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THE TRANSITIONING OF
INTERNATIONALLY EDUCATED
NURSES (IENS) INTO THE
ALBERTA HEALTH
CARE SYSTEM
Presented January 27, 2011 at the Prairie Metropolis Centre Node
Conference on Citizenship and Social, Cultural and Civic Integration
Dr Gina Higginbottom, Canada Research Chair in Ethnicity and Health & Associate Professor, Faculty of Nursing, University of Alberta, Canada
Email: [email protected]
Acknowledgements
Prairie Metropolis Centre for funding the study
The IENs who participated in this study
Study advisory board members Arturo del Rosario
(Filipino Nurses Association), Jean Farrar (CARNA),
Betty Sawchenko (AHS), Cathy Giblin and Cesar
Sandoval (Capital Health)
The research team – Dr Rwamahe Rutakumwa, Shirley
Mogale, and Eileen Omosa
Introduction – Global nursing shortages
The International Congress of Nurses have warned of
an impending global shortage of clinical
and academic nurses.
Many ‘high income’ nation states such as
Canada, Australia, New Zealand, the United States,
the United Kingdom (UK), Italy, and France welcome
IENs to redress shortfalls in the nursing workforce (Aboderin 2007, Obrey 2007 et al., O’Brien 2007, Brunero et al 2008, Xu et al
2008).
Introduction – Complexities of IENs
The ethics of recruitment strategies are complex and
it is not possible to explore this dimension fully in this
presentation, e.g. UK National Health Service ethical
clause
The mass movement and relocation of a highly skilled
workforce has consequences for both the country of
origin of the nurses and the host community.
Introduction – Contextual differences
Health care systems are configured and evolve in
relation to given set of socio-economic, political and
cultural circumstances.
There is wide variation between many countries in the
delivery of health care and the education and training
of health professionals, including nurses.
Introduction – Costs & retention
IENs’ financial and personal costs of relocation
Health authorities/institutions also have financial costs
of recruitment and the need to retain IENs
Introduction – Supports for IENs
IENs may need considerable support in transitioning
into a new social and health care environment,
including support in gaining the recognized
credentials and becoming registered as a nurse in the
host community.
However, there is a paucity of research evidence
arising from the Canadian context regarding issues
beyond credentialing.
Background – Research Context
Recruitment drives in Australia, India, the UK and the
Philippines
In 2008, there were 1000 contingent job offers to
IENs but the economic downturn in 2009 meant that
many positions were frozen.
Research Questions
Overarching question:
How do IENs transition into the
Alberta health care system?
Secondary research questions were grounded in the
findings of international research studies exploring the
experience of IENs.
Research Questions (cont.)
What are the motivations of IENs for relocation to Alberta?
What are the IENs’ experiences of recruitment, reception and support on arrival?
How have the IENs adjusted to working in the Alberta health care context?
How is living in Alberta experienced by IENs in Alberta?
How does their working life differ from the country of origin?
Have the IENs experienced racism and/or discrimination since arrival?
What strategies have IENs employed to overcome obstacles and barriers?
Methods
Phase 1 A critical review of the global literature on
transitioning of IENs (Newton, Higginbottom & Pillay, J Nurs Manag, 2011 In Press)
Phase 2 A qualitative approach utilizing semi-
structured interviews of IENs at 1-3 months & 9-12
months post-relocation.
The interview topic guides for both
interviews were developed with help
of an advisory group of key stakeholders
e.g. AHS, CARNA Filopino Nurses Association
Recruitment & Sample
IENs recruited at the Alberta Health Service Orientation
Program after presentation of the study.
Via Filipino Nurses Association, Edmonton
23 IENs participated in 31 interviews 14 IENs were
not available for follow-up interview due to
reorganization of health authority and relocation.
Philippines, New Zealand, Australia, UK and India
often ‘chain migrants’ who have worked in several
countries prior to re-location.
5 key-stakeholders – e.g. AHS, CARNA
Biographical information of IENs
M/F Age (yr) Self-assigned
ethnicity
Spoken
language Qualifications
Place of
trainingOther
countries
where worked
Entry in
Nursing
Current
position
Previous position
M 38 Filipino Filipino BSc in Nursing Philippines Saudi & U.K. 1993 GN RN
F 50 Filipino Filipino Masters in Public Health Philippines Saudi & U.K. 1980 NA Tutor/UN Co-ordinator
F 48 Filipino Filipino Masters in Nursing Philippines N/A 1981 NA Dean
F 43 New Zealander English BSc in Nursing New Zealand N/A 2000 GN RN
F 35 Filipino Filipino BSc in Nursing Philippines Saudi & U.K. 1994 GN RN
M 41 New Zealander English BSc in Nursing New Zealand Tonga & Pakistan 1989 GN Staff Nurse
F 36 Filipino Filipino BSc in Nursing Philippines New Zealand 1996 GN RN
F 30 Black English BSc in Nursing Caribbean USA 2004 GN RN
F 41 Black English BSc in Nursing Caribbean U.K. 2001 GN Staff Nurse
M 26 Australian/
European
English BSc in Nursing Australia U.K. 2004 GN RN
F 30 Australian/ European English Masters in Midwifery Australia U.K. 2003 GN RN & RM
F 46 British English Diploma in Nursing New Zealand None 2002 GN RN
F 39 Filipino Filipino Bsc in Nursing Philippines None 1991 LPN Staff Nurse
M 43 Black African Akan MA, BA (Hones), RMN United Kingdom U.K. 1992 PN Care Coordinator
M 25 Filipino Tagalong Bachelors of Nursing Philippines Philippines 2005 LPN Staff Nurse II
M & F 43 & 46 British (both) English (both) Diploma in Adult Nursing
(both)
United Kingdom New Zealand, Isle of
Man (both)
M: 2001, F:
1995
C.G.N. (Cert.
Graduate
Nursing ) (both)
Clinical Nurse Manager,
RN (Male); Clinical
Nurse Specialist, RN
(Female)
F N/A Barbadian English BsSc. & Diploma United Kingdom Not Given 2004 C.G.N. (Cert.
Graduate
Nursing )
R.P.N. (Reg. Psych.
Nurse)
M 25 Ilongo Tagalog BSN Philippines None 2005 LPN Clinical Instructor
F 23 Filipino Tagalog RN, BSN, NCLEX-Rn Philippines None 2006 LPN Staff Nurse
M 31 Asian Taglog BSN, BSC in Med Tech Philippines None 2005 LPN Staff Nurse
F 27 Filipino Tagalog RN, BSN Philippines None 2004 LPN Charge Nurse
F 35 Filipino Filipino BSc in Nursing Philippines None 1995 LPN RN level 3
Findings – 7 main themes
Motivation and Decision to Relocate
Experiences of Recruitment, Reception, Salary &
Support on Arrival (Expectations vs Reality)
Healthcare System Nursing Work Environment
Discrimination in the Professional Lives of IENs
Qualifying as a Registered Nurse
Life Beyond the Nursing Setting
Strategies IENs Learned to Overcome Challenges
Motivation and Decision to Relocate
The motivations of IENs from developing countries
differ from those with origins in high-income nations
For a better life…basically for my children, yeah, considering the fact
that, uh, we are experiencing some problems in the Philippines.Participant 2 - Philippines
I think Canada is a better place because I can learn more … In the
Philippines we are lacking of supplies. I must admit that we are not
doing good in procedure or something because we are lacking of
supplies. We let [patients’] relatives buy supplies. Let’s say we are going
to do one dressing. We will ask relatives to buy supplies, like gauze. And
even syringes.... Participant 13 - Philippines
Motivation and Decision to Relocate
We worked in the United Kingdom a few years ago, and we just
wanted to have another travel work experience. We like the
outdoors and things like that so we wanted to have a look at the
mountains and animals, and I like fishing and things like that so.
Really, other than that, there was no real intention.Participant 10 – Australian
Yeah to be honest with you the UK is a nice place, you know. It’s just
the cost of living is too high. So that’s the other reason why I came
here [Canada]. Because the salary that they gave me is a little bit
higher than what I am earning in the UK .. That’s one motivation.Participant 5 – Philippines
Experiences of Reception & Support on
Arrival
[On arrival] I was told to get a taxi. Well of course,
you’re in a new in a country… I complained about that
with my agency…I’ve never been to the place and [you]
ask me to take a taxi?
Participant 5 – Philippines
The first impression was Canadians made me feel that they
are doing me a favour for me…because I come from a
Third World country. I’ll be earning more. Participant 7 – Philippines
Experiences of Reception & Support on
Arrival
Accommodation-wise I had a problem with that
because … I was expecting it would be close
to the hospital… I did not finish the 45 days
because I can’t stand it anymore. It’s too far.Participant 5 – Philippines
The six weeks accommodation gave me freedom…It’s
wonderful most of the nurses that were in the hospital
stayed for the entire 45 days.Participant 3 – Philippines
Experiences of Support on Arrival
Six-week long orientation/retraining session
Preceptorship experiences varied. Some IENs
were left without assignment of a preceptor
and were trained at a task by watching a staff
nurse perform it once or twice.
Experiences of Recruitment…
Significant discontent was expressed regarding
expectations of working in their area of specialty.
We were told that ... you will always work in your area of specialty
which has turned out to not be true. They guaranteed that you would
always, if you are specialized in an area, then that is where you go. ...
they kept changing what they wanted to do with me every five minutes.
And then two weeks before I left
to come over here, like I was supposed to go to Emergency (I was
trained in Emergency and that is all I have ever done) they say “oh,
there is no positions anymore. You have to work on a medical ward.”
Participant 10 - Australia
Experiences of Recruitment…
To me it was more suicidal than anything... the contract was that
um, temporary full-time for one year... almost all Internationally
Educated Nurses who came, who didn’t really understand what
that entailed until we got here... given all those years of
experiences of working in the NHS no one would have swapped
that for a temporary one year position ...then because they used
an agency, the people that they employed at the agency
themselves didn’t really understand that.Participant 14 – United Kingdom
More unmet expectations…
Experiences of Recruitment & Salary…
Many IENs also had difficulty reconciling the fact that
they were recruited as RNs but CARNA (College and
Association of Registered Nurses in Alberta) did not
allow them to practice as RNs.
Graduate Nurse level work meant their actual salary
entitlements were lower than stated in their signed
contract.
Long-wait times (up to eight weeks was claimed) for
receiving their reimbursement of expenses.
Health Care System Nursing Work
Environment
The overwhelming sentiment towards working within
the health care system was negative.
In New Zealand, we actually wash our patients but they [Canadians] spend more time
on a computer…So you establish more rapport than here. You tend to talk more with
your patient, know your patient.
Participant 7 – New Zealand
I thought that the [Canadian] Healthcare system would be really advanced… I
thought it would make Australia’s healthcare system look really old-fashioned…
thought I would come over here and there would just be all this whiz/bang
technology, and all these different practices and I wouldn’t understand and I thought
I’d have lots and lots to learn. But that hasn’t ended up being a really accurate idea
that I had.
Participant 11 - Australia
Health Care System Nursing Work
Environment
I think they are a little bit foolish doing what they’re doing. I think they are chopping themselves off at the head by doing it. As an educator in New Zealand ... we had lots of international nurses come through the unit. And I loved the fact that they brought skills to
New Zealand that we didn’t have in New Zealand. You know, and everybody brought something. Canada’s not about that unfortunately, or not so far. It’s about their
way is the right way. …
Participant 4 – New Zealand
Perceived Discrimination in the
Professional Lives of IENs
Assignment of tasks unrelated to nursing, e.g..
dishwashing and vacuuming
Credentialing Issues
Assignment of clinical specialities and recognition of
previous skills
Non-nursing duties
But then when we get there, the Health Care Aide is the one who
gave us the orientation. She oriented us where the kitchen is.
Where the cleaning cart is. Because they ask us to do house-
keeping. That was really degrading on our part because you
know... I did house-keeping on the first day, dishwashing, that that
was really what happened on the first day. So the moment I get
home, it was already 11 p.m. and I can’t call my supervisor... I just
would like you to know that we’re doing house-keeping in this site.
Is it, is it proper? Because I, I don’t think this is what we should be
doing. I told her. I, uh, she told me, you know, you know what. I’m
not sure about it. Let me ask
Interview 10, Philippines
Qualifying as a Registered Nurse
Many of the IENs felt ill-informed of the criteria used when appointing IENs to the entry level of nursing (i.e. Graduate Nurse) at which they could expect to commence their employment in the province.
Expectations that CARNA would adjust credentialing criteria according to the IEN’s country of origin, and the perception that there were unclear guidelines on the criteria used to assign IENs to the different nursing levels/grades.
Qualifying as a Registered Nurse
My frustration was with CARNA they put you through hoops repeatedly to get
into the country. And once you get into the country, they put you through hoops
to become a nurse… fair enough that they put you through a test and they make
sure that you're practicing in the same way, but it is not fair that they do not
recognize what you’ve got. And they don’t look to see what you can bring in.
They could improve their services.
Participant 4 – New Zealand
They didn’t tell us about the SEC, that’s the Substantial Equivalent
Competency Exam that we have to go through for like 5 days. That’s written
and oral. And then after that, you, um, they’re going to assess us as to how
many courses are we going to take. So never, never in our wildest dreams.
Participant 22 - Philippines
Qualifying as a Registered Nurse
I’m frustrated for my Filipino colleagues, I worked with lots of Filipinos in
New Zealand and the one I am working with here… not having their
degrees recognized in Canada. I think that’s shocking. The Filipinos that I’ve
worked with are such wonderful nurses and the fact that they have come as
Registered Nurses and sit the Licensed Practical Nurse (LPN) and then the
Registered Nurse (RN) exam…I think that is racist and I can’t stand racism in
any form or shape.
Participant 4 - New Zealand
A little bit [upset] that I have been working as a Registered Nurse for many
year [in Philippines, the UK, Saudi Arabia all with registrations] that I have to
take the Registered Nurse exam again.
Participant 5 - Philippines
Life Beyond the Nursing Setting
We arrived in winter (laughter) the cold was a big challenge…we
coughed, sore throats and dry nose and I got cellulitus in my toe
and we had to walk everywhere and I was limping, I should have
gone to a doctor but I was waiting for my health card.Participant 4 – New Zealand
Strategies IENs Learned to Overcome
Challenges
Role of family members in both Canada and back
home
Communicating issues - if good English
Gained knowledge and knowledge from past
experiences
Continual learning
Conclusion
Clear communication and transparent expectations need to be
delivered from the employing health authority to the recruitment
agencies, to enable accurate information of the credentialing
process and orientation structure.
Orientation/bridging/retraining programs need to consider
findings from this and other studies which indicate that IENs
require extensive orientation (up to 6 months) and that which
considers wider social and economic dimensions of integration
into a new ethno-cultural context.
Conclusion
Since language and communication problems are paramount
for credentialing and transitioning of many IENs, programs
which assist with acquiring skills for communication within the
Canadian healthcare System (http://www.englishforhealth.com/)
should be offered at the recruitment stage.
Nurse managers need to be provided with comprehensive
training programs on supporting IEN’s during transition and
empowering their units to embrace and celebrate diversity and
the contributions IENs make to the healthcare system.
Thank you
