The globalisation of the nursing workforce: barriers confronting overseas qualified nurses in Australia

Control of resources in the nursing workplace: Power and patronage relations

Immigrant nurses make up a large percentage of the Australian nursing workforce. Since the support in the workplace is expected to be inclusive for all nurses, the aim of this article is to explore how support and opportunities for professional growth, learning and development are distributed across different categories of nurses working in a neonatal intensive care unit (NICU). An ethnographic approach has opened an examination of the everyday workplace practices in the NICU to gain insight into how nurses made sense of the social and power relations occurring between themselves and their senior colleagues and how they experienced the support and opportunities they received in their workplace. As today's workplaces such as the NICU are diverse in races, culture and experiences, the concepts of intersectionality and cultural safety assisted in identifying inequality and injustice related to such diversity. The results showed how patronage relations rendered nurses with immigrant status with major disadvantage and left them clinically and culturally vulnerable. Such inequity defeats the reasons for encouraging skilled migration of nurses and poses questions on the cultural competency of recruiting organisations. Considering how cultural safety might guide staff development offers opportunities for authentic support to culturally diverse nurses.

High-Skilled vs. Low-Skilled Migrant Women: the Use of Competencies and Knowledge—Theoretical and Political Implications: an Example of the Elderly Care Sector in Poland

This paper presents the influx of migrants into the elderly care sector in Poland, which, until recently, has been perceived as a country that “exports” caregivers. It describes the results of 31 individual in-depth interviews conducted with immigrant women who take care of elderly in Poland. The purpose of the study was to determine the profile of an immigrant taking up work in the elderly care sector, including the specification of their education level and competencies. It was determined that 55% of the respondents have higher education, including over 20% with a degree in nursing or physiotherapeutic education. It was established that, when analysing migrants in the care sector, it seems necessary not to divide migrants based on their education level (high- vs. low-skilled), but rather to consider the education profile as a whole (general and special profile education). Women with specialised education differ from the other migrants in regard to their better labour market position (higher remuneration, legal employment) and the scope of skill usage. The comparison of high-skilled and low-skilled workers in the care sector is very useful from the perspective of policymakers due to the fact that there is an issue of over-qualification in Poland. The article contributes to the literature, especially research dealing with brain waste, as there is theoretical and empirical gap in research on the differences between high-skilled and low-skilled migrants working in elderly care.

Outsiders in Nursing - Voices of Black African Born Nurses & Students in the US: An Integrative Review

Purpose:

The purpose of this integrative review was to describe the experience of being outsiders in nursing as described by Black African Born Nurses and Student Nurses (BABN&SN) in the U.S., give voice to their experiences in U.S. academia and healthcare settings, discuss the implications of the BABN&SN othering on the U.S. healthcare systems, and offer recommendations to address the issues based on the literature.

Methods:

An integrative review approach discussed by Whittemore and Knafl was utilized to review literature from nursing journal published from 2008 to 2019.

Results:

Major findings include collegial/peer isolation and loneliness; racism and discrimination, unwelcoming environment, silencing of voices, personal resilience, and sense of belonging. The results of this review indicate that BABN&SN experience in U.S. nursing contribute to harrowing periods of feeling like ‘an outsider.’

Conclusions:

BABN&SN are integral part of the U.S. nursing workforce and the healthcare system. Academic and work environments that support all nurses and students, despite their perceived differences, are essential to promoting an inclusive environment. Understanding the relational pattern that guides the BABN&SN socialization into nursing is vital to developing targeted support especially when entering the clinical practice environment.

Practices and Processes Used in the Return to Work of Injured New South Wales nurses: Are These Consistent With RTW Best Practice Principles?

Purpose Workplace injury and illness rates are high within the nursing profession, and in conjunction with current nursing shortages, low retention rates, and the high cost of workplace injury, the need for effective return to work (RTW) for injured nurses is highlighted. This study aimed to identify current practices and processes used in the RTW of injured nurses, and determine if these are consistent with the seven principles for successful RTW as described by the Canadian Institute for Work & Health. Method As part of a larger cross-sectional study, survey data were collected from New South Wales nurses who had sustained a major workplace injury or illness. Survey questions were coded and matched to the seven principles for successful RTW. Results Of the 484 surveys eligible for analysis, most were from Registered Nurses (52%) in the Public Hospital Sector (48%). Responses indicated four main areas of concern: a commitment to health and safety by the workplace; early and considerate employer contact; provision of modified work; and individual knowledge of and involvement in the RTW process. Positive participant responses to co-worker and supervisor involvement were identified as areas consistent with best practice principles. Conclusions These findings suggest the practices and processes involved in the RTW of injured nurses are inconsistent with best practice principles for RTW, highlighting the need for interventions such as targeted employer education and training for improved industry RTW outcomes.

The use of a Competence Fair to validate nursing competence

Strategies to ensure that nursing competence is maintained and validated are of increasing importance and are much discussed in the nursing literature. Professional bodies, employers, nurses themselves and most importantly patients need to have reassurance that competence across the profession is uniform and is maintained. This is of particular concern in the increasingly globalised and multinational workforces which exist in many health care institutions. This paper describes an educational initiative, and the evaluation thereof, which aimed to validate and enhance nurse competency in a multinational workforce in a medical city in the Kingdom of Saudi Arabia. Results indicate that there was variability in competencies across the organisation which allowed for targeted educational interventions. The initiative was well received by the nurses in the organisation and the evaluation points to the need for ongoing strategies to ensure that competence in maintained.

An examination of the causes, consequences, and policy responses to the migration of highly trained health personnel from the Philippines: the high cost of living/leaving-a mixed method study

BACKGROUND

Dramatic increases in the migration of human resources for health (HRH) from developing countries like the Philippines can have consequences on the sustainability of health systems. In this paper, we trace the outflows of HRH from the Philippines, map out its key causes and consequences, and identify relevant policy responses.

METHODS

This mixed method study employed a decentered, comparative approach that involved three phases: (a) a scoping review on health workers' migration of relevant policy documents and academic literature on health workers' migration from the Philippines; and primary data collection with (b) 37 key stakeholders and (c) household surveys with seven doctors, 329 nurses, 66 midwives, and 18 physical therapists.

RESULTS

Filipino health worker migration is best understood within the context of macro-, meso-, and micro-level factors that are situated within the political, economic, and historical/colonial legacy of the country. Underfunding of the health system and un- or underemployment were push factors for migration, as were concerns for security in the Philippines, the ability to practice to full scope or to have opportunities for career advancement. The migration of health workers has both negative and positive consequences for the Philippine health system and its health workers. Stakeholders focused on issues such as on brain drain, gain, and circulation, and on opportunities for knowledge and technology transfer. Concomitantly, migration has resulted in the loss of investment in human capital. The gap in the supply of health workers has affected the quality of care delivered, especially in rural areas. The opening of overseas opportunities has commercialized health education, compromised its quality, and stripped the country of skilled learning facilitators. The social cost of migration has affected émigrés and their families. At the household level, migration has engendered increased consumerism and materialism and fostered dependency on overseas remittances. Addressing these gaps requires time and resources. At the same time, migration is, however, seen by some as an opportunity for professional growth and enhancement, and as a window for drafting more effective national and inter-country policy responses to HRH mobility.

CONCLUSIONS

Unless socioeconomic conditions are improved and health professionals are provided with better incentives, staying in the Philippines will not be a viable option. The massive expansion in education and training designed specifically for outmigration creates a domestic supply of health workers who cannot be absorbed by a system that is underfunded. This results in a paradox of underservice, especially in rural and remote areas, at the same time as underemployment and outmigration. Policy responses to this paradox have not yet been appropriately aligned to capture the multilayered and complex nature of these intersecting phenomena.

[Visible minority nurses and vertical mobility in hospitals]

Canada has experienced a significant change in its ethnic and cultural composition in recent decades. The sustained immigration from non-European countries has given rise to new generation of visible minorities. This new trend is clearly reflected in healthcare institutions. However, the number of visible minority nurses (VMN) is particularly low in management positions. This research adopting critical ethnography and postcolonial approach focuses on the career paths of VMN in Canadian healthcare institutions. Nurses (n = eight, MVN) and managers (n = four caucasian) participated in a series of semi-structured interviews to gather relevant information about the representativeness of the VMN in management positions. Theoretical framework « Othering » was used to guide this research as it makes the link with “la lutte de classement” of Bourdieu. Four main themes closely associated with barriers emerged from the analysis namely ; Hiring and Promotion ; instrumentalization of IMV ; interpersonal and suffering and defensive strategies. Results showed that the VMN faced obstacles, often invisible, that contribute to keeping them at a lower level of the institutional hierarchy, including the hiring and promotion process that they describe as unfair and discriminatory.

A missing piece of the workforce puzzle. The experiences of internationally qualified nurses in New Zealand: a literature review

AIM

To analyse the literature regarding the context and experiences of internationally qualified registered nurses, particularly Filipino and Indian nurses, who have transitioned to New Zealand.

BACKGROUND

Internationally qualified nurses are a significant proportion of the nursing workforce in many developed countries including New Zealand. This is increasingly important as populations age, escalating demand for nurses. Understanding the internationally qualified nurse experience is required as this could influence migration in a competitive labour market.

DESIGN

Examination of peer-reviewed research, policy and discussion documents, and technical reports.

METHOD

A systematic literature search sought articles published between 2001 and 2014 using Google Scholar, CINAHL, and Medline. Articles were critically appraised for relevance, transferability, and methodological rigour.

RESULTS

Fifty-one articles met inclusion criteria and demonstrate internationally qualified nurses face significant challenges transitioning into New Zealand.

CONCLUSION

The internationally qualified nurse experience of transitioning into a new country is little researched and requires further investigation.

CaLD nurses transition to Australian tertiary hospital practice: Exposing the reality--A mixed methods study

PURPOSE

To investigate CaLD nurses' transition into the Australian workforce over the first 3 months of employment in tertiary hospitals.

DESIGN/METHOD

Descriptive mixed method design, informed by the critical paradigm. Survey questionnaire and a focus group were used for data collection.

FINDINGS

The existence of a specific hospital orientation program was identified as a crucial factor in participants' successful transition.

DISCUSSION

Without a hospital based orientation program participants were more likely to experience failure to 'fit in'. This led to maladaptive behaviors where they did not actively seek, support or question practice through fear of drawing increased attention to themselves. WORKPLACE IMPLICATIONS: Results from the study raise serious implications for workplace safety of both the CaLD nurses and the patients they nurse. Government and health administrators need to invest in providing specific hospital orientation programs that support CaLD nurses' transition. The development of such hospital orientation programs need to be developed as to the specific learning requirements of these nurses or risk exposing them to maladaptive behaviors and potential adverse events as a result of this learned behavior.

Transnational Contexts for Professional Identity Development in Accounting

Global expansion in the boundaries of professional work, the introduction of managerial concepts and thinking, and changes in the organizational form of professional service firms all impact the process by which professionals come to identify with their profession. The focus of this paper is on transnational professional careers and professional identity development, which remain an under-researched aspect of how globalization affects the professions. Based on original survey data from Australia, we chart the influence of social and organizational contexts on professional identity development for migrant and local accounting professionals respectively. Findings suggest that unlike the “boundaryless” opportunities associated with globe-trotting professionals, the majority of professional migrants are significantly constrained by the organizational and inter-subjective settings in which they work. Theoretically, we extend the concept of professional identity development to include not only formative early career experiences, but also large institutional jolts such as those provided by migration. Findings also help expand current understandings of organizations as sites of professionalization by shedding light on their impact on transnational careers.

Overcoming language barriers in healthcare: A protocol for investigating safe and effective communication when patients or clinicians use a second language

BACKGROUND

Miscommunication in the healthcare sector can be life-threatening. The rising number of migrant patients and foreign-trained staff means that communication errors between a healthcare practitioner and patient when one or both are speaking a second language are increasingly likely. However, there is limited research that addresses this issue systematically. This protocol outlines a hospital-based study examining interactions between healthcare practitioners and their patients who either share or do not share a first language. Of particular interest are the nature and efficacy of communication in language-discordant conversations, and the degree to which risk is communicated. Our aim is to understand language barriers and miscommunication that may occur in healthcare settings between patients and healthcare practitioners, especially where at least one of the speakers is using a second (weaker) language.

METHODS/DESIGN

Eighty individual interactions between patients and practitioners who speak either English or Chinese (Mandarin or Cantonese) as their first language will be video recorded in a range of in- and out-patient departments at three hospitals in the Metro South area of Brisbane, Australia. All participants will complete a language background questionnaire. Patients will also complete a short survey rating the effectiveness of the interaction. Recordings will be transcribed and submitted to both quantitative and qualitative analyses to determine elements of the language used that might be particularly problematic and the extent to which language concordance and discordance impacts on the quality of the patient-practitioner consultation.

DISCUSSION

Understanding the role that language plays in creating barriers to healthcare is critical for healthcare systems that are experiencing an increasing range of culturally and linguistically diverse populations both amongst patients and practitioners. The data resulting from this study will inform policy and practical solutions for communication training, provide an agenda for future research, and extend theory in health communication.

The impact of supervisor-nurse relationships, patient role clarity, and autonomy upon job satisfaction: Public and private sector nurses

In the Australian healthcare sector, many changes in the public sector have affected nurse management and thereby, nurses. Yet it is unclear whether such efficiency measures, based on private sector business models, have impacted private sector nurses in similar ways. This paper examines four important issues for nurses: supervisor–subordinate relationships; perceptions of autonomy; role clarity in relation to patients; and job satisfaction. The paper uses an embedded mixed methods research design to examine the four issues and then compares similarities and differences between public and private sector nurses. The findings suggest supervisor–subordinate relationships, patient role clarity and autonomy significantly predict job satisfaction. The private sector nurses reported more satisfaction than public sector nurses with their supervisor–subordinate relationships, plus higher perceptions of patient role clarity and autonomy, and hence, higher levels of job satisfaction. The findings raise questions about whether present management practices (especially public sector) optimise service delivery productivity.

The experience of China-educated nurses working in Australia: a symbolic interactionist perspective

BACKGROUND AND PURPOSE

Transnational nurse migration is a growing phenomenon. This study explored the experiences of China-educated nurses working in Australia.

DESIGN

Using a constructivist grounded theory method, 46 in-depth interviews were conducted with 28 China-educated nurses in two major cities in Australia.

RESULTS

The core category emerged was "reconciling different realities". Three phases of reconciling were conceptualised: realising, struggling, and reflecting. Realising refers to an awareness of the discrepancies between different realities. Struggling reflects the dilemma of the "middle position" and how being situated as "the other" is experienced. Reflecting is the process of making sense of the experience and rationalising the gains and losses associated with immigration.

CONCLUSIONS

This study produced a theoretical understanding of the experience of China-educated nurses working in Australia. The findings not only inform Chinese nurses who wish to migrate but contribute to the implementation of more effective support services for immigrant nurses.

Diaspora Knowledge Transfer as a Development Strategy for Capturing the Gains of Skilled Migration

Diaspora knowledge transfer views skilled migration as a process that does not necessarily lead to the loss of skills and knowledge for sending countries. Rather, it sees skilled migration as contributing to the intellectual, social, and economic capital of migrants, for which home countries gain through knowledge transfer. The paper revisits the concept to address conflicting views of its viability by analyzing how it works and the factors and conditions that affect its application. The paper discusses diaspora, home country, and host country factors and conditions that influence this complex process. The policy implications are discussed in the conclusion.

A Model of Adaptation of Overseas Nurses

Purpose: The purpose of the study was to investigate the experiences of Japanese nurses and their adaptation to their work environment in Australia. Using a qualitative research method and semistructured interviews, the study aimed to discover, describe, and analyze the experiences of 14 Japanese nurses participating in the study. Design: A qualitative study. Method: Fourteen Japanese registered nurses working in Australian hospitals participated in the study. Individual semistructured interviews were conducted from April to June in 2008. Thematic analysis was used to identify themes within the data. Results: Analysis of qualitative open-ended questions revealed the participants’ adaptation process. It consists of three themes or phases: seeking (S), acclimatizing (A), and settling (S), subsequently named the S.A.S. model. Discussion: The conceptual model of the adaptation processes of 14 Japanese nurses working in Australia includes the seeking, acclimatizing, and settling phases. Although these phases are not mutually exclusive and the process is not necessarily uniformly linear, all participants in this study passed through this S.A.S. model in order to adapt to their new environment. Implications for Practice: The S.A.S. model of adaptation helps to describe the experiences of Japanese overseas qualified nurses working in Australian hospitals. Future research is needed to examine whether this model can be applied to nurses from other countries and in other settings outside Australia.

The experience of discrimination by US and Internationally educated nurses in hospital practice in the USA: a qualitative study

AIM

To document experiences of nurses educated abroad and in the USA in 2 urban hospitals in the southeastern USA.

BACKGROUND

Nurses are responsible for providing quality patient care. Discrimination against nurses in the workplace may create hostile environments, potentially affecting patient care and leading to higher nurse attrition rates. Structuration theory posits that agents' interactions create structures. Agents' use of resources and rules shapes interactions, potentially changing the structures. In this study, nurses described interactions with patients and their families and other healthcare personnel, their strategies for managing interactions and rationales behind their selected strategy.

DESIGN

This study employed a qualitative, explorative approach using structuration theory.

METHODS

In 2011, 42 internationally educated and 40 USA-educated nurses practising in two urban hospitals in the southeastern USA were interviewed about their experiences in the workplace. Forty-one nurses were re-interviewed to explore the issues raised in the preliminary round: 21 internationally educated and 20 USA. Transcripts were analysed using the constant comparative method.

FINDINGS

Although internationally educated nurses experienced more explicit discrimination, all nurses experienced discrimination from their patients, their nurse colleagues and/or other hospital personnel. Internationally educated nurses and USA nurses shared similar coping strategies.

CONCLUSION

The prevalence of nurses' experiences of discrimination suggests that healthcare institutions need to strengthen policies to effectively address this harmful practice. More research is needed about discrimination against nurses in the workplace because discrimination may have serious psychological effects that impact nurse retention and the quality of patient care.

The downward occupational mobility of internationally educated nurses to domestic workers

Despite the fact that there is unmet demand for nurses in health services around the world, some nurses migrate to destination countries to work as domestic workers. According to the literature, these nurses experience contradictions in class mobility and are at increased risk of exploitation and abuse. This article presents a critical discussion of the migration of nurses as domestic workers using the concept of 'global care chain'. Although several scholars have used the concept of global care chains to illustrate south to north migration of domestic workers and nurses, there is a paucity of literature on the migration of nurses to destination countries as domestic workers. The migration of nurses to destination countries as domestic workers involves the extraction of reproductive and skilled care labor without adequate compensatory mechanisms to such skilled nurses. Using the case of the Canadian Live-in Caregiver Program, the study illustrates how the global movement of internationally educated nurses as migrant domestic workers reinforces inequities that are structured along the power gradient of gender, class, race, nationality, and ethnicity, especially within an era of global nursing shortage.

The impact of supervisor-nurse relationships, patient role clarity, and autonomy upon job satisfaction: Public and private sector nurses

In the Australian healthcare sector, many changes in the public sector have affected nurse management and thereby, nurses. Yet it is unclear whether such efficiency measures, based on private sector business models, have impacted private sector nurses in similar ways. This paper examines four important issues for nurses: supervisor–subordinate relationships; perceptions of autonomy; role clarity in relation to patients; and job satisfaction. The paper uses an embedded mixed methods research design to examine the four issues and then compares similarities and differences between public and private sector nurses. The findings suggest supervisor–subordinate relationships, patient role clarity and autonomy significantly predict job satisfaction. The private sector nurses reported more satisfaction than public sector nurses with their supervisor–subordinate relationships, plus higher perceptions of patient role clarity and autonomy, and hence, higher levels of job satisfaction. The findings raise questions about whether present management practices (especially public sector) optimise service delivery productivity.

The transitioning experiences of internationally-educated nurses into a Canadian health care system: A focused ethnography

Background

Beyond well-documented credentialing issues, internationally-educated nurses (IENs) may need considerable support in transitioning into new social and health care environments. This study was undertaken to gain an understanding of transitioning experiences of IENs upon relocation to Canada, while creating policy and practice recommendations applicable globally for improving the quality of transitioning and the retention of IENs.

Methods

A focused ethnography of newly-recruited IENs was conducted, using individual semi-structured interviews at both one-to-three months (Phase 1) and nine-to-twelve months post-relocation (Phase 2). A purposive sample of IENs was recruited during their orientation at a local college, to a health authority within western Canada which had recruited them for employment throughout the region. The interviews were recorded and transcribed, and data was managed using qualitative analytical software. Data analysis was informed by Roper and Shapira's framework for focused ethnography.

Results

Twenty three IENs consented to participate in 31 interviews. All IENs which indicated interest during their orientation sessions consented to the interviews, yet 14 did not complete the Phase 2 interview due to reorganization of health services and relocation. The ethno-culturally diverse group had an average age of 36.4 years, were primarily educated to first degree level or higher, and were largely (under) employed as "Graduate Nurses". Many IENs reported negative experiences related to their work contract and overall support upon arrival. There were striking differences in nursing practice and some experiences of perceived discrimination. The primary area of discontentment was the apparent communication breakdown at the recruitment stage with subsequent discrepancy in expected professional role and financial reimbursement.

Conclusions

Explicit and clear communication is needed between employers and recruitment agencies to avoid employment contract misunderstandings and to enable clear interpretation of the credentialing processes. Pre-arrival orientation of IENs including health care communications should be encouraged and supported by the recruiting institution. Moreover, employers should provide more structured and comprehensive workplace orientation to IENs with consistent preceptorship. Similar to findings of many other studies, diversity should be valued and incorporated into the professional culture by nurse managers.

Mentoring overseas nurses: barriers to effective and non-discriminatory mentoring practices

In this article it is argued that there are barriers to effective and non-discriminatory practice when mentoring overseas nurses within the National Health Service (NHS) and the care home sector. These include a lack of awareness about how cultural differences affect mentoring and learning for overseas nurses during their period of supervised practice prior to registration with the UK Nursing and Midwifery Council. These barriers may demonstrate a lack of effective teaching of ethical practice in the context of cultural diversity in health care. This argument is supported by empirical data from a national study. Interviews were undertaken with 93 overseas nurses and 24 national and 13 local managers and mentors from six research sites involving UK health care employers in the NHS and independent sectors in different regions of the UK. The data collected showed that overseas nurses are discriminated against in their learning by poor mentoring practices; equally, from these data, it appears that mentors are ill-equipped by existing mentor preparation programmes to mentor overseas-trained nurses from culturally diverse backgrounds. Recommendations are made for improving mentoring programmes to address mentors' ability to facilitate learning in a culturally diverse workplace and thereby improve overseas nurses' experiences of their supervised practice.

The Australian Labor Market for Medical Practitioners and Nurses: Training, Migration and Policy Issues

Australia has a long history of migration of medical practitioners and nurses. This paper will provide an overview of the current situation regarding the supply of and demand for doctors and nurses and Australia's immigration policies and regulatory framework. Trends in training numbers and the relationship to demand will be analyzed and it will be shown that a continuation of widespread shortages can be expected.

In recent years, Australia has been the forerunner, among Organisation for Economic Cooperation and Development countries, in its overt policy initiatives to attract overseas-trained doctors. It has shown little concern for the negative consequences on some sending countries that lose their doctors and nurses. Also, it has not entered into the spirit of international attempts to try to ameliorate the potential effects of developing-to-developed country health professional migration and trade, where there are negative consequences for the sending country. It will be argued that Australia could become a better global “citizen.”

Migration of nurses in Australia: where and why?

The Australian health care workforce has benefited from an increasing migration of nurses over the past decades. The nursing profession is the largest single health profession, making up over half of the Australian health care workforce. Migration of nurses into the Australian nursing workforce impacts significantly on the size of the workforce and the capacity to provide health care to the Australian multicultural community. Migration of nurses plays an important role in providing a solution to the ongoing challenges of workforce attraction and retention, hence an understanding of the factors contributing to nurse migration is important. This paper will critically analyse factors reported to impact on migration of nurses to Australia, in particular in relation to: (1) globalisation; (2) Australian society and nursing workforce; and (3) personal reasons. The current and potential implications of nurse migration are not limited to the Australian health care workforce, but also extend to political, socioeconomic and other aspects in Australia.

Overseas nurses in the National Health Service: a process of deskilling

AIMS AND OBJECTIVES

This paper shows that overseas nurses (OSN) recruited to UK hospital trusts become deskilled in technical aspects of clinical practice.

BACKGROUND

Existing research reports that many newly recruited OSN are prevented from using technical skills acquired in training abroad, to the detriment of the National Health Service (NHS) and the concern of the nurses themselves.

DESIGN

The author conducted case study work in three NHS hospital trusts in the northwest of England. The findings reported are part of a wider investigation into the assimilation(1) of OSN from the Philippines, India and Spain into NHS hospitals. Semi-structured interviews were undertaken with members of four groups of actors: managers, OSN, home nurses (HN) and mentors, which were analysed thematically. Results. The research confirms the finding that many OSN are prevented from using technical skills in the UK, but also suggests reasons why this is so. The finding of deskilling emerged strongly in all three cases and is singled out for discussion in this paper.

CONCLUSIONS

The experience of OSN highlights ambiguity surrounding the role of the nurse in British hospitals. This arises partly because OSN tend to be recruited to the bottom grades of nursing in the NHS, where their technical skills are underused.

RELEVANCE TO CLINICAL PRACTICE

Segmentation within the nursing hierarchy contributes to the conflicting messages and mismatch of expectations experienced by nurses at the ward level, regarding the role of the nurse.

International nurse migration: impacts on New Zealand

As a source and destination country, nurse flows in and out of New Zealand (NZ) are examined to determine impacts and regional contexts. A descriptive statistics method was used to analyze secondary data on nurses added to the register, NZ nurse qualifications verified by overseas authorities, nursing workforce data, and census data. It found that international movement of nurses was minimal during the 1990s, but from 2001 a sharp jump in the verification of NZ-registered nurses (RNs) by overseas authorities coincided with an equivalent increase in international RNs (IRNs) added to the NZ nursing register-a pattern that has been sustained to the present. Movement of NZ RNs to Australia is expedited by the Trans-Tasman Agreement, whereas entry of IRNs to NZ is facilitated by nursing being an identified Priority Occupation. Future research needs to consider health system and nurse workforce contexts and take a regional perspective on migration patterns.

Strangers in strange lands: a metasynthesis of lived experiences of immigrant asian nurses working in Western countries

Nurses from Asian countries make up the majority of immigrant nurses globally. Although there are a limited number of studies on the lived experiences of Asian nurses working in Western countries, the development of nursing science will be impeded if the rich understanding gleaned from these studies is not synthesized. Using Noblit and Hare's (Meta-ethnography: Synthesizing Qualitative Studies. Newbury Park, Calif: Sage; 1988) procedures, a metasynthesis was conducted on 14 studies that met preset selection criteria. Four overarching themes emerged: (a) communication as a daunting challenge; (b) differences in nursing practice; (c) marginalization, discrimination, and exploitation; and (d) cultural differences. Based on the metasynthesis, a large narrative and expanded interpretation was constructed and implications for nursing knowledge development, clinical practice, and policy making are elaborated.

Nurses on the move: a global overview

OBJECTIVE

To look at nurse migration flows in the light of national nursing workforce imbalances, examine factors that encourage or inhibit nurse mobility, and explore the potential benefits of circular migration.

PRINCIPAL FINDINGS

The number of international migrants has doubled since 1970 and nurses are increasingly part of the migratory stream. Critical nursing shortages in industrialized countries are generating a demand that is fueling energetic international recruitment campaigns. Structural adjustments in the developing countries have created severe workforce imbalances and shortfalls often coexist with large numbers of unemployed health professionals. A nurse's motivation to migrate is multifactorial, not limited to financial incentives, and barriers exist that discourage or slow the migration process. The migration flows vary in direction and magnitude over time, responding to socioeconomic factors present in source and destination countries. The dearth of data on which to develop international health human resource policy remains. There is growing recognition, however, that migration will continue and that temporary migration will be a focus of attention in the years to come.

CONCLUSIONS

Today's search for labor is a highly organized global hunt for talent that includes nurses. International migration is a symptom of the larger systemic problems that make nurses leave their jobs. Nurse mobility becomes a major issue only in a context of migrant exploitation or nursing shortage. Injecting migrant nurses into dysfunctional health systems-ones that are not capable of attracting and retaining staff domestically-will not solve the nursing shortage.

Working with a culturally and linguistically diverse (CALD) group of nurses

The Australian health care system exists within a particular sociopolitical environment which characterises its modus operandi and thus, the patient's and health professional's experiences of the system. Consumers' experiences are affected by their race, age, gender, ethnicity and class, and their relationships with health care staff. Health staff's experiences are largely affected by the interplay of the various health professions, manifested as power relations. This is particularly notable in the case of overseas qualified nurses (OQNs). With the growing reliance on, and acceptance of OQNs in Australia, the issue of their access to positions of power within the health system is worthy of analysis. This paper aims to provide a critical examination of the issues and challenges relating to the employment of OQNs within Australia and international contexts, strategies developed to enhance their employment experiences within the Australian health care system and their opportunities to contribute to the development of contemporary Australian nursing practice.

Patient dependency in the emergency department (ED): Reliability and validity of the Jones Dependency Tool (JDT)

BACKGROUND

Rising patient demand in emergency departments is an international problem. Patient dependency (the degree of nursing care required) has major implications for nursing. Nurse skill mix and staffing levels can be addressed more effectively when dependency can be measured. A valid and reliable method of determining patient dependency in the emergency department in the United Kingdom is required.

AIM

To test the validity, reliability and generalisability of the Jones Dependency Tool.

METHODS

Six emergency departments across England were included. The sample was 140 adult patients from each site (n=840). Information was collected by nurses on: demographics, triage, chief complaint, vital clinical signs, nurse's own subjective rating of patient dependency, Jones Dependency Tool ratings and a comparative tool ratings. For a sub-sample of 40 patients, observation data were collected.

RESULTS

There was a highly significant correlation between the Jones Dependency Tool scores and the nurses' subjective ratings of patient dependency (R=0.786,P<0.001). There was a significant correlation between triage rating and Jones Dependency Tool scores (R=0.58,P<0.001). The higher the dependency, the higher the proportion of patients with abnormal pulse rates (chi2=7.45,df=1,P=0.006), abnormal respiratory rates (chi2=15.683,df=1,P<0.001) and abnormal oxygen saturation (chi2=15.583,df=1,P<0.001). The higher the amount of time spent by nurses in direct care of patients the higher the patient's level of dependency (R=0,72,P<0.001). Length of time spent by nurses with patients was also significantly and positively correlated with the nurses' subjective ratings of patient dependency (R=0.49,P=0.001). There was a positive and significant correlation between Jones Dependency Tool scores and comparator scores (R=0.726,P<0.001). There was a good correlation between JDT scores measured over time (kappa=0.68) and good inter-rater reliability (kappa=0.75).

CONCLUSIONS

The Jones Dependency Tool can be recommended as a valid and reliable tool for the measurement of patient dependency in the emergency department.

Support for overseas qualified nurses in adjusting to Australian nursing practice: a systematic review

OBJECTIVES

The objective of the review was to summarise the best available evidence supporting overseas nurses' adjustment to Australian nursing practice. The specific review question was: what supportive interventions assist overseas nurses to adjust to Australian nursing practice?

INCLUSION CRITERIA

The review considered qualitative and quantitative papers that addressed adjustment issues of overseas qualified nurses coming and working in Australia. The types of participants were nurses who have received basic nursing education outside Australian, and either nurses who already registered and were working as nurses in Australia or nurses who were undertaking courses required for registration in Australia. Interventions of interest included creating positive work and educational environments that support overseas qualified overseas nurses' adjustment to nursing practice in Australia.

SEARCH STRATEGY

The search strategy sought to find both published and unpublished papers in English language. The search was performed using the following databases: Medline, CINAHL, ERIC, AUSTRUM, APAIS, Sociological Abstract, ProQuest, Dissertation Abstract. In addition, the reference lists and bibliographies of the articles were also hand-searched to identify other studies. Relevant worldwide websites were also searched.

METHODOLOGICAL QUALITY

Each paper was assessed by two reviewers for methodological quality prior to inclusion in the review using a critical appraisal instrument from Qualitative Assessment and Review Instrument (QARI) software developed by the Joanna Briggs Institute (JBI).

RESULTS

A total of 12 papers, qualitative, quantitative and textual in nature, were included in the review. Sixty-four papers were identified and 52 papers were excluded as they did not meet the inclusion criteria. There were: three papers utilising qualitative methodology (two phenomenology, one grounded theory), three program evaluation reports, two descriptive studies, and four expert opinions being included. Findings from two qualitative studies utilising a phenomenological approach were extracted and meta-synthesised using JBI-QARI. Two syntheses were derived: (i) overseas nurses find entry into Australian culture very difficult; and (ii) overseas nurses who feel lonely, isolated or 'outsiders' experience difficulty in settling in to nursing in Australia. Findings from other papers were discussed in narrative form.

CONCLUSION

The clash of cultures between overseas nurses and the dominant Australian culture should be addressed in a transition program. If strategies to assist overseas nurses to establish informal networks of friends and professional colleagues are in place, the transition to becoming effective practitioners could be greatly enhanced.

Overcoming strangeness and communication barriers: a phenomenological study of becoming a foreign nurse

BACKGROUND

This paper presents a study that explored the lived experience of foreign nurses working at hospitals in Iceland.

AIM

The aim was to generate an understanding of this experience both for local and international purposes.

METHOD

The methodology that guided the study was the Vancouver school of doing phenomenology. Sampling was purposeful and consisted of 11 registered nurse from seven countries. The data were collected in dialogues; the analyses were thematic.

FINDINGS

The findings are presented in five main themes that describe the essence of the experience with the overall theme of 'Growing through experiencing strangeness and communication barriers'. The first theme portrays how the nurses met and tackled the multiple initial challenges. One of the challenges, described in the second theme, was becoming outsiders and needing to be let in. The third theme explores the language barrier the nurses encountered and the fourth theme the different work culture. The fifth then illuminates how the nurses finally overcame these challenges and won through.

CONCLUSION

The findings and their international context suggest the importance of language for personal and professional well-being and how language and culture are inseparable entities.