation, which you may have under statute or common law. What would happen in this study? If you decide to take part in this research you will be asked to participate in one or two semi-structured individual interviews of approximately one hour each. Broad open ended questions will guide and facilitate the conversation however you will be able to elaborate and extrapolate at ease on valuable information. The overall interview process is to capture the complexity and the richness of your working life experiences. Furthermore I may come and observe your work dynamic during one shift in order to provide information about how you interact with staff and patients. This observation may take a couple of hours.
161
All interviews will be audio taped, in order to facilitate accuracy of data collection. Notes will be taken during the interviews. All transcripts of interviews and notes from the observation will be given to you for verification and adjustment if necessary. Please be reassured that a pseudonym will be used to protect your identity. All information that you provided will be treated as highly confidential and will only be utilised for the proposed research. What are the possible benefits of taking part? You will contribute to developing research in nursing which is part of your professional role. On completion of the research you will receive a certificate for participation which you will be able to add to your professional portfolio. Your input combined with those of other participants will enhance our understanding of the situation faced by NESB OQNs working in the WA health care system. With this knowledge we will be able to develop educational, organisational and structural strategies at government and health care levels to support these nurses integration into the nursing workforce. What are the possible risks of being involved? There is no risk as all information will remain highly confidential. What happens at the end of the study? At the end of the study you will be asked to verify the authenticity of the transcript of your interviews. You will receive a letter thanking you for your participation and a professional certificate. Who will see my records and what will happen to them? All audio tapes, notes and data analysis will be securely stored in a locked filing cabinet at UWA. Transcripts will be in word documents and protected by a password. Only people who are directly connected to the study will be permitted access to these records. After the study, the records will be kept in a locked archive for at least 7 years from the time the study is closed, and will be destroyed after that time. By taking part in this study you agree not to restrict the use of the data even if you withdraw. Your rights under any application data protection laws are not affected. Study costs Transportation to and from interview locations will be subsidised. Further information and contacts during the study If you require more information about this study before you decide to join (or at any other time), or if you decide to take part in the study and you experience any stress please do not hesitate to contact me on the number below. Christine D.A Smith Phone: 6488 7372 Email: [email protected]
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Appendix B: Consent Form
Thank you very much for your time in considering this research study
PARTICIPANT CONSENT FORM Masters Thesis Study Topic: “ How do Non English Speaking Background (NESB) Overseas Qualified Nurses
(OQNs) Experience Nursing in Western Australia?” I ________________________________________( print your name), agree to volunteer to take part in the above named study being supervised by the Clinical Teaching and Education Centre in the Faculty of Medicine, Dentistry and Health Sciences at the University of Western Australia (UWA). I am aware of the purpose of this study. Further, I have read a copy of the Participant Information Sheet and the procedures involved. I am aware that the data collection will involve one or two individual interviews that will be audio taped and that notes will also be taken during that process. Data may also be collected in an observation session. It has been explained to me that I am free to withdraw my participation from the study at any time, and that withdrawal will not result in prejudice of any kind. I am aware that at no time will my name be reported with the results of the study and that the information I supply will be kept confidential. I understand there will be no re-imbursement made to me for participation in this study. Participant’s Signature Signed: _________________________ Date: _________________________ Phone number: __________________ (It is optional but valuable if I need to clarify any issues at a later time)
16
2
163
INVITATION FOR NURSES TO PARTICIPATE IN A STUDY on INVITATION FOR NURSES TO PARTICIPATE IN A STUDY on INVITATION FOR NURSES TO PARTICIPATE IN A STUDY on INVITATION FOR NURSES TO PARTICIPATE IN A STUDY on
How How How How do do do do Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience
nursing in Western Australia?nursing in Western Australia?nursing in Western Australia?nursing in Western Australia?
PPPPlease contact lease contact lease contact lease contact Christine Smith Christine Smith Christine Smith Christine Smith todaytodaytodaytoday: : : :
IIII llllook forward to hearing from you.ook forward to hearing from you.ook forward to hearing from you.ook forward to hearing from you. Participants will receive aParticipants will receive aParticipants will receive aParticipants will receive a Certificate of Participation Certificate of Participation Certificate of Participation Certificate of Participation
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A Participant Information Sheet and Consent Form will be provided upon your acceptance to this study....
This research haThis research haThis research haThis research has been approved by the Human Research Ethics Committee of the University of Western Australia s been approved by the Human Research Ethics Committee of the University of Western Australia s been approved by the Human Research Ethics Committee of the University of Western Australia s been approved by the Human Research Ethics Committee of the University of Western Australia and SCGH.and SCGH.and SCGH.and SCGH.
Are you a Female Nurse (EN or RN) from a Are you a Female Nurse (EN or RN) from a Are you a Female Nurse (EN or RN) from a Are you a Female Nurse (EN or RN) from a
Non EnglishNon EnglishNon EnglishNon English Speaking Background Speaking Background Speaking Background Speaking Background????
Did you do your nursing education and Did you do your nursing education and Did you do your nursing education and Did you do your nursing education and
qualified in a qualified in a qualified in a qualified in a language otherlanguage otherlanguage otherlanguage other than English? than English? than English? than English?
Would you like to reflect upon your Would you like to reflect upon your Would you like to reflect upon your Would you like to reflect upon your
experiences AND contribute to research experiences AND contribute to research experiences AND contribute to research experiences AND contribute to research
concerning crossconcerning crossconcerning crossconcerning cross----cultural communication in cultural communication in cultural communication in cultural communication in
nursing practice?nursing practice?nursing practice?nursing practice?
� If you meet tIf you meet tIf you meet tIf you meet these criteria please come and share your hese criteria please come and share your hese criteria please come and share your hese criteria please come and share your
work experiences with the researcher.work experiences with the researcher.work experiences with the researcher.work experiences with the researcher.
� The times, length of meeting and place of the The times, length of meeting and place of the The times, length of meeting and place of the The times, length of meeting and place of the
interview can be organised to suit youinterview can be organised to suit youinterview can be organised to suit youinterview can be organised to suit you. Y. Y. Y. Your personal our personal our personal our personal
details and information will be kept confidential.details and information will be kept confidential.details and information will be kept confidential.details and information will be kept confidential.
Appendix C: poster for SCGH
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INVITATION FOR NURSES TO PARTICIPATE IN A STUDY on INVITATION FOR NURSES TO PARTICIPATE IN A STUDY on INVITATION FOR NURSES TO PARTICIPATE IN A STUDY on INVITATION FOR NURSES TO PARTICIPATE IN A STUDY on
How How How How do do do do Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience
nursing in Western Australia?nursing in Western Australia?nursing in Western Australia?nursing in Western Australia?
PPPPlease contact lease contact lease contact lease contact Christine Smith Christine Smith Christine Smith Christine Smith todaytodaytodaytoday: : : :
IIII llllook forward to hearing from you.ook forward to hearing from you.ook forward to hearing from you.ook forward to hearing from you. Participants will receive aParticipants will receive aParticipants will receive aParticipants will receive a Certificate of Participation Certificate of Participation Certificate of Participation Certificate of Participation
Email:Email:Email:Email: [email protected]@[email protected]@uwa.edu.au T T T Tel:el:el:el: 6488 73726488 73726488 73726488 7372 which can be included in which can be included in which can be included in which can be included in theirtheirtheirtheir Professional Portfolio Professional Portfolio Professional Portfolio Professional Portfolio
A Participant Information Sheet and Consent Form will be provided upon your acceptance to this study.... This research has This research has This research has This research has been approved by the Human Research Ethics Committee of the University of Western Australia been approved by the Human Research Ethics Committee of the University of Western Australia been approved by the Human Research Ethics Committee of the University of Western Australia been approved by the Human Research Ethics Committee of the University of Western Australia and the and the and the and the cooperation of the Administration of HPH. cooperation of the Administration of HPH. cooperation of the Administration of HPH. cooperation of the Administration of HPH.
Are you a Female Nurse (EN or RN) from a Are you a Female Nurse (EN or RN) from a Are you a Female Nurse (EN or RN) from a Are you a Female Nurse (EN or RN) from a
Non English Non English Non English Non English Speaking BackgroundSpeaking BackgroundSpeaking BackgroundSpeaking Background????
Did you do your nursing education and Did you do your nursing education and Did you do your nursing education and Did you do your nursing education and
qualified in a qualified in a qualified in a qualified in a language otherlanguage otherlanguage otherlanguage other than English? than English? than English? than English?
Would you like to reflect upon your Would you like to reflect upon your Would you like to reflect upon your Would you like to reflect upon your
experiences AND contribute to research experiences AND contribute to research experiences AND contribute to research experiences AND contribute to research
concerning crossconcerning crossconcerning crossconcerning cross----cultural communication in cultural communication in cultural communication in cultural communication in
nursing practice?nursing practice?nursing practice?nursing practice?
� If you meet thIf you meet thIf you meet thIf you meet these criteria please come and share your ese criteria please come and share your ese criteria please come and share your ese criteria please come and share your
work experiences with the researcher.work experiences with the researcher.work experiences with the researcher.work experiences with the researcher.
� The times, length of meeting and place of the The times, length of meeting and place of the The times, length of meeting and place of the The times, length of meeting and place of the
interview can be organised to suit youinterview can be organised to suit youinterview can be organised to suit youinterview can be organised to suit you. Y. Y. Y. Your personal our personal our personal our personal
details and information will be kept confidential.details and information will be kept confidential.details and information will be kept confidential.details and information will be kept confidential.
Appendix D: poster for HPH
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Appendix E: Flyer for SCGH
Attention: NON ENGLISH SPEAKING BACKGROUND NURSES
� Are you a Are you a Are you a Are you a Female NurseFemale NurseFemale NurseFemale Nurse????
� Did you do your Did you do your Did you do your Did you do your NNNNursing ursing ursing ursing EducationEducationEducationEducation and and and and
qualified in a qualified in a qualified in a qualified in a LLLLanguage other than English?anguage other than English?anguage other than English?anguage other than English?
Would you like to Would you like to Would you like to Would you like to share share share share your experiences your experiences your experiences your experiences andandandand add to add to add to add to
our understour understour understour understanding of Canding of Canding of Canding of Crossrossrossross----culturalculturalculturalcultural CCCCommunication ommunication ommunication ommunication
in in in in NNNNursing?ursing?ursing?ursing?
PPPPlease contact lease contact lease contact lease contact ChristineChristineChristineChristine: : : : Participants will receive a Participants will receive a Participants will receive a Participants will receive a
EmailEmailEmailEmail:::: [email protected]@[email protected]@uwa.edu.au Certificate of Participation Certificate of Participation Certificate of Participation Certificate of Participation
TTTTel:el:el:el: 6488 76488 76488 76488 7372372372372 which can be included in which can be included in which can be included in which can be included in theirtheirtheirtheir
Professional PortfolioProfessional PortfolioProfessional PortfolioProfessional Portfolio I lI lI lI look forward to hearing from youook forward to hearing from youook forward to hearing from youook forward to hearing from you....
This This This This Master Master Master Master research research research research project project project project has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of Western Australia and SCGHWestern Australia and SCGHWestern Australia and SCGHWestern Australia and SCGH
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Appendix F: Flyer for HPH
Attention: NON ENGLISH SPEAKING BACKGROUND NURSES
� Are you a Are you a Are you a Are you a Female NurseFemale NurseFemale NurseFemale Nurse????
� Did you do your Did you do your Did you do your Did you do your NNNNursing ursing ursing ursing EducationEducationEducationEducation and and and and
qualified in a qualified in a qualified in a qualified in a LLLLanguage other than English?anguage other than English?anguage other than English?anguage other than English?
Would you like to Would you like to Would you like to Would you like to share share share share your experiences your experiences your experiences your experiences andandandand add to add to add to add to
our understour understour understour understanding of Canding of Canding of Canding of Crossrossrossross----culturalculturalculturalcultural CCCCommunication ommunication ommunication ommunication
in in in in NNNNursing?ursing?ursing?ursing?
PPPPlease contact lease contact lease contact lease contact ChristineChristineChristineChristine: : : : Participants will receive a Participants will receive a Participants will receive a Participants will receive a
EmailEmailEmailEmail:::: [email protected]@[email protected]@uwa.edu.au Certificate of Participation Certificate of Participation Certificate of Participation Certificate of Participation
TTTTel:el:el:el: 6488 76488 76488 76488 7372372372372 which can be included in which can be included in which can be included in which can be included in theirtheirtheirtheir
Professional PortfolioProfessional PortfolioProfessional PortfolioProfessional Portfolio I lI lI lI look forward to hearing from youook forward to hearing from youook forward to hearing from youook forward to hearing from you....
This This This This Master Master Master Master research research research research project project project project has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of has been approved by the Human Research Ethics Committee of the University of Western Australia and Western Australia and Western Australia and Western Australia and the cooperatiothe cooperatiothe cooperatiothe cooperation of the Administration of HPH. n of the Administration of HPH. n of the Administration of HPH. n of the Administration of HPH.
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Appendix G: Letter of invitation
Letter of invitation
Dear Colleague, 03/05/2009
Invitation to participate in a study to determine how Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience nursing in Western Australia.
I am writing to gain support from you to participate in a study that would review how Non English Speaking Background (NESB) Overseas Qualified Nurses (OQNs) experience working in WA. This project is a Masters Thesis Study that would be supervised by the Clinical Teaching and Education Centre in the Faculty of Medicine, Dentistry and Health Sciences at the University of Western Australia (UWA). This study is to look at how NESB OQNs’ socio-linguistic background influences their working experience in the WA hospital environment. The aim is to gain a better understanding of potential difficulties that may be detrimental to their smooth integration into the nursing workforce. If you meet the following criteria:
• Female Registered or Enrolled Nurse • Trained and gained your initial nursing qualifications in a language other
than English, • Lived in Australia for a maximum of 10 years • Registered with the NMBWA and currently working in Perth
Please contact me on: 6488 7372 or by email at: [email protected] If you chose to participate a Participant Information Sheet and a Participant Consent Form will be sent to you. Participants will receive a Certificate of Participation which can be included in their Professional Portfolio I look forward to hear from you. Yours truly, Christine D.A. Smith
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Appendix H: Demographic form
DEMOGRAPHIC DATA
Date:
Name:
Age:
Place of Birth
1st language
Where did you gain your nursing qualifications?
Which language was used in your nursing training?
How long have you been learning English?
Which hospital do you work in now?
How long have you been in Australia?
Reasons for working in Australia
Optional:
Citizenship
Religious beliefs
Marital status
Do you have children?
If yes, what are their ages?
Telephone number
Email address
169
Appendix I: Guiding Questions
Preamble to interview:
I am interested in your experiences and feelings about your work as a RN in Perth. I
would like to hear about how your working life here compares with your working life
in your home country, and in particular any aspects of your working life that you
have found particularly interesting and/or challenging in Perth.
The following questions are to give you an idea of the issues the researcher is
interested in. They are guidelines, rather than being prescriptive.
Guiding Questions:
• Think about your 1st day working as a registered nurse in WA? Tell me about
your experiences and feelings at the time.
• Tell me about an encounter with an Australian patient which highlights some
cultural / linguistic differences / difficulties.
• Tell me about an encounter with an Australian colleague which highlights
some cultural / linguistic differences / difficulties.
• Tell me about some similarities and differences in practicing nursing in your
home country and in Perth. What did you find easy to adjust to? What did you
find difficult to adjust to?
• Looking back now can you tell me about your preparation to practice nursing
in WA. Were you well prepared? Were you not so well prepared? Can you
explain why?
• Were there any barriers to working effectively as a RN in WA?
• At work what aspects of the Australian cultural and communication styles do
you find challenging / different / difficult to understand / to adjust to? Can you
explain why?
• Can you elaborate on your current level of professional satisfaction?
Thank you.
170
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