Resilience among Internationally Educated Nurses: New Insights on

Transitions in the Work Place

NDOLO NJIE-M, RN MSCNUniversity of Ottawa’s Heart Institute

Part-Time Professor, University of Ottawa

BackgroundSignificancePurpose and ObjectiveLiterature ReviewResearch MethodologyRigorResearch FindingsDiscussions and Implications Conclusion

PRESENTATION OUTLINE

Nursing shortages in the workforce Increased international recruitment

(developed/underdeveloped) Aging nurse population Early retirement Fewer graduating nurses

Sources: Canadian Institute for Health Information, 2010; Health Canada, 2004; O’Brien-Pallas et al., 2003)

BACKGROUND

Work place challenges during transition:• Frustration• Adapting to the workforce; understanding

the ways of nursing in Canada• Accent, language barriers

BACKGROUND

Search Strategy: CINAHL, PUBMED, ERIC (2000-2011) Grey Literature:

• Nursing Associations• Reports• University Research Centers

LITERATURE REVIEW

• Three Major Themes:•Language and Communication Barriers

•Cultural Influences and Role Expectations / Licensing Pass Rates

•Marginalization

LITERATURE REVIEW

Development of new insights that describe IEN transition experience

Create support programs that will promote the overall integration of IENs

Enhance skill acquisition and reduce vulnerability to workplace adversity

SIGNIFICANCE

• Transition: An internal process individuals go through, and come to terms with, related to a new situation brought about by change

(Bridges, 2003)

• Resilience: An active process involving an individual’s ability to adjust to adversity, maintain equilibrium, retain some sense of control over their environment, and continue to move on in a positive manner

(Jackson, Firtko & Edenborough, 2007)

DEFINITIONS

• Presents the findings of a recent study that examined the transition experiences of internationally educated nurses in one region of Canada, centering on the recurring theme of resilience as a resource to facilitate transition into the workplace

PURPOSE OF PAPER

• Describe the meaning IENs ascribed to professional relationships with their nursing colleagues and other disciplinary teams during transition into their places of work

OBJECTIVE

• University of Ottawa REB

• Qualitative study

• Descriptive Phenomenology(Wojnar & Swanson, 2007)

METHODOLOGY

• Ottawa; second largest city with a higher than average immigrant population within the province of Ontario

(Statistics Canada, 2009)

• Access• Homogenous participant group (similar provincial licensing legislation)

SETTING

• Initiated through purposive sampling and facilitated through snowball sampling techniques

• RNs only in Ontario to maintain a common scope of practice

• Local nursing networks• Eleven IENs were final participants.

RECRUITMENT AND DATA COLLECTION

• Strategies: In-depth semi-structured interview (transcribed verbatim)

• Notes from follow-up discussions during data analysis and validation

• Personal research journal (audit trail)

RECRUITMENT AND DATA COLLECTION

• RN Group: Uniformity in licensure and scope of practice

• Maximum variation: ethnicity, age, place of nursing education, type and location of current nursing practice

• Data Saturation: following interviewing eleven participants

SAMPLE

• Bracketing• Data Analysis involved:

1. Recurrently reading and listening to participant narratives

2. Highlighting sections of the transcripts3. Proposing ideas about its meaning4. Clarifying and validating the proposed meanings with

IENs.5. Organizing meanings into groups of themes.• Quality Audits: reading each transcript while

simultaneously listening to audiotapes.

DATA ANALYSIS

• Eligibility criteria: • Minimum of one year and maximum of five years post-

RN licensure• Obtained their nursing education outside of Canada

• Profile:• Females• Landed immigrant status• All but one was married• Aged from 25 to 47 years old (average age 34)

CHARACTERISTICS OF STUDY PARTICIPANTS

REGION OF ORIGIN

0

1

2

3

4

5

6

Asia

USA Carribean Africa

Eastern Europe

NU

MBE

R O

F IE

Ns

AREAS OF EMPLOYMENT

INTENSIVE CARE UNIT (1)

OPERATING ROOM (2)

MED-SRG(3)

MENTAL HEALTH (2)

COMMUNITY (1)

CRITICAL CARE (2)

• RELATIONSHIP WITH COLLEAGUES ◦The majority of IENs felt their colleagues

questioned their knowledge and competence◦Overall, these attitudes either facilitated or

hindered their work relationship in a positive or negative way◦Four sub-themes (teamwork, acceptance

by staff, incivility, and proving one’s self).

FINDINGS

• “I depend on others’ personalities, some nurses become irritated if you ask questions while some are helpful. Some nurses are not very helpful and this hinders question asking. This is a problem especially on this unit where patients are unpredictable due to their mental status”.

SUB-THEME 1…TEAMWORK

• “If a nurse is busy, it hinders the quality of care patients receive; there is no –this is my load and that is yours, as it is here in Canada. If a patient needs something I take care of it. Nursing care is ongoing, if you are done, you help others willingly.”

SUB-THEME 1…TEAMWORK

• In Canada, there is no division between experienced nurses versus non-experienced nurses. There is no hierarchy, we all work together, there are OR aides here. Back home the nurses do all the jobs. Nurses have it easy here, but they still complain.”

SUB-THEME 1…TEAMWORK

• “I am a new nurse on the floor, you learn a lot from mistakes and from the mentorship of more experienced nurses and their clinical judgment, my colleagues are receptive, and I feel I am not left alone.”

SUB-THEME 2…ACCEPTANCE BY COLLEAGUES

• “Operating room nursing is not direct patient care like on the floors, you deal with colleagues, not patient care. Some words are hard to pronounce, I have a hard time spelling some drugs. The nurses are good and friendly here, they help me.”

SUB-THEME 2…ACCEPTANCE BY COLLEAGUES

• “Make the environment conducive…teach the nurses how to work with other people, it’s not easy coming to work in another country. They need to put themselves in other people’s shoes”

SUB-THEME 2…ACCEPTANCE BY COLLEAGUES

• “Sometimes they [some surgeons] are mean to me…they ask ‘are you Canadian?’ I think the hospitals should hire Canadians first. I need to learn to speak up.”

SUB-THEME 3…INCIVILITY

• “Some surgeons or anesthetists if they don’t like you, they treat you badly…they don’t talk to you, and this hinders communication.”

SUB-THEME 3…INCIVILITY

• “I don’t understand why nurses bully [their colleagues]. We need to be more patient and adjustable, I don’t take the bullying personally; I am more tolerant…it’s due to differences in situations, i.e., us coming to work here.”

SUB-THEME 3…INCIVILITY

• “Everyone has their territorial thing, before they[the Canadian trained nurses] thought I didn’t know what to do because I came from another country. I had to prove myself when you shouldn’t because the college has assessed everything. Once they see that you know what you are doing, they’ll come around after you prove yourself.”

SUB-THEME 4…PROVING ONE’S SELF

• “You have some staff who are difficult to work with and who gossip, especially about IENs; I just work hard to show them that I am capable. Nurses are harder on IENs because they feel they don’t have the same educational background as them, we wrote the same nursing exams.”

SUB-THEME 4…PROVING ONE’S SELF

• “Canadian-trained nurses have some difficulty accepting us; sometimes people underestimate us by their attitudes. Maybe because of their mental status or it’s just their personality…we are less expressive culturally, most here are expecting more in terms of expression; knowingly or unknowingly we are learning to adapt…(But) their attitudes change once they see your experience and knowledge”.

SUB-THEME 4…PROVING ONE’S SELF

• This study revealed an underlying theme of resilience as an important coping mechanism.

• Resilience was manifested over time in the IENs’ unrelenting attempts to prove their capability to provide care to patients in a Canadian context

DISCUSSION

• Demonstrates an inner strength and unwavering ability to perform well at their nursing duties in order to establish credibility among their nursing colleagues.

DISCUSSION

• Needing time to adapt • Need for Canadian-educated nurses to understand different cultural behaviors unique to IENs

• New insights on IENs personal resilience during their transition as RNs

IMPLICATIONS

• Its contribution has broadened the description of IEN transition in different clinical settings

• Highlights the value of IENs personal resilience in lowering their vulnerability levels to adversity at the workplace

IMPLICATION

• ClinicalCreate formal discussion forums

• EducationUse different cultural behaviors as clinical learning examples incorporated into undergraduate nursing education

RECOMMENDATION

AdministrationNeed for increased need for time to adapt into their new work environment during their transition period

ResearchExploring the concept of personal resilience to create a comprehensive support mechanism during transition for more decisive conclusions

RECOMMENDATION

Requires more than successfully obtaining their provincial licenses

Inclusive work environments Developing innovative ways of leveraging

and nurturing resilience among IENs during transition is vital and requires the involvement of all stakeholders

CONCLUSION

Canadian Institute for Health Information (CIHI) (2010). Regulated Nurses: Canadian Trends, 2006 to 2010.

[Online] Available at https://secure.cihi.ca/free_products/RegulatedNursesCanadianTrends2006-2010_EN.pdf

Bridges, W. (2003). Managing transitions: Making the most out of change. Cambridge: Perseus books.

Health Canada. (2004). Health human resources: Balancing supply and demand. Health policy research bulletin.

[Online] Database 8. Available from

http://www.hc-sc.gc.ca/sr-sr/pubs/hpr-rpms/bull/2004-8-hhr-rhs/index-eng.php.

Jackson, D., Firtko, A., and Edenborough, M. (2007). Personal resilience as a strategy for surviving and

thriving in the face of workplace adversity: a literature review. Journal of Advanced Nursing, 60 (1): 1 - 9.

O’Brien-Pallas, L., Alksnis, C., Wang, S., Birch, S., Tomblin Murphy, G., Roy, F.A., & Sajan, P. (2003) Early

retirement among RNs: Estimating the Size of the Problem in Canada. Hospital Quarterly, 7 (1): 1– 8.

Statistics Canada. (2009). Table 4 Summary table of peer groups and principal characteristics. Archived 2012-12-13. Retrieved

from http://www.statcan.gc.ca/pub/82-221-x/2012001/regions/hrt4-eng.htm

Wojnar, D., & Swanson, K. (2007). Phenomenology: An exploration. Journal of Holistic Nursing, 25, 172–182.

REFERENCES