Original Research: Nurses' Experiences with Racial, Ethnic, Cultural, and Religious Discrimination in the Workplace: A Qualitative Study

BACKGROUND

As the health care workforce diversifies, understanding and addressing the lived experiences of health care professionals facing prejudice and discrimination becomes increasingly important. Previous studies have focused on physicians and medical trainees, but there remains a dearth of research exploring nurses' experiences-even though nurses make up the largest sector of the nation's health care workforce.

OBJECTIVE

This qualitative study explored nurses' experiences of personally mediated workplace discrimination based on race, ethnicity, culture, or religion.

METHODS

We conducted in-depth interviews with a convenience sample of 15 RNs at one academic medical center. Using an inductive thematic analysis approach, we identified several themes emerging from RNs' experiences and responses to a discriminatory event ("encounter"). Themes were grouped across three phases: pre-encounter, encounter, and post-encounter.

RESULTS

Participants reported wide-ranging experiences, from insensitive joking to overt exclusion, coming from various people including patients, patients' family members, colleagues, and physicians. For many, discrimination was cumulative: similar encounters occurred outside the workplace as well as within the clinical setting, often repeatedly, and were influenced by the sociopolitical context. Participants reported a variety of responses, including emotional reactions such as shock, fear of retaliation, and frustration at being expected to represent one's identity group. Silence or inaction predominated bystander and supervisor responses. Although the encounters themselves were fleeting, their impact was enduring. Early-career encounters were most challenging, and participants grappled internally with lasting effects for years. Long-term effects included avoidance of perpetrators, disconnection from colleagues and their own professional role, and leaving the workplace.

CONCLUSIONS

The findings illuminate nurses' experiences with racial, ethnic, cultural, and religious discrimination in the workplace. Understanding how such discrimination affects nurses is critical to developing effective responses to encounters, creating safer workplaces, and promoting equity within the profession.

Three paths to a Swedish nursing license: Two for internationally educated nurses and one for regular nursing students - A cross-sectional study of self-rated professional competence, self-efficacy, and thriving

BACKGROUND

Bridging programs are offered to support migrated nurses, but in some countries, nurses can also choose to validate their nursing competence. Thus far, little is known about how migrated nurses estimate their competence when they are about to enter working life in a new country and how this differs from regular nursing students.

OBJECTIVE

To compare two groups of internationally educated nurses' - those from bridging programs and those who chose validation - and one group of regular nursing students' self-rated professional competence when they are about to start working as registered nurses. The hypotheses were: 1) internationally educated nurses rate their competence higher than regular nursing students and 2) those from bridging programs rate their competence higher than those who chose validation. In addition, the aim was to compare the groups' self-efficacy and thriving.

DESIGN

A cross-sectional, comparative design.

SETTINGS

Five universities in Sweden.

PARTICIPANTS

Nurses educated in non-European countries from a bridging program (n = 128, response rate 79.0 %) or validation process (n = 61, response rate 59.2 %) and students graduating from the regular nursing program (n = 213, response rate 68.3 %).

METHODS

Data were collected with coded questionnaires (paper or online) between 2019 and 2021 and analyzed using non-parametric tests, e.g., Kruskal-Wallis.

RESULTS

Both groups of internationally educated nurses had higher median scores on total nursing competence (both groups p < 0.001), general self-efficacy (bridging programs p < 0.001, validation p = 0.020), and total thriving (bridging programs p < 0.001, validation p = 0.012) than regular nursing students did. However, comparing the groups of internationally educated nurses showed no significant differences.

CONCLUSION

Internationally educated nurses rated their competence high but with differences within the groups for different competence areas. More research is needed to investigate whether the different paths are important for nurses' competence later in working life, and some of the competence areas might need extra attention when nurses start working.

African born black nurses' perception of their U.S. work environment: Race matters

BACKGROUND

Healthy work environment is essential to patients' safety, staff recruitment, retention, and organization's financial viability. It is imperative to examine, understand and mitigate any and all factors that may contribute to unhealthy work environment.

PURPOSE

This study aimed to describe how African-born Black nurses felt their race affected their experience of the work environment and whether these experiences contributed to perceptions of unhealthy work environments.

METHOD

Thematic analysis was performed on data obtained from unstructured interviews of 17 African born Black nurses in this qualitative descriptive study.

FINDINGS

Seven themes emerged from the study: disregard for personhood, poor communication, democratic disqualification, lack of recognition, missing authentic leadership, attrition, and finding control.

DISCUSSION

The finding suggests African born Black nurses' experiences are uniquely and qualitatively different from that of their American born counterparts. Creating healthy work environment require authentic nurse leaders who can influence and support others in its achievement.

Experiences of nurses educated outside the European Union of a Swedish bridging program and the program's role in their integration into the nursing profession: a qualitative interview study

BACKGROUND

Countries all over the world are experiencing a shortage of registered nurses (RNs). Therefore, some countries, including Sweden, have tried to solve this by recruiting internationally educated nurses (IENs). Countries offer bridging programs as educational support to qualify IENs for nursing work in the destination country. However, there is little research on IENs' experiences of bridging programs in European countries and how these programs facilitate their integration into the world of work and their new society. The aim of this study is to explore the experiences of nurses, originally educated outside the EU (European Union)/EES, of the Swedish bridging program and of the program's role in facilitating their integration into the nursing profession in Sweden.

METHODS

A qualitative descriptive design was used to explore the topic based on 11 informants' perspectives and experiences. Purposive sampling was used to recruit participants at one university in Sweden. Data were collected by individual interviews using a semi- structured interview guide during the year 2019 and were analysed using an interpretative thematic approach.

RESULTS

Two main themes emerged from the analysis: 1) Return to nursing, and 2) The bridging program as a tool for transition to nursing in Sweden. The first theme includes conditions and experiences such as personal motivation and determination, and support from others that the participants described as important in order to achieve the goal of re-establishing themselves as registered nurses in Sweden. Furthermore, the second theme describes the participants' experiences of the bridging program as mostly positive because it led to new learning and achievements that were valuable for the transition to nursing in Sweden; however, the participants also emphasised the challenges of their transition into the nursing profession, which were related to instances of misrecognition of their professional competence and the uncertain outcome of the program.

CONCLUSIONS

This study found that the bridging program facilitated integration into the nursing profession for nurses educated outside the EU/EES, especially knowledge gained in clinical-based training. Thus, it is important to recognise and value the IENs' experience and previous knowledge and training when developing the bridging program's curriculum.

Discourse of race and racism in nursing: An integrative review of literature

BACKGROUND

Race is a barrier and source of inequality affecting ethnic minorities in nursing practice and education.

PURPOSE

This integrative review study aimed to determine whether racism and institutionalized racism are explicitly named in the titles and abstracts of peer-reviewed publications on nursing education, leadership, and the nursing profession, and to explore the depth of discussion of racialized concepts in peer-reviewed nursing literature.

METHOD

Whittemore and Knafl's integrative review approach was used to review 23 studies published in nursing journals published from 2008 to 2020.

FINDINGS

Four themes were extracted: the context of racism discussions in the literature; consequences of experiences of racism; emotional and physical effects of racism on nurses and students of color; and scholars' recommendations.

DISCUSSION

Nursing must start to openly acknowledge the issue of racism within the profession, and to address it by providing safe spaces for authentic dialogue in academic and practice settings.

Barriers to career advancement in the nursing profession: Perceptions of Black nurses in the United States

Background

There is a paucity of Black and minority ethnic group nurse leaders and faculty in the nursing profession, even though the overall number of nurses within this demographic has increased. This study aimed to examine Black nurses' perceptions of the barriers to career advancement in nursing profession in the United States.

Procedure

Participants included 30 Black nurses aged 25 to 65 from health care settings across five US states recruited through purposive sampling. The study used a focused ethnographic design with semi‐structured interviews to elicit responses about participants perceptions and experiences of seeking leadership and faculty positions.

Results

Thematic analysis revealed seven main themes: maintaining white comfort, distrust, no one like me, paving the way, worthy of representation, leadership role not expected of Black nurses, and an advanced degree does not equal advanced opportunities.

Conclusion

The findings suggest that Black nurses face significant challenges in entering leadership or faculty positions. They face racial discrimination and lack access to mentorship and support which discourages sufficiently qualified and experienced nurses from applying for high‐level positions. Ensuring all nurses are afforded equal opportunity for career advancement is essential for the nursing profession's continued growth.

International Operating Room Nurses' Challenges in Providing Person-Centered Care During Organ Procurement Surgery

PURPOSE

International operating room (OR) nurses assisting in organ procurement surgery believe that it is their responsibility to provide continued and comprehensive person-centered care to donors through their surgical journeys. This study explored the challenges these nurses encountered in providing person-centered care during surgical care stages of organ procurement surgery in Australia.

DESIGN

The phenomenological approach by van Manen was used to portray 18 OR nurses' organ procurement experiences.

METHODS

Semistructured interview data were transcribed verbatim.

FINDINGS

International OR nurses encountered challenges in providing person-centered care during organ procurement surgery, which were described in different surgical care stages. They faced emotional challenges in handling family grief and clinical challenges in interacting with other health professionals. These challenges could cause personal distress and affect their professional practice.

CONCLUSIONS

Recognizing and managing these challenges is essential for supporting staff and providing quality person-centered care to deceased donors and their families during the organ procurement process.

Discrimination in In-Patient Geriatric Care: A Qualitative Study on the Experiences of Employees with a Turkish Migration Background

In most studies, nurses with a migrant background report experiences of interpersonal discrimination. These often occur in interaction with those in need of care. However, in Germany this topic has remained largely unexplored, although a large proportion of the employees in geriatric care have a migration background. The aim of the study was to investigate whether care workers with Turkish migration background in in-patient geriatric care are exposed to discrimination from residents. Furthermore, the reasons for discrimination, handling of discrimination and recommendations for in-patient geriatric facilities to avoid/reduce discrimination were examined. In a qualitative, explorative study, 24 employees with Turkish migrant background working in in-patient geriatric care were interviewed in 2017. The semi-structured interviews were evaluated using a qualitative content analysis according to Mayring. The majority (N = 20) experienced or observed discrimination. This occurred mainly in the form of xenophobic insults and rejections. They perceived visible traits (dark hair and eye color, clothing) as potential reasons. To deal with the discrimination, most of them temporarily left the scene. They recommend that institutions should primarily make the diversity of the workforce transparent to avoid/reduce discrimination. More research is needed about discrimination against care workers with migration background because discrimination may have serious psychological effects that impact employee retention and the quality of care.

Caribbean nurse migration-a scoping review

BACKGROUND

The migration of Caribbean nurses, particularly to developed countries such as Canada, the United States, and the United Kingdom, remains a matter of concern for most countries of the region. With nursing vacancy rates averaging 40%, individual countries and the region collectively are challenged to address this issue through the development and implementation of sustainable, feasible strategies. The aim of this scoping review is to examine the amount, type, sources, distribution, and focus of the conceptual and empirical literature on the migration of Caribbean nurses, and to identify gaps in the literature.

METHODS

Identified records were selected and reviewed using Arksey and O'Malley's scoping framework. A comprehensive search was conducted of eight electronic databases and the Google search engine. Findings were summarized numerically and thematically, with themes emerging through an iterative, inductive process.

RESULTS

Much of the literature included in our study (N = 6, 33%) originated in the United States. Publications steadily increased between 2003 and 2016, and half of them (N = 9) were journal articles. Many (N = 6, 33%) of the records used quantitative methods. The themes identified were as follows: (1) migration patterns and trends; (2) post-migration experiences; (3) past and present, policies, programs, and practices; and (4) consequences of migration to donor countries. More than half (N = 11, 56%) of the literature addressed nurse migration policies, programs, or practices, either solely or in part. Several gaps were identified including the need for evaluation of the effectiveness of current nurse migration management strategies and to study policies, trends, and impacts in understudied Caribbean countries.

CONCLUSION

This review demonstrates the need for future research in key areas such as the impact of nurse migration on health systems and population health. The literature tends to focus on Caribbean countries with higher levels of nurse migration. However, data regarding this phenomenon in other Caribbean countries is needed for a more comprehensive understanding of the plight of the Caribbean region and would answer the call from the International Organization for Migration to study policies, trends, and impacts in understudied Caribbean countries.

Internationally educated nurses' and medical graduates' experiences of getting a license and practicing in Sweden - a qualitative interview study

BACKGROUND

The Swedish healthcare system has an increased need for nurses and physicians, and the number of International Educated Nurses (IENs) and International Medical Graduates (IMGs) seeking job opportunities and a license to practice in Sweden is rising. This study explored how IENs and IMGs describe their experience of getting a license to practice, their perceptions of working in Sweden and of how their intercultural competence is utilized.

METHOD

A qualitative study based on semi-structured interviews with 11 IENs and 11 IMGs. The interviews were conducted between 2015 and 2017. The data were analyzed using qualitative content analysis.

RESULTS

Three main themes were identified: 'Getting a license - a different story,' 'The work is familiar, yet a lot is new,' 'Trying to master a new language.' The time to obtain a license to practice and finding a job was shorter for IENs and IMGs coming from European countries than for those from non-European countries. Some of the experiences of getting a license to practice and of entering a new workplace in another country were the same for nurses and physicians. In general, both IENs and IMGs felt welcomed and used their intercultural competence at work. Lack of language skills was regarded as the main problem for both professions, while workplace introduction was shorter for IMGs than for IENs.

CONCLUSIONS

Problems related to language and culture are often underestimated, therefore organizations and managers employing IENs and IMGs should provide longer workplace introduction to facilitate the acculturation process. More time-efficient language courses specifically adapted to IENs and IMGs could make the transition easier and shorten the time to obtain a license to practice for both professions.

Foreign educated nurses' work experiences and patient safety-A systematic review of qualitative studies

AIM

The aim of this systematic review was to identify the evidence contributed by qualitative research studies of foreign educated nurses' work experiences in a new country and to link the results to patient safety competencies.

DESIGN

A systematic literature review of qualitative studies.

METHODS

Electronic searches in the Ovid MEDLINE, Embase, PsycINFO, Cochrane Library and Cinahl databases and additional manual searches in five scientific journals. A content analysis of 17 qualitative articles was conducted.

RESULTS

The analysis revealed one main theme: "Being an outsider at work" and two themes: "Cultural dissonance and Unfamiliar nursing practice. Two sub-themes emerged from the first theme; Loneliness and discrimination" and "Communication barriers". The second theme was based on the following two sub-themes: "Handling work-related stress" and "Role uncertainty and difficulties in decision-making". A better prepared and longer orientation period with continual clinical supervision including systematic reflection on practice experiences is needed to support foreign educated nurses in the transition period and strengthen their Patient Safety Competencies. Nurse Managers have an important role in ensuring the inclusion of foreign educated nurses and providing desirable working conditions.

Predictors of Turnover Among Asian Foreign-Educated Nurses in Their 1st Year of US Employment

OBJECTIVE

The aim of this study was to investigate factors affecting turnover of Asian foreign-educated nurses (FENs), which may lead to improvements in retention strategies.

BACKGROUND

Asian FENs working in the United States have considerable rates of turnover. Little is known about which factors are related.

METHODS

A cross-sectional design was used. A convenience sample (n = 201) of Asian FENs completed surveys by regular mail and through a website. Backward multivariable logistic regression was performed to identify factors associated with turnover in their 1st year of employment.

RESULTS

Most participants were from the Philippines and Korea. Perceived quality of orientation predicted organizational-level turnover and trended toward predicting unit-level turnover.

CONCLUSIONS

Healthcare institutions may benefit from developing organizational programs for FENs that are sensitive to their unique needs, in the interest of reducing rapid or early turnover and accompanying negative effects on hospital finances and patient care.

Double nursing degree: potentialities and challenges of an international student academic experience

Objective To share the experience of a Double Nursing degree promoted between the Nursing School of the Universidade de São Paulo and the Health Sciences Institute of the Universidade Católica Portuguesa, reflecting on the potentialities and challenges of this opportunity for graduate students. Method This is an experience report presented in chronological order and of a descriptive nature. The double degree in Nursing was accomplished over a period of 6 months in a different institution from the institution of origin. Results Among the activities developed during the Double Degree are: participating in examining boards, congresses, seminars, courses, meetings, lectures, colloquium, classes, research groups and technical visits to health services. A table presents and describes the main benefits of the experience experienced by the authors. Conclusion When well-planned and well-developed, a double degree can promote personal, cultural and professional development of the students, favoring internationalization and contributing to the qualification of graduate programs.

Experiences of Nigerian Internationally Educated Nurses Transitioning to United States Health Care Settings

Introduction: Successful transition to practice of internationally educated nurses (IENs) can critically affect quality of care. The aim of this study was to characterize the facilitators and barriers to transition of Nigerian IENs (NIENs) to the United States health care setting. Method: Using a descriptive phenomenology approach, 6 NIENs were interviewed about their transitional experiences in the United States. Thematic methods were used for data analysis. Results: The three major themes identified from the participants’ stories were “fear/anger and disappointment” (FAD), “road/journey to success/overcoming challenges” (RJO), and “moving forward” (MF). The FAD theme predominated, including experiences of racism, bullying, and inequality. The RJO theme included resilience, and the MF theme encompassed personal growth. Discussion: NIENs face personal and organizational barriers to adaptation, especially fear, anger and disappointment. Future research should seek to develop a model for optimal adaptation that focuses on improving both personal and organizational facilitators and decreasing barriers.

Internationally Educated Nurses in Transition in the United States: Challenges and Mediators

International migration has doubled worldwide since 1970, and nurses are increasingly becoming a part of this trend. In 2008, approximately 5.6% of RN positions were filled by nurses educated in other countries. One of the critical issues is the transition of these immigrated nurses to the U.S. health care system and acculturation in a new society. Continuing education is necessary to promote adjustment and provide for a successful transition while ensuring quality patient care. The life patterns model provides a framework to describe the challenges and potential mediators in the transition process. J Contin Educ Nurs. 2017;48(3):139-144.

The intersection of culture in the provision of dementia care: A systematic review

AIMS AND OBJECTIVES

To understand the intersection of healthcare professionals' and care workers' culture and their provision of person-centred care for people with dementia.

BACKGROUND

Due to the nature of global immigration and recruitment strategies, health care is provided by a culturally diverse workforce. Consequently, there is a need to understand healthcare professionals' and care workers' cultural values of illness, disease and dementia. Cultural values and beliefs regarding dementia and care of the older person differ, and currently, there is a lack of clarity regarding the intersection of culture in the provision of person-centred dementia care.

METHOD

A search of the following databases was completed: Medline, CINAHL, Psychology and Behavioural Sciences, PsycINFO and PubMed for papers published from 1st January 2006 to 31st July 2016.

RESULTS

A total of seven qualitative studies met the inclusion and exclusion criteria, all explored the impact of healthcare professionals' and care workers' culture in relation to their provision of person-centred dementia care. A meta-synthesis of the data from these studies identified four themes: cultural perceptions of dementia, illness and older people; impact of cultural perceptions on service use; acculturation of the workforce; and cross-cultural communication.

CONCLUSION

Limited evidence was found on the impact of healthcare professionals' and care workers' culture on their provision of person-centred dementia care. The intersection of culture and dementia included the understanding of dementia, care and family roles. Acculturation of migrant healthcare workers to the culture of the host country, workplace, and support with the communication was identified as necessary for the provision of person-centred dementia care.

RELEVANCE TO CLINICAL PRACTICE

Open access education and training to support communication is required, alongside the development of robust interventions to support the process of acculturation of migrant healthcare professionals and care workers to provide culturally competent person-centred dementia care.

Competence evaluation processes for nursing students abroad: Findings from an international case study

BACKGROUND

Assessing clinical competence in nursing students abroad is a challenge, and requires both methods and instruments capable of capturing the multidimensional nature of the clinical competences acquired.

OBJECTIVES

The aim of the study was to compare the clinical competence assessment processes and instruments adopted for nursing students during their clinical placement abroad.

DESIGN

A case study design was adopted in 2015.

SETTING AND PARTICIPANTS

A purposeful sample of eight nursing programmes located in seven countries (Belgium, Denmark, Greece, Norway, Poland, Portugal and Italy) were approached.

METHODS

Tools as instruments for evaluating competences developed in clinical training by international nursing students, and written procedures aimed at guiding the evaluation process, were scrutinised through a content analysis method.

FINDINGS

All clinical competence evaluation procedures and instruments used in the nursing programmes involved were provided in English. A final evaluation of the competences was expected by all nursing programmes at the end of the clinical placement, while only four provided an intermediate evaluation. Great variability emerged in the tools, with between five and 88 items included. Through content analysis, 196 items emerged, classified into 12 different core competence categories, the majority were categorised as 'Technical skills' (=60), 'Self-learning and critical thinking' (=27) and 'Nursing care process' (=25) competences. Little emphasis was given in the tools to competences involving 'Self-adaptation', 'Inter-professional skills', 'Clinical documentation', 'Managing nursing care', 'Patient communication', and 'Theory and practice integration'.

CONCLUSIONS

Institutions signing Bilateral Agreements should agree upon the competences expected from students during their clinical education abroad. The tools used in the process, as well as the role expected by the student, should also be agreed upon. Intercultural competences should be further addressed in the process of evaluation, in addition to adaptation to different settings. There is also a need to establish those competences achievable or not in the host country, aiming at increasing transparency in learning expectations and evaluation.

The continuing quest for parity: HBCU nursing students' perspectives on nursing and nursing education

The benefits of a diverse nursing workforce are well-recognized, yet, the attainment of a sustainable, competent and diverse nursing workforce continues to be a global challenge. In this qualitative study, we describe nursing students' perceptions on nursing and nursing education at a Historically Black College/University (HBCU). Focus groups were conducted with 16 graduate and undergraduate nursing students. Four themes emerged: communication, lack of resources, support systems and professional socialization. Mentoring and civility were identified as factors important to enhance a diverse workforce.

Determinants of intention to work abroad of college and specialist nursing graduates in Serbia

BACKGROUND

In a country with a poor economy and limited job opportunities, the outmigration of students is not commonly perceived as a problem but rather is perceived as a solution to the high unemployment facing young health professionals.

OBJECTIVES

Study objectives were to identify the prevalence of intention to work abroad of nursing graduates to point to the predictors of intention to work abroad and predictors of having a firm plan to work in a foreign country.

DESIGN

Descriptive study, a survey.

SETTINGS

College and specialist nursing schools, Serbia.

PARTICIPANTS

719 nursing graduates from the 2012/2013 school year.

METHODS

Voluntarily completed a questionnaire that was designed with regard to similar surveys administered in EU-candidate countries during the pre-accession period. Data were analysed with descriptive and multivariate regression analyses.

RESULTS

Almost 70% (501) of respondents indicated an intention to work abroad. Of the nurses, 13% already had established a firm plan to work abroad. Single graduates and those with a friend or relative living abroad were more likely to consider working abroad than were their counterparts (odds ratios were 2.3 and 1.7, respectively). The likelihood of considering working abroad decreased by 29% when the individuals' financial situation was improved. Factors associated with having a firm plan were previous professional experience in a foreign country, having someone abroad and financial improvement (5.4 times, 4.8 times and 2 times greater likelihood, respectively).

CONCLUSIONS

The high prevalence of intention to work abroad suggests the need to place the issue of the out-migration of nursing graduates on the policy agenda. College and specialty nursing graduates and health technicians are prepared to work abroad in search of a better quality of life, better working conditions and higher salaries.

A meta-ethnography of the acculturation and socialization experiences of migrant care workers

AIM

To report a meta-ethnography of qualitative research studies exploring the acculturation and socialization experiences of migrant care workers.

BACKGROUND

Migrant care workers are increasingly participating in health and social care in developed countries. There is a need to understand this increasingly socioculturally diversified workforce.

DATA SOURCES

A comprehensive search through 12 databases and a manual search of journals related to transculture for studies on socialization and acculturation experiences (published 1993-2013) was completed. The inclusion criteria were peer-reviewed studies on the acculturation or socialization experiences of migrant care workers published in English in any country, using a qualitative or mixed-methods approach.

DESIGN AND REVIEW METHODS

This meta-ethnography employed the seven-phase Noblit and Hare method with reciprocal translation, refutational synthesis and lines-of-argument to synthesize qualitative studies.

RESULTS

Three main themes were identified: (a) schema for the migration dream: optimism; (b) the reality of the migration dream: so close, yet so far; and (c) resilience: from chaos to order. A general framework of motivated psychosocial and behavioural adaptation was proposed. This meta-ethnography also revealed the vulnerabilities of migrant nurses in the process of acculturation and socialization.

CONCLUSIONS

The general framework of behavioural and psychosocial adaptation revealed factors that impede and facilitate behavioural and psychosocial changes. Strategies to enrich external and internal resources should be targeted at encouraging multiculturalism and at improving the psychosocial resources of migrant care workers. It is suggested that research investigating the prominence of nursing vulnerabilities be conducted.