Mary Dunnion, MSc, RSM, RGN, is director of nursing, Mercy University Hospital, Cork; Martina O’Riordan, MSc, is researcher, National Suicide Research Foundation, Cork; Elizabeth Dunne, PhD, was an academic, Department of Applied Psychology, University College Cork and the principal investigator on this project until her untimely death in December 2006.
Dunnion, M. et al (2008) Internationally recruited nurses: adaptation process. This is an extended version of the article published in Nursing Times; 104: 1, 37-38.
This article reports on a one-year action-based research project on the adaptation of 70 internationally recruited nurses (IRNs) from the Philippines to a hospital in Cork, Ireland.
To describe the adaptation of IRNs and the impact this had on the indigenous nursing staff.
The researchers followed group 1 and group 3 through the adaptation process along with their Irish colleagues and ward managers.
The research examines the challenges for both international and indigenous staff and the achievements of both groups in overcoming these. The challenges ranged from cultural issues to matters of trust, professional competency and loneliness. The achievements include becoming part of the team, confidence and competence. The study also highlights the need for a broader definition of adaptation and a corporate involvement in this process.
Healthcare institutions recruiting international nurses need to invest in:
Appropriate support to enable overseas nurses to adapt to a different health system;
Supporting existing staff in managing this process while maintaining standards of nursing care;
Developing systems to evaluate the successful progress of multicultural teams.
Justification for the study
There is currently a global shortage of suitably qualified nurses and Ireland is not exempt from this phenomenon. In 2002, the Irish nurse-education curriculum changed from a three-year nursing diploma to a four-year degree programme. These changes meant there would be no new nursing graduates to fill vacancies in Irish hospitals in 2005. In common with most hospitals, Mercy University Hospital (MUH) in Cork faced a significant shortfall in registered nursing staff. To address this, the department of nursing at MUH decided to use internationally recruited nurses (IRNs) to fill the high number of vacancies.
The number that needed filling dictated that, within just six months, a quarter of MUH’s nursing complement would be from overseas. It was the first time that an acute hospital in Ireland had recruited internationally in such numbers in such a short time. Having decided to recruit from the Philippines and later from India, it was recognised that the introduction of IRNs for such a high number of posts would present major challenges for both the indigenous workforce and the nurses recruited.
The study’s context
The director of nursing and a senior clinical nurse manager (CNM) initially conducted recruitment by travelling to the Philippines with an external HR company and interviewing candidates via an agency there. A total of 70 nurses were recruited and subsequently employed, joining the hospital workforce in seven groups over a six-month period.
To achieve professional registration in Ireland, all internationally trained nurses must successfully complete a 6–12 week professional competency framework programme designed by An Bord Altranais (the Irish nursing board). The adaptation programme requires these nurses to have designated staff nurses in the role of preceptor, providing guidance and support during the adaptation programme – this function is in addition to the staff nurse’s regular nursing duties.
Recognising the challenges that the introduction of many IRNs would present, the director of nursing commissioned the Department of Applied Psychology in University College Cork to carry out an action-based research project and report on their progress over the first 16 months. The aims of the research study were:
To describe the challenges experienced by IRNs in an Irish hospital over an initial one-year period;
To describe the challenges experienced by Irish nurses (clinical and managerial) working with the IRNs over one year;
To describe the level attained in terms of satisfactory performance by the IRNs;
To explore the meaning of adaptation for an IRN working in an Irish hospital.
A comprehensive literature review was carried out to explore previous related research and relevant theory. Searches were undertaken on a wide range of databases including:
Cochrane database of systematic reviews;
Index of theses (the US, Great Britain and Ireland).
The search of these databases provided a comprehensive review of the relevant literature in the field.
The keywords ‘internationally recruited nurses’, ‘Philippines’, ‘challenges’ and ‘definition of adaptation’ produced a large number of matches and these were complemented by extensive desktop research of healthcare journals and reading lists/bibliographies. Some main themes were identified.
Difficulties with nurse staffing
The reduction in the availability of registered nurses is an international phenomenon. As in Ireland, countries such as the US, Canada, Australia and the UK have all experienced a decrease in indigenous nursing staff in recent years. For example, in the UK between 2001 and 2002 there were more overseas nurses added to the register than nurses from within the UK (Buchan and Sochalski, 2004).
Although internationally educated nurses have been an integral part of US nursing staff since the end of World War II, employers are presently targeting greater numbers of nurses from other countries (Xu and Kwak, 2007). Critically, an increasing nursing shortage is predicted in the US over the next 20 years (Brush et al, 2004). In the current climate of international migration, ability to work effectively with people of varied cultures is important for all professions and, in nursing, this competency becomes essential as health management may conflict with patients’ cultural beliefs, standards and practices (St. Clair and McKenry, 1999).
Kline (2003) found that the primary donor countries in international nurse migration are Australia, Canada, the Philippines, South Africa and the UK. India is also becoming a prominent donor country. The primary receiving countries are Australia, Canada, Ireland, the UK and the US. Buchan and O’May (1999) identified three sources of ‘inflow’ to the pool of nurses in the UK, namely, new entrants from education within the UK, re-entrants to nursing and new entrants from overseas. This model of inflow sources can also be applied to other countries such as Ireland. Thus, when a situation occurs where there are no new entrants from education within the country and there are more nurses leaving the profession than re-entering, the focus turns to overseas recruitment.
‘Push’ and ‘pull’ factors of international migration of nurses
A number of ‘push’ and ‘pull’ factors can be identified in the literature. In a six-country migration study, Awases et al (2003) identified a number of push factors for nurses leaving their country of origin. These included poor working conditions, low salary and a lack of career-development opportunities, along with social and political factors.
Pull factors for choosing one of the primary receiving countries include opportunities for professional development, and better remuneration and standard of living (Thupayagale-Tshweneagae, 2007). In a study of the experience of 11 overseas nurses in Iceland, Magnusdottir (2005) reported that all participants agreed they experienced less workload, rush and stress, and better staffing than they were used to. These nurses were from seven different nationalities, seven western, four non-western. Further positive features of international migration are an increase in professional nurses’ knowledge, expertise and training (Buchan and O’May, 1999).
Challenges in the adaptation of IRNs
There is a dearth of research examining challenges in the transition of overseas nurses into the healthcare practice environments of their host country (Sherman, 2007). Referring to unpublished data from the UK NMC, Buchan (2002) highlighted that while there were 29,313 registered nurses (RNs) in the UK in February 1999, at most only 20,000 were actually resident in the UK. This suggests that many overseas RNs had only spent limited time in the UK before either moving on to another country or returning home.
There is a need to identify what successful adaptation of nurses should involve and how this could be measured empirically. Gerrish and Griffith (2004) identified five meanings of successes in the progression towards successful adaptation. These were:
Gaining professional registration;
Reducing the nurse vacancy factor;
Fitness to practise;
Equality of opportunity;
Promoting an organisation that values cultural diversity.
While the first two are easily quantifiable, the definition of fitness to practise independently following registration may differ between ward managers and health institutions.
In the context of this study fitness to practise refers to the concept of critical thinking and decision-making, building and sustaining interpersonal relationships, and demonstrating competence in the theory and application of skill. In essence, this measures the extent to which an IRN fulfilled the expectations of a similarly qualified and experienced RGN in the area in which they worked. It is more difficult to measure equality of opportunity between overseas and indigenous staff given that the two groups may value career progression in the host country differently. Likewise, the definition of an organisation that values cultural diversity can be subjective and would need strict guidelines to become an assessable factor.
Four stages of adaptation were monitored in this action-based research study. Reflecting a ‘stepped approach’ of changes in an individual’s behaviour, attitude and values and using Pilette’s (1989) five phases of adjustment, the researchers used a modified version from Daniel et al (2001), shown in Table 1 below. A modified version was used due to time constraints of the project and data saturation being reached in IRNs’ challenges and achievements.
Table 1. Four stages of adaptation for an IRN
TIME OF MEASURE
Training period and close tutoring and mentoring
After 6 weeks
After 12 weeks
Recognising differences between own and host systems and coping with that and with being ‘different’
1 month post registration
Working out and accepting differences
4 months post registration
Feeling part of and identifying with the host organisation
8 months post registration*
MUH recruited 70 Filipino nurses between September 2005 and March 2006. In addition, 32 nurses were recruited from India at a later stage. IRNs arrived in seven groups of varying number. The researchers followed groups 1 and 3, comprising 20 nurses in all. The research started alongside the IRNs’ initial induction phase and followed their progress and that of their Irish colleagues and management for a period of eight months. Senior nurse managers also took part in a reflective focus group 16 months after the arrival of the IRNs. Some 17 staff nurses, 10 preceptors, 12 clinical nurse managers (ward managers), 20 IRNs and seven members of senior management participated.
The research study used a combination of focus groups and semi-structured interviews (Table 2) that were recorded and later transcribed.
Table 2. Data collection periods
Stage at which data collection took place
Internationally recruited nurses
· After the initial orientation programme
· After 6 weeks
· After 12 weeks
· After 1 month working as RNs
· After 3 months working as RNs
· After 8 months working as RNs
Irish staff nurses
A focus group:
Clinical nurse managers
A thematic analysis was carried out to elicit the main themes from the recorded interviews (Braun and Clarke, 2006). The researchers gave feedback in the form of a brief report to the director of nursing following each focus group to ensure that appropriate changes could be made to make the transition less stressful for both Irish and overseas staff. This method of action-based research is a participative approach with the objectives of understanding, change and critical reflection. Following reflection, there was an opportunity to explore how things might be done differently in preparation for the next group of overseas nurses.
The primary challenges initially experienced by both Irish and international staff are presented in Table 3.
Table 3. Initial challenges experienced by IRNs and Irish nursing staff
The frequency for arrival of IRNs resulted in over-saturation of, and excess strain, on the nursing staff.
Differences in understanding of basic nursing-care standards
Differences in understanding of basic nursing care standards
Anxiety regarding registration programme
Perceived lack of initiative by IRNs
Pace of work
As can be seen from Table 3, both IRNs and Irish nurses experienced initial difficulties communicating with each other, building trust and understanding that basic nursing-care standards differed between their two countries.
Examples of these challenges are outlined below.
‘They [Irish staff] really talk fast, especially during handover.’ (IRN)
‘Communication would be the main problem, because some families have difficulty understanding what the nurses are saying to them…if there is a problem do they understand you? There have been difficulties on the phone, things like that and difficulties in getting them to express their concerns.’ (Irish CNM)
‘The thing we lack is the trust from the Irish nurses.’ (IRN)
‘You can’t trust them to do something, you have to keep double-checking.’ (Irish CNM)
Understanding of basic nursing care
‘It just so happens that in the Philippines we have relatives that go bedside…not so much ward attendants but the relatives are there you know, almost 24 hours.’ (IRN)
‘When you talk to them, their work at home is very different to what we do here, they don’t do as much basic nursing care. It’s probably just the way they are trained…we had to get back to the basics of nursing care.’ (Irish CNM)
Irish nursing staff found the timeframe for the IRNs’ arrival extremely challenging – within six months, a quarter of their staff complement were from overseas and staff nurses were precepting these along with their own duties:
‘The place became supersaturated…in fact we had very few coping mechanisms to cope with it, we had never encountered it and the support was not available.’
‘There were too many together, between December and April we had eight IRNs that needed to be precepted and we had 12 students at the same time.’
The Filipino nurses missed their families very much initially and reported feeling quite homesick:
‘The first few weeks we were here, almost every day we go to the payphone or to an internet shop to email or to call our family or loved ones. But now we know how to give time to it on our day off…if sometimes we have spare money to call them then we can do an additional call.’
‘Most of us here left families and kids behind and just have to work here for their future, we just have to adjust to it, it’s how it is I guess.’
Time management/pace of work
Time management and pace of work of their overseas colleagues were issues that the Irish nurses found challenging initially:
‘Their main thing is management and organisation of care and managing their time on the ward.’
The IRNs were very surprised at the volume of reporting that is done in Irish hospitals. In the Philippines there is only one handover/report to attend to:
‘The handover is very different. There are a lot of reports here. You go on general report in the morning, then there’s the report for those who were off the day before and there is another report for the ward sister and there’s another in the middle of the day and there’s another one at night. In the Philippines there is just one report, one for the incoming and one for the outgoing.’
Anxieties surrounding their registration programme and the effects of the experience on their self-esteem were further challenges for overseas nurses:
‘It is a question in my mind, on what grounds do my colleagues fail when the others passed…was it personal? Not everybody is getting along with everyone, that’s reality.’
‘Sometimes your self-esteem goes so low because you are used to doing that in the Philippines, giving IV medication.’
In one focus group 10 months after the IRNs’ arrival, the issue of possible racial discrimination was also raised:
‘We feel somehow discriminated in a way, because of our colour.’
While the other findings relate to themes that were mentioned by several nurses, it is important to note that if even one overseas nurse feels discriminated against on the grounds of colour, it becomes an issue that the healthcare institution must be aware of and respond to.
Of the 70 Filipino nurses who came to work in MUH, 94.3% passed the adaptation programme and 91.4% passed their probation. A total of 12.9% left before completing their adaptation or probation. Ten months after the arrival of the first group of IRNs, the Irish ward managers had the following positive reflections on their experience:
‘They have very much become part of our team now.’
‘We have depended on them hugely, they are settling in well.’
‘They have certainly improved. You don’t want to be always talking about them as ‘IRN’, they are part of your staff and you just get on with it.’
The Filipino nurses were also more confident in their own abilities and performance:
‘When you are getting to know things, you are getting the confidence and the self-esteem is going up.’
‘Before you didn’t know what they [Irish staff] were asking for, you couldn’t understand them but it’s easier now.’
‘We are in a continuous learning process and I would say that they [Irish staff] are the same…nursing is a continuous update of learning.’
In their reflective focus group 16 months after the IRNs’ arrival, members of MUH’s senior nursing management were eager to highlight the achievements of Irish staff in supporting and precepting their overseas colleagues, while simultaneously carrying out their regular nursing duties:
‘It brought people together, we had a common purpose.’
‘At ward level the nurses did support each other. The IRNs would be well defended by their ward manager or colleague.’
In 2005, there were 850 elective procedures cancelled in MUH due to staff shortages and ward closures. In 2006, this number was reduced to 250. Following the IRNs’ recruitment, 31 public medical beds were re-opened, four coronary-care beds were opened and the ICU opened two further ventilated beds. However, the accompanying pressure on both Irish nursing staff and their overseas colleagues to ensure the IRNs were at an appropriate standard for this to happen must be recognised.
Action on ongoing feedback
Given the action-research design of this study, there was an opportunity for nurse management to act on ongoing feedback from the researchers. This was particularly important when Irish staff were feeling unsupported or there was another group of overseas nurses due to arrive while saturation point had already been reached among preceptors and ward managers. Table 4 records some actions taken as a direct result of feedback from the research team.
Table 4. Action on ongoing feedback
IRNs had difficulty finding accommodation for the short term while awaiting results of the registration programme
Nurse management assisted IRNs in finding appropriate accommodation
IRNs found it difficult when their preceptors changed on a daily basis due to shifts/staff shortages etc
Management identified associate preceptors for IRNs so every IRN had two preceptors, one of whom would be available all the time, where possible
Irish nurses reported they had reached saturation point with the number of overseas nurses who had arrived in a short time
· Arrival of next group of IRNs immediately delayed
· Nurse practice development staff redeployed into clinical areas to ease burden
· Basic nurse skillsets facilitated
There appeared to be some confusion between acquisition of skills for registration and competency to practise
Clarification made: skill is an objective the learner can accomplish in a specific time period; competency reflects the quality of an individual’s practice
Irish nurses reported they were not sufficiently informed about the timeframe for the arrival of IRN groups
Although there had been information days and news bulletins, this practice was stepped up and Irish staff were also updated on their achievements in precepting the IRNs and re-opening beds
The understanding of adaptation
Following analysis of the IRNs’ final focus group (eight months post-registration) it can be concluded that they are still at the ‘indignation’ stage – recognising the differences between their own system and that of MUH and coping with these differences and with being ‘different’:
‘We have to prove ourselves again and again…probably until we finish the contract.’
‘We were expecting a lot of difficulties but not this difficult.’
‘Patients here are given too much freedom, they should not be allowed to smoke…when you are in the hospital you should follow the rules…we find it strange to see patients out there smoking in their gowns and they have their IVs.’
Initially, however, adaptation was considered to be merely the achievement of professional registration. The idea of adaptation being a longer-term objective following the other three stages (orientation, indignation and resolution – see Table 1) was something that was not explored until the final focus group. At this point, it became clear that many could see that adaptation was a lengthy process:
‘In terms of their adaptation and integration – [in] its 16th month at this stage – we would be lucky if a percentage of them are integrating.’
‘In some clinical areas there are more overseas [nurses] than there are Irish, so who needs to integrate is the question.’
‘It really is nearly taking us two years to adapt these people so if they leave in two years it would be devastating.’
Thus, the initial definition of an ‘adaptation programme’ – that of fulfilling the registration requirements while working alongside a preceptor – was viewed as having only adequate success by ward managers. Of 12 CNMs interviewed 10 months after the arrival of the first group of IRNs, their responses on a Likert scale of satisfaction ratings for this six-week adaptation programme showed that only one was ‘satisfied’, 10 felt the programme was ‘adequate’ and one was ‘dissatisfied’.
The realisation that ‘adaptation’ of overseas nurses involves considerably more than meeting the registration requirements of the host country was the most significant outcome for the participants in this research. After eight months of working as RNs and 10 months of arriving at MUH, the IRNs were still at the indignation phase of the process (Daniel et al, 2001). However, this should not undermine the achievements of both Irish and Filipino nurses in overcoming the various initial challenges such as communication, standards of basic nursing care and trusting one another.
The most important lesson learnt by nurse management in this study is that a shortage of nurses is an issue not just for their department but for the healthcare institution as a whole (Buchan and Calman, 2004). Thus, a corporate response, including input from human resources, is needed to help with the initial challenges experienced by both indigenous and overseas nurses. In this study, the action on feedback came only from the department of nursing, which had also been responsible for recruitment and registration.
In addition, it is important to remember that pressure to re-open wards should not result in nurses who are not yet fit to practise overseas being rushed through the registration process. Standards of communication, basic nursing care and trust that nurses are able to complete tasks independently must be present before nurses are deemed ready for registration.
As the adaptation process itself is such a lengthy one, there must be a simultaneous focus on staff retention to safeguard this investment in training and development of international nurses.
This study was limited by the fact that hospital environments are extremely busy places where people work to a rota that covers the 24-hour period. It was, therefore, not possible to include more participants or ensure there was full attendance at each focus group. Focus groups with members of other disciplines, including consultants, junior doctors, general managers and care attendants would have given more information on the IRNs’ progress and the effect of their presence on the multidisciplinary team. Unfortunately, time and funding constraints did not allow for this.
Recommendations for the future
The shortage of nursing staff in MUH had become so acute that in order for vital beds to be re-opened, the international nurses’ arrival could not occur on a more phased basis. This meant that within six months, the nursing staff complement went from being almost 100% Irish to 25.9% comprising of overseas nurses. International trends of nurse shortages should be formally recognised by the institution in a timely manner and a stepped response put in place, so that the department of nursing would not be under such intense pressure to recruit staff. This response should incorporate the establishment of IRN manager posts. The role of the preceptor needs to be put on a more formal standing with appropriate rewards for the immense effort involved. Furthermore, if undergraduate nursing programmes were to contain modules on working in a multicultural environment, indigenous staff might be better equipped to adapt to working with international colleagues. Finally, An Bord Altranais should re-evaluate the 6-12 week professional competence framework for specialist nursing. In the context of this study, nursing competencies and skills for the overseas nurses did not appear to be at a comparable level as would be expected from an indigenous nursing workforce with similar qualifications and years of experience. Consequently, the initial adaptation period designed needs to be significantly extended.
The continuing shortage of nurses implies that Ireland and many other countries will have to engage in ongoing international recruitment over the next decade. To facilitate ease of transition for both indigenous and international staff, a phased recruitment process is necessary. The entire healthcare institution should be involved and positions of responsibility should be established. International trends should be monitored and cultural awareness should be emphasised from undergraduate nursing programmes onwards. The approach should be based on understanding of the four levels of adaptation, support for all staff in coping with initial challenges and recognition of achievement in overcoming these challenges to eventually function effectively as part of a multicultural nursing team.
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