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The transition to practice in Canada : the experiences of nurses educated outside of Canada Nelson, Lori Jane 2005

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T H E T R A N S I T I O N T O P R A C T I C E I N C A N A D A : T H E E X P E R I E N C E S O F N U R S E S E D U C A T E D O U T S I D E O F C A N A D A by L O R I J A N E N E L S O N B . S . N . , The Un ive r s i t y o f B r i t i s h C o l u m b i a , 1996 A T H E S I S S U B M I T T E D I N P A R T I A L F U L F I L L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R O F S C I E N C E i n T H E F A C U L T Y O F G R A D U A T E S T U D I E S N u r s i n g T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A A p r i l 2005 © L o r i Jane N e l s o n , 2005 Abstract T o address the current and predicted nurse shortage i n Canada many organizat ions are recrui t ing nurses f rom abroad (Canadian Nurses A s s o c i a t i o n [ C N A ] , 2002b). It is projected that i n order to meet future demand estimates, an increasing number o f nurses educated outside o f Canada w i l l need to be recruited. A c r o s s Canada i n 2002, there were more than 1800 new nurse registrants f rom other countries, a significant increase f rom the 1,072 w h o registered i n 2000 (Bar ry , Sweatman, L i t t l e , & D a v i e s , 2003; C N A , 2002b) . The transit ion to practice engages nurses i n a complex , chal lenging process o f adaptation. The purpose o f this study is to describe and understand the experiences o f nurses, educated i n a country other than Canada , as they make the transi t ion to practice w i t h i n the Canad ian health care system. A qualitative design us ing ethnographic methods o f data co l lec t ion , namely in-depth interviews, was used i n this study. F o r the purposes o f in-depth in te rv iewing it was important that the participants were able to provide a r i c h descr ipt ion o f their transit ion experience to pract ic ing i n Canada . F o r this reason purposeful sampl ing was u t i l i zed to select the 13 participants. Participants inc lude 11 w o m e n and 2 m e n w h o had m o v e d to Canada i n the past 4 years f rom Aus t ra l i a , B r i t a i n , and the Ph i l ipp ines . Seven o f the participants were marr ied and five had chi ldren. There were s ix nurses w i t h w o r k permits, another s ix have landed immigrant status and one is a permanent resident. M o s t were employed ful l - t ime i n acute care; one nurse was unemployed at the t ime o f the interview. The participants ' descriptions o f the experiences o f m a k i n g the transi t ion to practice i n Canada led to a better understanding o f w h y nurses choose to move , misconcept ions that occur related to relocat ion, and challenges nurses experience i n adapting to Canada. Other themes identif ied i n the f indings include: isolat ion, professional support, quest ioning one 's o w n competence, feel ing valued, and the s ignif icance o f w o r k and soc ia l support networks. Recommendat ions identif ied f rom the f indings relate to government sectors o f human resources, customs, and immigra t ion , regulatory bodies, health care organizations, future immigrant nurses, and research. i v Table o f Contents Abst rac t i i L i s t o f Table v i i Chapter 1: Introduction 1 P r o b l e m Statement 3 Purpose 4 Chapter 2 : Literature R e v i e w 5 Stressors o f M i g r a t i o n 6 L o s s 6 Effect o f Stressors 7 M i g r a t i o n and W o m e n 8 E m p l o y m e n t 8 Language 9 S o c i a l Support 9 M i g r a t i o n and Nurses 10 N o v e l t y 10 D i s c r i m i n a t i o n 12 W o r k Env i ronment 12 Regulat ions for recruitment and registration 13 Support Strategies 15 Summary o f the State o f K n o w l e d g e 17 Research Ques t ion 17 Chapter 3: Me thods 18 V Ethnographic M e t h o d s 18 Sample 1 9 Descr ip t ion o f the Part icipants 23 D a t a C o l l e c t i o n 25 A n a l y s i s 26 E th i ca l Considerat ions 27 Chapter 4: F ind ings 29 Reason to M o v e 29 Re loca t i on Misconcep t ions 33 Chal lenges i n A d a p t i n g to Canada 39 Isolat ion 47 Professional Support 51 Ques t ioning One ' s Competence 56 Fee l i ng V a l u e d 63 W o r k Support N e t w o r k 6 6 Soc ia l Support N e t w o r k 73 Summary 77 Chapter 5: Summary o f F ind ings , Conc lus ions , and Recommendat ions 78 Summary o f F ind ings 79 Reason to M o v e 79 Re loca t i on Misconcep t ions 8 0 Chal lenges i n A d a p t i n g to Canada 80 Isolat ion 81 v i Professional Support 82 Ques t ioning O n e ' s Competence 85 Fee l ing V a l u e d 85 W o r k Support N e t w o r k 85 Soc ia l Support N e t w o r k 89 Conc lus ions 89 Recommendat ions 90 Recommendat ions for Government 90 Recommendat ions for Regula tory B o d i e s 91 Recommendat ions for Hea l th Care Organizat ions 92 Recommendat ions for Future Immigrant Nurses 93 Recommendat ions for Research 93 Summary 95 References 96 Appendices A p p e n d i x A : Summary o f Literature R e v i e w e d 103 A p p e n d i x B : Information Letter 107 A p p e n d i x C : Part icipant Recrui tment Adver t i sement 109 A p p e n d i x D : Nurse Demograph ic F o r m 110 A p p e n d i x E : Interview Quest ions I l l A p p e n d i x F : T i m e l i n e 112 A p p e n d i x G : Informed Consent F o r m 113 L i s t o f Table Table 1: Demograph ic Summary o f the Participants Trans i t ion to Pract ice 1 < Chapter 1 > Introduction T o address the current and predicted nurse shortage i n Canada many organizat ions are recrui t ing nurses f rom abroad (Canadian Nurses A s s o c i a t i o n [ C N A ] , 2002b). N e a r l y h a l f o f the registered nurses i n B r i t i s h C o l u m b i a ( B C ) received their educat ion outside o f the province (Branswe l l , 2003). In 2000, o f the 948 new registrants i n B C more than 19% were f rom other countries, w h i c h is a 10% increase over 1999. The majori ty o f these n e w registrants came f rom the Ph i l ipp ines (n = 97), f o l l o w e d by B r i t a i n (n = 23), the U n i t e d States (n = 19), and A u s t r a l i a (n = 17) (Registered Nurses A s s o c i a t i o n o f B r i t i s h C o l u m b i a [ R N A B C ] , 2001). Ry ten (1997) projects that i n order to meet future demand estimates, an increasing number o f nurses educated outside o f Canada w i l l need to be recruited. M o r e recent projections for the addi t ion o f nurses between 2001 and 2010 show that the recruitment o f nurses educated outside o f Canada is expected to add 11,700 new nurses by 2011 ( C N A , 2002b) . A l t h o u g h one m a y project the need for nurses educated outside o f Canada, the actual number o f additions o f these nurses is very dif f icul t to project due to the statistical irregularities o f their c o m m e n c i n g nurs ing practice i n Canada ( C N A , 2002b) . Some immigrants may decide not to practice as a nurse i n Canada w h i l e others may not successfully pass the registration exam. A d d i n g to the Canad ian supply o f nurses is not direct ly related to attracting more immigrants w h o are nurses, but more about h o w many w i l l actually become registered nurses when i n Canada. A c r o s s Canada i n 2002, there were more than 1800 new nurse registrants f rom other countries, a significant increase from the 1,072 who registered i n 2000 (Bar ry , Sweatman, L i t t l e , & Dav ie s , 2003; C N A , 2002b). A c c o r d i n g Trans i t ion to Pract ice 2 to the C N A (2002b), nurses w h o immigrate are t yp i ca l ly between the ages o f 35 to 44 w h e n they start pract ic ing i n Canada. Consequent ly , their nurs ing careers are shorter, m a k i n g a successful transit ion into the Canad ian health care system essential. Y e t nurses w h o have emigrated f rom other countries to w o r k i n Canada often share stories o f the challenges they experienced i n m a k i n g the transit ion into a new health care system. Often their self-confidence and be l i e f i n their ab i l i ty as a nurse is shattered w h e n they beg in to practice i n a new setting (Pilette, 1989). One is compe l l ed to quest ion what it is about such a transfer f rom one country to another w i t h i n the profession o f nurs ing that creates immense challenges and potential ly devastating effects, and h o w nurses educated outside o f Canada can best overcome these obstacles. Col leagues o f mine w h o have immigra ted to Canada share s imi la r stories. A t t imes they doubted their dec i s ion to m o v e and thought it w o u l d have been easier to return home to their o r ig ina l country and pos i t ion rather than to continue nursing i n Canada. They expressed anxiety and stress around encountering a who le new health care system and numerous differences i n practice. W h a t helped these nurses succeed through such a chal lenging transit ion t ime? Wha t enabled them to confidently, competently, and safely practice nursing? H o w d i d they get over the hurdles o f l o w self-esteem, lack o f confidence, d is i l lus ionment , and confusion? Throughout this paper reference to "nurses" is focused o n those w h o are non-Canadian born registered nurses who completed their nursing educat ion i n a country other than Canada, unless otherwise specified. These nurses m a y have immigra ted to Canada to l ive permanently or temporar i ly migrated to fu l f i l l a short-term contract. T h e y came voluntar i ly by their o w n choos ing and legal ly traveled or immigra ted here to reside and w o r k ( B o y l e , 2003). It is recognized that there m a y be Canad ian registered nurses w h o completed Trans i t ion to Pract ice 3 their education i n another country; however , because the a i m o f this study is related to issues o f migra t ion and transit ion to a new country, this group was exc luded f rom this study. Problem Statement There are no studies to date speci f ica l ly exp lo r ing the transit ion process experienced by nurses f rom other countries when c o m i n g to Canada. Furthermore, most o f the studies pertaining to nurses pract ic ing i n countries different f rom where they were educated have been completed i n the U n i t e d States and Br i t a in . L i p s o n , M c E l m u r r y , and L a R o s a (1997) identify that m u c h o f the literature focuses on the phys ica l and psycho log ica l dysfunct ion experienced by immigrants rather than h igh l igh t ing ind iv idua l s w h o have had a successful transit ion. Research needs to focus on the dynamics o f adaptation, w h i c h , al though diff icul t to characterize, provides a more realistic perspective o f migra t ion ( L i p s o n et al .) . M a k i n g a transit ion to practice i n Canada engages nurses i n a complex , chal lenging process o f adaptation. In this study the experiences o f transit ion were explored, thereby beginning to f i l l a gap i n research and potent ial ly be the impetus for an expanding body o f research. The transit ion experience needs to be explored to enable a fu l l understanding o f the nurses' responses to the stress o f migra t ion (Me le i s , 2003). Cravener (1992) notes that even h igh ly s k i l l f u l , resilient ind iv idua ls may experience d i f f icul ty and inadequacy o f their cop ing sk i l l s w h e n confronted by the mul t ip le challenges o f immigra t ion . Hence , it is predictable that a propor t ion o f immigrants cou ld definitely benefit f rom services designed to assist w i t h the transit ion to the new culture. W h e n both the phys ica l and psycho log ica l needs o f the nurse are met, there is increased j o b satisfaction and professional performance (Di jkhu izen , 1995). The p r imary issue o f concern is the transit ion experience o f nurses educated outside o f Canada. Trans i t ion to Pract ice 4 Purpose The purpose o f this study is to describe and understand the experiences o f nurses, educated i n a country other than Canada, as they make the transit ion to practice w i t h i n the Canad ian health care system. The thesis is organized i n five chapters. A n int roduct ion and background to the issue o f study was presented i n Chapter 1. A n ove rv i ew o f the literature related to the stressors o f migra t ion , migra t ion and women , and migra t ion and nurses comprises Chapter 2. In Chapter 3 there is a d i scuss ion o f the research method used to complete the research. The f indings o f the study are out l ined i n Chapter 4 w i t h a summary o f f indings, conclus ions , and recommendations i n Chapter 5. Trans i t ion to Practice 5 < Chapter 2 > Literature R e v i e w The impetus to explore the transit ion experience o f nurses educated outside o f Canada to pract ic ing w i t h i n the Canad ian health care system came f rom reading the literature synthesis Immigrant Women and Their Health by A r o i a n (2001), combined w i t h overseas recruitment by m y employer at the t ime. The synthesis p rov ided di rec t ion to further explora t ion o f the literature. T o facilitate the search o f the literature the Cumula t ed Index to N u r s i n g and A l l i e d Hea l th Literature ( C I N A H L ) (1982 - 2003), M E D L I N E (1980 - 2003), and the Soc ia l Sciences C i t a t ion Index (1992 - 2003) were u t i l i zed i n retr ieving articles i n the t ime periods specif ied w i t h i n the parentheses. The key search words/phrases used independently or i n conjunct ion w i t h "nurse" or "educat ion" inc lude: foreign, immigran t / immigra t ion , international, ass imi la t ion , acculturation, adjustment process, recruitment, and travel . Other search words were: race, rac ism, rac ia l iza t ion , marginal iza t ion , d iscr iminat ion , culture, cul tural safety, and socia l we l l -be ing . U s i n g the aforementioned words the l ibrary systems o f the U n i v e r s i t y o f B r i t i s h C o l u m b i a ( U B C ) and the R N A B C were also searched. The references o f each article were also rev iewed for potential literature that w o u l d be benef ic ia l to examine. The research that was rev iewed is summar ized i n A p p e n d i x A . The literature rev iewed is organized around core themes: stressors o f migra t ion , migra t ion and w o m e n , and migra t ion and nurses. A summary o f the state o f knowledge w i l l be presented fo l l owed by the research question. The issues o f migra t ion related to the core themes are interdependent. A focused discuss ion o f each issue w i l l be presented under one o f the themes. In the sect ion related to stressors o f migra t ion , loss and the effect o f stressors w i l l be explored. E m p l o y m e n t , Trans i t ion to Pract ice 6 language, and soc ia l support w i l l be expounded upon i n the section o n migra t ion and w o m e n . In the f inal section, migra t ion and nurses, the issues o f novel ty , d i sc r imina t ion , w o r k environment, regulations for recruitment and retention, and support strategies w i l l be highl ighted. Stressors of Migration " M i g r a t i o n is a stressful experience requi r ing accommodat ion , adaptation, or c o p i n g " ( L i p s o n et a l . , 1997, p . 50). In a Canad ian survey by M a t u k (1996), " 8 4 % o f a l l newcomers reported that their l ives were ' v e r y ' to ' f a i r l y ' stressful" (p. 54). The stressors o f migra t ion have been conceptual ized as novel ty , occupat ion, language, d i sc r imina t ion , loss, and not feel ing at home ( A r o i a n , N o r r i s , Patsdaughter, & Tran , 1998). M e l e i s and Rogers (1987) state, "Unders tanding the process o f dec i s ion m a k i n g related to immigra t ion is significant i n understanding the health and adjustment o f immigrants i n their new loca le" (p. 207). Loss. The major sense o f loss is not feel ing at home. B e i n g i n an unfami l ia r environment is uneasy for most people. In m o v i n g , the famil iar is left beh ind inc lud ing phys ica l space and socia l contexts. Immigrants tend to more c lose ly examine the values and beliefs that make them different. A s they deeply explore their separateness, i sola t ion, and what they left behind, immigrants are forced to sort, evaluate, retain, and let go o f some o f those values, beliefs, and behaviors that identify their self-concept (Pilette, 1989). "The changes that occur can influence the w a y they l ive and think as w e l l as their personal heal th" (Sh in & S h i n , 1999, p. 603). A c c o r d i n g to D i j k h u i z e n (1995), integration occurs more rapid ly w h e n basic needs are identif ied and appropriate interventions are implemented to meet them. / Trans i t ion to Practice 7 Effect of stressors. The pressure o f mul t ip le stressors i n a t ime o f adaptation can have a negative impact o n some indiv iduals . Immigrants focus o n their p sycho log ica l discomfort , w h i c h m a y manifest as phys ica l or socia l issues ( B o y l e , 2003; L i p s o n et a l . , 1997; Pilette, 1989). Pilette identifies excessive fatigue, headaches, and gastrointestinal dysfunct ion as the c o m m o n phys ica l complaints . Immigrants tend to pay little attention to their phys ica l health unless they require treatment (Matuk , 1996). P s y c h o l o g i c a l distress is greater among immigrants than the host popula t ion (Franks & Faux , 1990); however , there does not appear to be significant differences i n the incidence o f mental /emotional i l lness according to culture or race (Cravener, 1992). In a survey o f 860 K o r e a n immigrants to Canada, it was found that w o m e n are eight t imes more l i k e l y to manifest distress as depression and anxiety than men ( N o h , W u , Speechley, & Kaspar , 1992). The researchers found that m e n capi tal ize better on the benefits o f social resources such as education, marriage, employment , and income than do w o m e n . A r o i a n et a l . (1998), i n a correlat ional study o f former Soviet immigrants to the U n i t e d States, also found differences i n psycho log ica l distress to be a function o f gender. The cross-sectional survey o f four ethnocultural groups i n Canada by Franks and F a u x revealed h igh depression scores throughout a l l o f the groups. These are significant f indings to consider, as 9 5 % o f nurses i n Canada are female ( C N A , 2002a). F o r w o r k i n g immigrant w o m e n distress may originate f rom the relat ional aspects w i t h i n the setting, such as d i sc r imina t ion and estrangement by colleagues (Jackson, 1996). Franks and Faux found research to associate depression, cop ing styles, and soc ia l resources. T h e y noted the l i n k between depression and stress and the acceptance o f the adverse impact o f p sycho log ica l stress o n mental health. Trans i t ion to Pract ice 8 The pr imary effects o f stress for immigrant w o m e n are depression, loneliness, and tension, w h i c h take precedence over phys ica l health problems (Anderson , 1985). L a c k o f socia l support and loss o f identity leads to loneliness and, eventually, depression. Depress ion is d i sab l ing to w o m e n as they experience increased phys ica l ailments and functional l imita t ions ( B o y l e , 2003) . M e l e i s and Rogers (1987) correlate w o m e n ' s phys ica l and mental health w i t h three p r imary roles: marriage, employment , and parenthood. A n d e r s o n notes that the mental health issues immigrant w o m e n encounter have a long-las t ing impact . Feel ings o f depression and loneliness may st i l l be felt years after being i n Canada. Migration and Women The focus o f the literature r ev iew w i l l n o w be on the impact o f migra t ion o n w o m e n because the ove rwhe lming propor t ion o f nurses i n Canada is female ( C N A , 2002a). The experiences out l ined are c o m m o n to many w o m e n i n the literature rev iewed; however , not a l l experiences are the same. The transitions and adjustments required o f people w h e n migra t ing create exponent ial stress, w h i c h is par t icular ly concerning for w o m e n . The results o f a cross-sectional survey o f Canad ian w o m e n show that immigrant w o m e n ' s h igh r isk o f mental i l lness is attributable to the factors o f employment , language s k i l l , soc ia l support, and cul tural attitudes (Franks & Faux , 1990). Employment. A shift i n responsibi l i ty m a y occur w i t h i n a fami ly as the w o m a n m o v i n g to a new country may sole ly carry the duty to settle and fit i n to the new society (Fox , 1991). Distress might result f rom the imposed pressure to succeed i n the new culture ( S h i n & S h i n , 1999). I f they are the first to be employed or move to Canada, and the f ami ly fo l lows , another potential stressor w o m e n m a y encounter is a change i n their role (Matuk , 1996; S h i n & Shin) . There cou ld poss ib ly be a change i n power dynamics w i t h i n marriages Trans i t ion to Pract ice 9 as the wi fe may n o w be earning more than her spouse. D u e to the abovementioned factors, w o m e n m a y be car ry ing the total f ami ly and economic responsibi l i ty . Language. Language becomes a socia l power through w h i c h interpretation occurs and meaning is created (Re imer K i r k h a m et a l . , 2002) . A key to gain ing acceptance by the host society is prof ic iency o f language. The value o f language t ra ining is repeatedly emphasized by the literature ( A r o i a n , 1990; A r o i a n et a l . , 1998; Jackson, 1996; M a t u k , 1996; Y a h e s & D u n n , 1996). Language s k i l l is related not on ly to prof ic iency i n speaking, but also i n understanding. L y n a m (1985), i n an ethnographic study o f 12 Canad ian w o m e n , describes a feel ing o f i so la t ion sensed by immigran t w o m e n due to a lack o f mutual understanding. Immigrant w o m e n described their o w n lack o f "understanding o f the cul tural values gu id ing social interactions or the cul tural context w i t h i n w h i c h socia l resources or services were developed" i n this study ( L y n a m , p. 329). Hence , they often felt misunderstood or complete ly avo id contact w i t h outsiders. F o r those w o r k i n g w i t h immigrant w o m e n , M e l e i s and Rogers (1987) state "knowledge o f the identity, values, and norms o f famil ies i n different sectors o f commun i ty is essential" (p. 214). A Canad ian ethnographic study o f 30 Chinese and Euro -Canad ian w o m e n by Ande r son , B l u e , H o l b r o o k , and N g (1993) found that knowledge o f everyday l ife circumstances needs to be incorporated da i ly into c l i n i c a l practice so that day-to-day socia l issues are considered w i t h i n health care decisions. Social support. It is w o m e n w h o generally facilitate the process o f creating balance and harmony between ass imi la t ing into a new culture w h i l e main ta in ing traditions and characteristics o f the o l d for their famil ies ( M e l e i s & Rogers , 1987). Schreiber, Stern, and W i l s o n ' s (1998) grounded theory study describes the experience o f role burdening as be ing Trans i t ion to Pract ice 10 when immigrant w o m e n are s t i l l expected to fu l ly care for their f ami ly and home w h i l e w o r k i n g . In a new communi ty , cont inuing to act as the negotiator and mediator i n the f ami ly m a y become more frustrating and demanding and less rewarding for immigran t w o m e n ( M e l e i s & Rogers) . There m a y be l imi t ed access to, or a lack of, resources that support w o m e n i n these roles. W h e n seeking help, immigrant w o m e n tend to turn to their private selves; that is , relatives and close friends, rather than outsiders ( L y n a m , 1985; M e l e i s & Rogers) . W o m e n w h o are exper iencing psycho log ica l issues may be s t igmat ized by ethnic groups as w e l l as health professionals, so w o m e n may v i e w alterations and diff icul t ies as part o f a normal l ife cyc le (Anderson , 1987; Franks & Faux , 1990). Frustrations arise i n "starting over" due to a lack o f transferability o f status and accomplishments f rom their home country. Soc ia l inequity becomes the prominent concern for immigrant w o m e n related to a heightened sense o f soc ioeconomic inequal i ty ( M e l e i s & Rogers) . I f the transi t ion to the new society is approached i n a supportive manner, immigrants may thrive o n the strong foundation p rov ided to assist i n their integration. Migration and Nurses The d iscuss ion w i l l n o w focus o n the experience o f migra t ion related spec i f ica l ly to nurses inc lud ing recommendations f rom the literature as to h o w nurses can best be supported throughout this experience. Nurses are mot ivated to move related to: novel ty o f travel and employment abroad; better economic , w o r k i n g , and l i v i n g condi t ions; i m p r o v e d learning and practice opportunities; and personal safety (International C o u n c i l o f Nurses ( I C N ) , 2002a; K i n g m a , 2001). Novelty. There is so m u c h that is n e w when m o v i n g to a n e w country that a lack o f basic informat ion and knowledge can be ove rwhe lming ( A r o i a n , 1990). S o o n the very Trans i t ion to Pract ice 11 attraction to immigra t ion , opportunist ic soc ia l condi t ions , especial ly i n the labour market, may i n turn cause some o f the greatest angst i n the adjustment process ( M e l e i s & Rogers , 1987). Mig ran t s begin to c lose ly examine their dec i s ion and consider the losses and gains o f their choice. The o l d life and j o b back home m a y be reflected o n as better than that o f the present. It is recognized that nurses m o v i n g to another country to practice experience a per iod o f transit ion to their new setting beginning w i t h a "honeymoon phase" w h e n everything is new and exc i t ing (Dav i s & M a r o u n , 1997; W i t c h e l l & Ousch , 2002). T h i s is f o l l o w e d by a possible per iod o f d is i l lus ionment and frustration when the reali ty o f l i v i n g and w o r k i n g i n a new culture is evident. D u r i n g this stage the nurse may also feel impatient, incompetent, and angry ( W i t c h e l l & Ousch) . Pilette (1989) identifies ind iv iduals that immigrate f rom a s imi la r culture to be at r i sk o f interpreting l ife i n the new setting as they d id at home, w h i c h m a y create some diff icul t soc ia l challenges. Even tua l ly a turning point is reached when the mirse either decides to return home or is more posi t ive and understanding i n relat ion to migra t ing. W h e n the nurse recognizes that the new culture has m u c h to offer integration occurs ( W i t c h e l l & Ousch) . Nurses are chal lenged even i n meeting their basic needs, especia l ly i n relat ion to hous ing and finances (D i jkhu izen , 1995; Pearce, 2002). U p o n ar r iva l , nurses are often p laced i n hous ing pre-arranged by the employer , w h i c h may compromise the safety and support o f the i nd iv idua l depending on locat ion and w i t h w h o m the residence is shared. A c c o r d i n g to a B r i t i s h anecdote, w i t h i n a short per iod o f t ime, these nurses are forced to f ind suitable, affordable hous ing i n an unfamil iar c i ty w i t h litt le support - a daunting task (Pearce). A d d i t i o n a l l y , nurses f ind the monies p romised i n recruitment are insufficient to cover their Trans i t ion to Practice 12 cost o f l i v i n g . There is litt le left to save or send back home to fami ly left behind. The prosperity and h igh income nurses educated i n other countries anticipate is often never attained as they enter a downward spiral o f occupat ional m o b i l i t y by accept ing a status demot ion to lower level posi t ions than they prev ious ly he ld ( A r o i a n , 1990; Godfrey , 1999; Pearce). Th rough the processes o f reorganizat ion and desk i l l ing , hospitals further erode the status o f nurses educated i n other countries (Das Gupta , 1996). Discrimination. Nurses educated i n other countries have raised concerns related to rac i sm and d i sc r imina t ion i n the workplace (Das Gupta , 1996; Pearce, 2002) . Despi te sharing experiences ar is ing f rom the intersection o f gender and migrat ion, nurses educated i n other countries have a lot o f divers i ty w i t h i n the group and cannot be characterized un id imens iona l ly ( M e l e i s , 2003). Nurses educated outside o f N o r t h A m e r i c a often stand out f rom the mainstream because o f their accents, mannerisms, or responses (Me le i s ) . These differences m a y lead to feelings o f marginal iza t ion . Das Gupta , i n detai l ing the experiences o f two B l a c k nurses w i t h rac ism, outlines that being seen as different equates being targeted as a scapegoat, w h i c h is compounded dur ing t imes o f economic cr is is . Protect ion must be p rov ided to ensure fair treatment o f nurses educated outside o f Canada i n order to prevent wage abuse, sufferable l i v i n g condi t ions, and sexual harassment (D i jkhu izen , 1995; Tabone, 2000). T o develop knowledge that is not marg ina l i z ing , an explora t ion o f power differentials i n relationships and o f the groups themselves needs to be inc luded ( M e l e i s & Im, 1999). Work environment. Occupa t iona l adjustment has been identif ied as the essential component o f successful migra t ion ( A r o i a n , 1990). Th i s is often chal lenged by a lack o f transferability o f credentials and status demot ion when a j o b is secured. There is greater stress when one is unemployed and not l o o k i n g for w o r k than when an ind iv idua l is act ively Trans i t ion to Pract ice 13 seeking employment ( A r o i a n et a l . , 1998). Berns te in and Shuva l (1998) i n a cohort fo l low-up study found older respondents to be at an occupat ional disadvantage. Pilette (1989) states that being able to " internal ize w o r k and societal norms potentiates accul turat ion" (p. 280). In a grounded theory study by A r o i a n , P o l i s h immigrants to the U n i t e d States described f inancia l opportunities, se l f growth, and freedom as posi t ive aspects o f migra t ion . H a v i n g a j o b that is commensurate w i t h one 's education and experience also increases morale ( A r o i a n et al .) . It is essential that a nurse be able to competently funct ion w i t h i n the w o r k setting. There is an assumption by employers that, on ar r iva l , nurses are ready to w o r k even though they often are not immedia te ly fit to practice. The safety and competency i n the p r o v i s i o n o f patient care is the key concern i n nursing. The phenomenon o f culture shock is accompanied by depression and learned helplessness, w h i c h may inhibi t a nurse's effectiveness and abi l i ty to practice (Dav i s & M a r o u n , 1997). Trouble i n the workplace m a y first appear as a breakdown i n communica t ion due to inaccurate or inappropriate use o f language (Burner , Cunn ingham, & Hattar, 1990). W h e n w o r k i n g w i t h staff o f diverse backgrounds, G i g e r and M o o d (1997) note that ach iev ing effective interpersonal communica t ion is quite l i k e l y to be a formidable barrier between team members. There m a y be fear or embarrassment to admit a lack o f understanding for both the immigrant and the person who is f rom the host country (Burner et al.). Nurses may long for their fami l ia r support system, as they are seemingly unable to resolve issues and function successfully w i t h i n the new culture and organizat ion (Dav i s & M a r o u n ) . Regulations for recruitment and registration. In response to aggressive recruitment o f nurses w o r l d w i d e , the I C N (2002b) developed a pos i t ion statement on ethical nurse recruitment, w h i c h outl ines thirteen key pr inc ip les . These pr inciples create an ethical Trans i t ion to Practice 14 framework for nurse recruitment based on: effective human resources p lann ing and development; credible nurs ing regulat ion; access to fu l l employment ; freedom o f movement ; freedom from d iscr imina t ion ; good faith contracting; equal pay for w o r k o f equal value; access to grievance procedures; safe w o r k environment; effective orientation, mentor ing, and supervis ion; employment t r ia l periods; freedom o f associat ion; and regulat ion o f recruitment ( I C N , 2001). The I C N emphasizes that the credib i l i ty , strength, and universa l i ty o f these pr inciples is dependent o n the actions o f health care stakeholders and the implementa t ion o f regulatory mechanisms. Centra l to the pos i t ion statement, Ethical Nurse Recruitment, is the be l i e f that quali ty health care has a direct correla t ion w i t h an adequate supply o f qual i f ied and commit ted nursing personnel and good w o r k i n g condi t ions. Canada has no organized system o f support i n place to assist nurses educated i n other countries i n their transit ion to pract ic ing w i t h i n the Canad ian health care system, even though there is increased recruitment o f nurses f rom abroad. A recent article (Bar ry et a l . , 2003) highl ighted a regulatory f ramework that has been created by C N A to guide the process o f registration and integration o f nurses educated outside o f Canada. T h i s is to ensure that the registration requirements for nurs ing i n Canada are respected. The framework outlines components o f the transi t ion process that are the funct ion o f the nurse as w e l l as the regulatory body. It also encompasses new nat ional ini t iat ives that w i l l support nurses educated outside o f Canada and streamline components o f the transit ion process. A c c o r d i n g to the Standards for Registered Nursing Practice in British Columbia ( R N A B C , 2003), nurses must i nd iv idua l ly assume the pr imary responsibi l i ty for main ta in ing competence and fitness to practice; that is , one 's o w n phys ica l , mental , and emot ional w e l l -being. T o ensure competency, an organizat ion needs to foster an environment that Trans i t ion to Pract ice 15 encourages i nd iv idua l ini t ia t ive, accountabil i ty, communica t ion , and a commitment to fu l f i l l the development o f the i nd iv idua l ' s capacity for personal g rowth (Koerner , 1997). F o r nurses from other countries, the lack o f educat ion about the work ings o f the Canad ian health care system is a barrier i n s t r iv ing towards excel lence i n practice. Wi thou t this education, the practice o f these nurses m a y be compromised , w h i c h may lead to detrimental patient outcomes. Support strategies. Further measures are needed to m i n i m i z e the stress o f a transit ion to a new practice setting and l i v i n g i n a new country. Var iab les associated w i t h psycho log ica l distress may inc lude: potential language di f f icul ty (e.g., different names for medicat ions); different methods o f care de l ivery; variance o f pol ic ies and procedures; different organizat ional and socia l culture; and lack o f socia l support (Bernstein & Shuva l , 1998; H u r h & K i m , 1990). Pilette (1989) suggests that the recruitment in te rv iew be used as an assessment tool to estimate the adjustment o f a prospective employee. A nurse exper iencing somatic symptoms related to a chal lenging transit ion w i l l be at r i sk o f engaging i n unsafe practice and face the potential o f being deemed incompetent. A r o i a n et a l . (1998) suggest that interventions be focused o n a l lev ia t ing feelings o f d iscr imina t ion , loss, and discomfort . A session o n values c lar i f ica t ion that explores values and cultural differences is recommended ( W i l l i a m s , 1992). Th i s m a y enhance awareness o f one 's o w n cultural values and enable recogni t ion o f h o w they m a y intersect w i t h aspects o f the culture o f the n e w country. Immigrant w o m e n need support dur ing the transit ion to Canada through va l ida t ion and credit for their roles, knowledge about resources, and socia l equali ty ( M e l e i s & Rogers , 1987). Th i s support may be i n the form o f programs for relocat ion, t ra ining, and language s k i l l instruction. S i m p l y g i v i n g a list o f resources is not sufficient; w o m e n need to sense a Trans i t ion to Pract ice 16 genuine interest by others to facilitate their par t ic ipat ion ( M e l e i s & Rogers) . Pilette notes that addressing psycho log ica l issues requires a considerable amount o f inner strength and conf l ic t resolut ion s k i l l . Fo rma t ion o f a support group m a y help i n the development o f cop ing sk i l l s through the p romot ion o f therapeutic relationships ( W i l l i a m s ; Yahes & D u n n , 1996). Y a h e s and D u n n , as a result o f a survey on the cont inuing education needs o f nurses educated i n other countries, suggest that by emphas iz ing one 's uniqueness, there w i l l be enhancement o f self-esteem, w h i c h leads to improved professional performance. Franks and Faux c a l l for a re-examinat ion o f the p r o v i s i o n o f psycho log ica l health care to immigrant w o m e n to enable an integration o f socia l and life sk i l l s w i t h care o f their phys ica l health needs. Employe r s w h o recruit and hire nurses educated outside o f Canada should have strategies and programs i n place to ease the transit ion into the workplace . W i l l i a m s (1992) recommends an extended orientation course that highl ights the role o f the nurse i n the g iven setting, communica t ion and the use o f id ioms , pharmacology o f medicat ions used i n the agency, nursing process i nc lud ing phys ica l assessment and a m o c k code, t ime management, assertiveness sk i l l s , and support services. Or ienta t ion programs should be further strengthened through the incorporat ion o f socia l and cul tural experiences that ins t i l l intercultural understanding (Pacquiao, 2002). The R N A B C is able to provide informat ion o n resources avai lable through other agencies to provide nurses educated outside o f Canada w i t h refresher courses, t ransi t ion programs, and language s k i l l workshops speci f ica l ly designed to target those educated outside o f Canada. H o w e v e r , informat ion f rom the R N A B C can be diff icul t to obtain and nurses must take the ini t ia t ive to seek it out. Trans i t ion to Pract ice 17 Summary of the State of Knowledge M i g r a t i o n is c lear ly a stressful event: stress increases w i t h increasing age and for w o m e n ( A r o i a n , 1990; A r o i a n et a l . , 1998; Franks & Faux , 1990; M a t u k , 1996; N o h et a l . , 1992). C o m m o n factors that relate to stress i n the transit ion process include: loss, occupat ional stressors, l ack o f famil iar i ty w i t h the language, novel ty , and d iscr imina t ion . A t t imes the stress o f these factors creates phys ica l and mental health concerns. D e v e l o p i n g a sense o f be longing is c r i t i ca l ly important to immigrant w o m e n and nurses as it alleviates c h i e f complaints o f loneliness and depression (Anderson , 1985; Ande r son , 1987; Jackson, 1996; L y n a m , 1985). N o research was located o n the transit ion experience o f nurses to pract ic ing i n Canada. Further, no research was found related to the most c o m m o n groups o f new nurses f rom other countries: Ph i l ipp ines , B r i t a in , U n i t e d States o f A m e r i c a , or Aus t r a l i a . Because so li t t le o f the research related to migra t ion is based i n nurs ing, one must be cautious to consider the va ry ing contexts w i t h i n w h i c h nurses are exper iencing their transit ion to pract ic ing i n Canada. H i g h l i g h t i n g these issues from the literature is on ly the beginning o f an explora t ion o f the migra t ion experience o f nurses. T h i s provides a foundation upon w h i c h further study can commence to understand the experience o f nurses and make comparisons to the present literature. Research Question The research question addressed i n this study was: Wha t are the experiences o f nurses, educated i n a country other than Canada, as they make the transi t ion to practice i n Canada? The research method used to address this quest ion w i l l be described i n the next chapter. Trans i t ion to Pract ice 18 < Chapter 3 > Methods T h i s chapter w i l l out l ine the study design inc lud ing a descr ipt ion o f research methods, sample, data co l lec t ion , and ethical considerations. Ethnographic Methods A qualitative design us ing ethnographic methods o f data co l lec t ion was chosen to be used for this study as understanding o f a g iven cultural group, nurses educated outside o f Canada, was sought to prov ide descriptions o f the transit ion experience to pract ic ing i n Canada. T h i s method p rov ided f l ex ib i l i t y i n the direct ion o f the research as the study unfolded to br ing a greater understanding o f the ways i n w h i c h people make meaning o f their w o r l d (Morse , 1989). The ethnographer "attempts to learn what knowledge people use to interpret experience and m o l d their behavior w i t h i n the context o f their cul tura l ly constituted environment" ( M o r s e , p. 30). T h r o u g h d iscovery and representation o f the true nature o f social phenomena, ethnographic methods were w e l l suited to descr ibing peoples ' socia l reali ty (Hammers ley , 1992). Ethnographic methods are useful i n def ining a p rob lem that is unclear and exp lo r ing associated factors to enable better understanding and provide opportunities to address the issues ( L e C o m p t e & Schensul , 1999). The researcher learned f rom the nurses educated outside o f Canada what the " w o r l d " is l ike to them. "People construct the socia l w o r l d , both through their interpretations o f it and through the actions based o n those interpretations" (Hammers ley , p. 44). In-depth interviews achieved the purpose o f this study - to describe and understand the experiences o f nurses educated outside o f Canada i n m a k i n g the transit ion to practice i n Canada. The use o f ethnographic approaches to in te rv iewing enabled the transi t ion f rom Trans i t ion to Pract ice 19 broad questions to contrast questions to explore s imilar i t ies and differences between experiences w i t h i n a theme (Morse , 1995). In ethnographic interviews topics emerge naturally as the participants describe their everyday experience. The researcher uses neutral probes to direct the in te rv iew and expound dense descript ive data (Bauman & Greenberg, 1992). Th rough exp lor ing and understanding the experiences o f nurses educated outside o f Canada i n their transit ion to practice i n Canada, knowledge about the soc ia l contexts o f the nurses was developed. T h i s knowledge w i l l be useful i n predic t ing potential needs o f future nurses exper iencing a s imi la r transit ion, as w e l l as behavioral and emotional responses to the transit ion process. Lea rn ing f rom the part icipants ' experiences, the data has been interpreted to provide an understanding o f the t ransi t ion process experienced by nurses educated i n countries other than Canada to prac t ic ing i n Canada . Sample F o r the purposes o f open-ended, in-depth in te rv iewing it is important that the participants w i l l be able to provide a r i c h descr ip t ion o f their transit ion experience to practice i n Canada. F o r this reason purposeful sampl ing was u t i l i zed . Th rough purposeful sampl ing the researcher selects informat ion r i c h cases to a l l o w for the most insightful data co l l ec t ion for in-depth study i n answer ing a part icular quest ion or explora t ion (Coyne , 1997). The nurses selected were recognized as key informants being able to provide insight into the experience under study. They were w i l l i n g and able to discuss and examine their transit ion experience to prac t ic ing i n Canada as nurses educated outside o f Canada. B e y o n d s i m p l y te l l ing their story, the participants were able to explore their experience through in-depth reflect ion and introspection. These nurses have engaged themselves i n a unique professional Trans i t ion to Pract ice 20 transition. There was a change not on ly i n their practice setting, but i n the who le social context w i t h i n w h i c h they practice nursing. W h e n this study was designed certain assumptions were made as to the wi l l ingness o f nurses to participate i n research on this topic and the meri t that w o u l d be in t r ins ica l ly recognized for part icipat ion. It was assumed by the researcher that participants i n this study w o u l d recognize the benefits o f the research as ou tweigh ing any potential r i sks as w e l l as recogniz ing opportunity for involvement . It was be l ieved that these interviews w o u l d provide a debriefing for nurses educated outside o f Canada about their experiences and, i n turn, a l l o w them to feel va lued and heard as ind iv idua ls . Several participants expressed r e l i e f i n be ing able to f ina l ly share their experiences. T h e y were appreciative that someone w o u l d l isten to their stories. T h i s led to the assumption that nurses are altruistic and desire to help others. B y part icipating i n this research they m a y have p rov ided assistance to other nurses educated outside o f Canada. One participant described h o w she hoped this study w o u l d help create change to benefit future immigrant nurses. Ano the r assumption surrounded the be l i e f that the transit ion experience to practice i n Canada for a nurse f rom another country is cha l lenging and w o u l d benefit f rom the help and support o f others. The nurses i n this study described various support networks that they va lued: professional , work , and socia l . Some o f the participants were recruited through the R N A B C . One o f the registration advisors was identif ied as a key contact related to her interaction w i t h nurses educated outside o f Canada w h e n they in i t i a l ly register w i t h the R N A B C . Potent ial participants were identif ied by the registration advisor f rom the database o f registrants and sent an informat ion letter (refer to A p p e n d i x B ) about the study. U p o n rece iv ing an informat ion letter f rom the R N A B C , the potential participant contacted the researcher d i rect ly to express interest i n Trans i t ion to Pract ice 21 part icipat ion. Ano the r method o f recruitment was to place an advertisement i n Nursing BC classifieds (refer to A p p e n d i x C ) . Respondents to the advertisement were sent an informat ion letter and then conf i rmed their interest i n part icipat ion. The sample ava i lab i l i ty was k n o w n by R N A B C registration demographics. T w o participants were recruited f rom the letters sent by R N A B C and three were recruited f rom the advertisement i n Nursing BC. Col leagues and friends sharing informat ion about the study enabled the recruitment o f the other eight participants. The sample for this study compr ised 13 registered nurses w h o were born outside o f Canada and completed their basic education i n a country other than Canada. T h e y were enrol led into the study through purposeful sampl ing . The participants had to be fluent i n E n g l i s h and currently employed i n B r i t i s h C o l u m b i a w i t h i n the Greater V a n c o u v e r R e g i o n a l Dis t r ic t . The sample was composed o f nurses who have m o v e d to Canada and started to practice nurs ing w i t h i n the past 5 years. Th i s ensured that the nurses were able to reca l l their experiences and challenges o f transit ion w h i l e not being so far a long that it m a y be dif f icul t to remember the experiences and the supports u t i l i zed . G a i n i n g entrance and being accepted by the group is c r i t ica l (Burns & G r o v e , 1997). In this study, experiences, not people per se, were the objects o f purposeful sampl ing (Coyne , 1997; Sande lowsk i , 1995). The size o f the sample was shaped by pract ical considerations such as the amount o f t ime avai lable to the researcher and restricted by volunteer ing o f nurses and the cri ter ia for par t ic ipat ion. Saturation o f data was also a factor; that is , there was informat ion redundancy. W h e n themes were identif ied i n the data, it was decided i f the next few data samples fit into these themes, and i f the themes represented the experience be ing studied. The last four interviews, a l though valuable demographic contrasts, generated few new ideas and were more a conf i rmat ion o f Trans i t ion to Practice 22 themes already identif ied. A t this point the data was saturated and data co l lec t ion was complete (Bever idge , 2003) . S a m p l i n g adequacy is evident by saturation and repl icat ion o f data account ing for a l l aspects o f the experience (Morse , Barrett, M a y a n , O l s o n & Spiers, 2002). Sande lowsk i describes an adequate sample as enabl ing in-depth case-oriented analysis that results i n a new dense understanding o f the experience under study. In this study, the sample compr ised three o f the four most c o m m o n groups o f nurses f rom other countries: Aus t r a l i a , B r i t a in , and the Ph i l ipp ines . N o nurses from the U n i t e d States o f A m e r i c a responded to any o f the recruitment measures. E a c h o f the participants shared detailed insight into their experiences i n m a k i n g the transit ion to practice i n Canada, w h i c h enabled the generation o f n e w knowledge that w i l l be explored i n Chapter 5. Purposeful sampl ing incorporates different approaches to achieve var iabi l i ty . Sande lowsk i (1995) defines these strategies as demographic var ia t ion, phenomenal var ia t ion, and theoretical var ia t ion. Demograph ic var ia t ion relates to people-related characteristics. Th i s was in i t i a l ly u t i l i zed to ensure that the sample was inc lus ive o f nurses f rom a variety o f the more c o m m o n countries f rom w h i c h nurses migrate to Canada. Phenomenal var ia t ion is associated w i t h the target experience be ing studied. Ano the r a i m o f the sampl ing was to have a m i x o f socia l identities, for example , age, mari ta l status, w o r k experience, employment status, etcetera, to enable the experience to be explored f rom a variety o f perspectives. Information col lected on the nurse demographic forms (refer to A p p e n d i x D ) at the t ime o f in i t i a l contact w i t h a potential participant assisted i n selecting appropriate nurses to meet the select ion cri teria. Some nurses were not selected as participants as they had l i v e d i n Canada for greater than five years; completed nursing education i n Canada pr ior to registering and beg inn ing to practice; or were not qual i f ied as a Regis tered Nurse . Trans i t ion to Pract ice 23 Description of the Participants A descr ipt ion o f the participant demographics provides context to the experiences described. The 13 nurses w h o participated i n the study were f rom Aus t ra l i a , B r i t a in , and the Ph i l ipp ines as shown i n Table 1 (page 24). T w o male participants were inc luded i n the sample as potential contrasting cases. At tempts were made to recruit males f rom other countries for further compar ison . There was also a m i x o f mari tal and fami ly status that a l l owed for compar i son o f experiences. The nurses were employed i n a variety o f w o r k settings that p rov ided interesting elements o f contrast i n the analysis . M o s t were emp loyed o n a ful l - t ime basis, but one was unemployed at the t ime o f in terv iew as she had been i n a contract pos i t ion that had expi red and needed to resolve some issues related to her immigra t ion status before she c o u l d secure employment . O v e r h a l f o f the nurses i n this study came w i t h the intent o f s taying or decided to stay i n Canada after some t ime. Some o f those w i t h a w o r k permit have begun the process to become a permanent resident or have decided to renew their permit to enable them to extend their stay. Trans i t ion to Pract ice 24 Table 1 Demographic Summary of the Participants n=13 Gender M a l e 2 Female 11 A g e M e a n 35 Range 25 - 57 years M a r i t a l Status M a r r i e d 7 S ingle 6 F a m i l y Status H a v e ch i ld ren 5 Ci t i zensh ip A u s t r a l i a 3 Ph i l ipp ines 6 U K 4 Leng th o f t ime i n Canada 1+ year 4 2+ years 3 3+ years 3 4+ years 3 M e a n 2.4 years Range 1 - 4 years Immigrant Status L a n d e d Immigrant 6 Permanent Resident 1 W o r k Permi t 6 Educa t ion Degree 9 D i p l o m a 4 Workp l ace A c u t e Care 7 Educa t ion 1 Intermediate Care 1 Operat ing R o o m 3 Rehab 1 Current E m p l o y m e n t F u l l - t i m e 12 U n e m p l o y e d 1 Trans i t ion to Pract ice 25 Data Collection The pr inc ipa l investigator in terviewed each participant once. In i t ia l ly it was proposed that participants m a y be in terviewed up to two t imes; however , the t ime allotted i n one in terv iew session was ample for each participant to share details o f their experience. Adjustment to the number o f interviews was based o n the leve l o f data saturation achieved w i t h i n the ongoing analysis; that is , there was no need identif ied to in te rv iew greater than 13 participants. Interviews were chosen as the p r imary data co l l ec t ion tool to enable the capturing o f the nurses' stories. The interviews occurred i n a loca t ion desired by the participants, most often i n the part icipant 's home. The participant was encouraged to ensure that the locat ion had an undisturbed, quiet, and re lax ing atmosphere. E a c h in te rv iew session was tape-recorded to a l l o w the researcher to g ive complete attention to what was be ing said. F i e l d notes were kept o f the in terv iew setting, events that transpired dur ing the in terview, general m o o d and tone o f the in terview, non-verbal communica t ion o f the participant, patterning o f actions and responses, use o f metaphors to represent experience, and reflections o f the researcher (Fetterman, 1998; M o r s e , 1989). T o understand the transi t ion experience o f nurses educated outside o f Canada the interviews focused o n the meanings o f i nd iv idua l s ' actions and explanations. A n open-ended in terv iew guide, w i t h trigger questions and prompts, was developed to assist the researcher i n mainta in ing focus o f content throughout the interviews; however , the participants p r i m a r i l y directed the interviews and were a l l owed to speak for themselves (refer to A p p e n d i x E for in terview questions). The researcher prompted the participant to further explore the experience and offer insight into key phrases and va ry ing examples. Trans i t ion to Practice 26 A researcher cannot be disconnected f rom the socia l w o r l d be ing studied. Ethnographic in te rv iewing makes the contr ibut ion o f the researcher i n the research setting expl ic i t through engaging i n ref lexiv i ty (Morse , 1989). The analysis process needs to include quest ioning o f the relat ionship and encounters between the researcher and the participants (Anderson , 1991). Af te r each in terv iew I made notes about the session, i nc lud ing questions raised for me and m y reactions to what was be ing shared. A c c o r d i n g to F i n l a y (2002), " ref lexive analysis i n research encompasses cont inual evaluat ion o f subjective responses, intersubjective dynamics , and the research process i t s e l f (p. 532). R e f l e x i v i t y acknowledges researcher bias and subjectivity and balances purposeful , personal analysis (F in lay) . Throughout the study I was forced to set aside m y established thoughts o n the experience o f m a k i n g the transi t ion to practice i n Canada and mainta in an open m i n d so that I cou ld learn f rom the participants. A s I progressed through the analysis to make recommendat ions I needed to ensure the recommendat ions were based o n the f indings, not m y preconceived ideas. It is cr i t ica l that the researcher be engaged i n qualitative research as an iterative process, m o v i n g between design and implementat ion, to constantly ver i fy the re l iabi l i ty , va l id i ty , and r igor o f the study (Morse et a l . , 2002). Analysis Data co l lec t ion and analysis proceeded concurrently. Refer to A p p e n d i x F for the project t imel ine . A s the researcher col lected and rev iewed the data, nurses were asked to clar i fy points that were unclear. T h i s occurred dur ing the interviews as w e l l as i n some informal conversations I had w i t h a few participants i nd iv idua l ly dur ing the analysis phase. T h i s step was essential to guarantee the re l iab i l i ty o f the data (Mackenz i e , 1994). E a c h in terview tape was transcribed by a transcriptionist who had signed a confident ial i ty Trans i t ion to Pract ice 27 agreement. Mic roso f t W o r d and E x c e l programs were u t i l i zed to assist w i t h the data management. The transcripts and tapes were rev iewed for accuracy and to enable immers ion i n the data. H a v i n g a r i ch understanding o f the data was essential to begin the process o f analysis and interpretation. Ethnographic analysis goes beyond basic descr ipt ion o f an experience to interpret aspects o f socia l patterns (Morse , 1995). The data was systematical ly analyzed to identify emerging categories and recurrent ideas. The steps o f " c o d i n g f ie ld notes and interviews, sort ing to identify patterns, genera l iz ing constructs and theories, and m e m o i n g to note personal reflections and ins ights" (Roper & Shapira, 2000, p. 93) were fo l lowed . A s themes and patterns were identif ied the data was examined for repetit ion o f these as w e l l as for contrary cases. F r o m this induct ive process there was a synthesis o f m a i n ideas into a coherent account o f the nurses' t ransi t ion experience. Ethnography engages the researcher i n a natural t r iangulat ion o f data co l l ec t ion strategies: f ie ld notes, interviews, and examinat ion o f related literature (Roper & Shapira , 2000). The data f rom each source has been u t i l i zed to judge the va l id i ty o f the data f rom the other sources. T o ensure rel iable and consistent data co l lec t ion and analysis , the research supervisors r ev iewed the interpretations. The supervisors also assisted i n ra is ing the researcher's awareness o f issues and biases for further reflection. Ethical Considerations The proposed study was subject to r ev iew and approval by the U B C Behav iou ra l Research Eth ics B o a r d . T o initiate their part ic ipat ion, interested nurses contacted the researcher through a private v o i c e m a i l . The process o f ach iev ing informed consent f rom the participants began w i t h t ime for nurses to carefully consider par t ic ipat ion and rev iew detailed informat ion about the study. Refer to A p p e n d i x G for the Informed Consent F o r m . The Trans i t ion to Pract ice 28 consent was reconf i rmed pr ior to the start o f each in terview. Conf ident ia l i ty o f the participants has been maintained through use o f code numbers o n a l l field notes, tapes, and transcripts o f the interviews. In the compi l a t ion and reporting o f the study findings no names or other potential ident i fy ing informat ion have been u t i l i zed so as to m i n i m i z e potential association o f data to an i nd iv idua l participant. A l l documents and recordings have been kept i n a l ocked file cabinet w i t h i n the researcher's personal office throughout the durat ion o f the study and after the comple t ion o f the study. S tor ing the data is necessary to enable its use for further publ icat ions. It was recognized that the nurses m a y have felt a sense o f vulnerabi l i ty through part ic ipat ion i n the study, par t icular ly i f the transi t ion to Canada has been dif f icul t w i t h notable distress. Some may also have sensed a soc ia l s t igma around be ing i n v o l v e d i n research. Resource and support informat ion were avai lable i n ant icipat ion that the nurses may seek advice f rom the researcher throughout the in terview, w h i c h w o u l d have been v i ewed as a component o f socia l interaction and not separated f rom the research process. He lp-seek ing behavior is a soc ia l reali ty and was not d ismissed as inappropriate w i t h i n the research process ( D y c k et a l . , 1995). F o r example , one participant questioned h o w she should fo l low-up o n the concerns she had i n her first pos i t ion , w h i c h she felt forced to leave due to ongoing confl icts . B y sharing appropriate resources, rather than offering specific advice , the researcher assisted the nurses i n taking control over their experience (Anderson , 1991; D y c k et al.). The findings o f the study w i l l be described i n the next chapter. Trans i t ion to Pract ice 29 < Chapter 4 > Find ings The a i m o f this study was to describe and understand the experiences o f nurses, educated i n a country other than Canada, as they make the transi t ion to practice w i t h i n the Canad ian health care system. In this chapter the stories o f nurses ' experiences w i l l be discussed i n thematic categories that emerged throughout the analysis process. In i t ia l ly i n analysis, many pre l iminary themes and concepts were identif ied as c o m m o n experiences amongst the participants or contrasting experiences that were surpr is ing or unexpected. The interdependence and connect ivi ty between the nurses ' experiences led to the ident i f icat ion o f more abstract themes and concepts. The concepts w i l l be out l ined through sharing excerpts o f the in-depth interviews completed w i t h the participants. The stories o f the participants illustrate the experiences o f t ransi t ion to practice i n Canada as nurses educated i n another country. These descriptions are organized chronolog ica l ly , beginning w i t h the transit ion per iod , understanding the reason to move , and progress to experiences o f re locat ion misconcept ions , challenges i n adapting to Canada , isolat ion, professional support, quest ioning one 's competence, feel ing va lued , and the importance o f w o r k and soc ia l support networks. Reason to Move The impetus to m o v e to Canada var ied amongst the participants; one o f the participants had traveled to Canada i n the past and had a friend i n the c i ty that p rov ided support to her and her f ami ly c o m i n g to Canada. W h e n asked about the role her friends p layed i n her f ami ly c o m i n g to Canada she described it as: Trans i t ion to Practice 30 It was probably part of the decision because, um, she had boys just a little bit older than my boys and they go to the same school. But I've always wanted to come back to [this city]. I've always said I want to come back. And [my husband] had just decided he had enough of the business and this ad just came in the paper sort of at the right time for all of us. The novel ty o f travel and employment abroad was a factor for several other nurses i n the study. One o f the single participants had a s imple w a y o f v i e w i n g her adventure. "I haven't got anything to rush back home for, so got to be somewhere on the planet. Here's a pretty nice place and I've got a lot of things I want to see and do. " The inspira t ion for others came as a result o f d is i l lus ionment i n their home country and v i e w i n g a move to Canada as a chance to start over and steer their l ives i n another direct ion. One participant shared: Well, we had had some problems anyway in [home country], plus I was disillusioned with nursing, and we thought, you know, if we 're going to kick start our lives again, we need to have a change. We need to completely change our lifestyle. We need to get away from all the old stuff and maybe set out a new. My husband had always wanted to come back to Canada but we were never in a position to do that. One participant felt that the experience o f w o r k i n g abroad w o u l d assist her i n career advancement and better prepare her to teach nurs ing: / came to Canada two years ago, and I decided that, um, I wanted to come and work in another country simply because I want to go into teaching nursing students. And I thought, um, that coming to Canada would be good for me in the sense of it would be more experience, and I would have more to offer my students later on. Trans i t ion to Practice 31 The opportunities that Canada affords were the basis o f the mult ifaceted reasoning o f one part icipant 's dec i s ion to move . F o r her it was not on ly the practice and learning opportunities, but the type o f l ifestyle her f ami ly cou ld enjoy: But I very much wanted to come to Canada: a) for the lifestyle, and b) Ifeel it is important sometimes to see how other health organizations operate and to actually have the challenge of you know, perhaps learning new skills, new ways of working, particularly as you become more senior. You know, it's good that you can learn, adjust and prove to yourself that you 're flexible. F o r this nurse language was also a factor i n where she decided to relocate her fami ly . "A big choice was really I didn't have to particularly speak a different language . . . . So the language was important to me that I didn't have to sort of work in an area where maybe language would be a real barrier for me. " In the end the success o f the transit ion was judged by both personal happiness and that o f her ch i ld ren as w e l l as the match o f the communi ty pr inciples o f l i v i n g w i t h personal l ifestyle choices: My sort of issues were that I came so that my family could have a good lifestyle. You know, my children could go grow up in a country where Ifelt I liked the ethos of the country. You know, Hike the multicultural approach. Hike the way that's the justice. To me, I've not been disappointed. And Hike the Canadian people. You know, I find them polite. I don't find there's the violence and the vandalism that you sometimes see, you know, in other places. The children are happy in school. So it's lifestyle as well as the job. Trans i t ion to Practice 32 H a v i n g f ami ly that l ives i n Canada was the mot iva t ion for several participants to move here. F a m i l y can p lay an instrumental role i n faci l i tat ing the transit ion to a new country. One participant described the role f ami ly p layed i n her m o v i n g to Canada: Everything was planned for us because our mom was here, um, working for a long time, so we practically just finished, um, BSN back home, 'cause there are no job opportunities whatsoever there, and it would be really beneficial for all of us to move, like, at the same time, because, anyway, we were classmates; we would be finished at the same time. Some participants wanted to j o i n their partner w h o l ives i n Canada. "My purpose of coming here is to visit my fiancee who is here on a working permit and the second is to take the Nursing Board exam. " One participant was sponsored by his wi fe to come to Canada. "Basically my experience was, uh, I needed some work. I was sponsored by my wife, so in like in 2001 we got married and then after six months my visa arrived and I went, I came here December 2001. " O n arr ival f ind ing employment as a Registered Nurse ( R N ) p roved to be cha l lenging for this i nd iv idua l such that he took up menia l jobs to earn an income: / did cleaning with my wife . . . so I swallowed my pride you know, I didn't do that in my life like cleaning other's house. So vacuuming, you vacuum the house and then you know cleaning so, it's so hard you know. I told my wife that if I pass the RN exam I won't do that again.... We're all intellectuals I mean we 're all educated, so we 're professionals so as much as possible we practice our profession. So that's my pride. E v e n though this nurse had mul t ip le f ami ly members l i v i n g i n Canada, he had no idea o f the challenges he w o u l d face i n relocat ing and f ind ing a j o b that matched his interests. The misconcept ions nurses experience when relocat ing w i l l be discussed i n the next section. Trans i t ion to Pract ice 33 Relocation Misconceptions F o r the participants i n this study, m o v i n g to Canada p rov ided opportunities for professional growth and l ifestyle improvements . Several participants were attracted by advertisements o f Canada ' s nurs ing shortage or by agencies recrui t ing for nurs ing i n Canada. Secur ing a nursing pos i t ion that matched the professional interest o f the i nd iv idua l p roved to be more o f a challenge than the nurses were l ed to bel ieve. One participant described her issues w i t h bureaucracy requirements o f a w o r k permit not correlat ing w i t h the types o f posi t ions vacant i n the j o b market: It's really frustrating, because we read some ads that there's a shortage of nursing and you 're here and you take the Board exam. I already renewed my license, but I haven't practiced yet. It's really frustrating but I'm not losing hope . . . . The problem is when I go to employers they can not employ me because it's a requirement that if you are a foreign worker under a work permit, then you must be on full-time. So I cannot work as a nurse because the position offered to start is in a casual position . . . . there is a shortage and I was informed by Health Match that if you have a work permit, you can work, so that is my hope. The employers have no control about immigration laws, so I understand the concern. No matter how they want to hire me but immigration won't. It's still another hindrance. Anothe r participant was chal lenged by his lack o f w o r k experience i n Canada: . . . / receive an e-mail that, ah, that they told me that ah, I need Canadian experience before, before, before they would hire me. But I told them I just passed the CRNE. It's a bit of irony because Ijust started so I don't have any experience. Because they told me they can't afford to train me like that, so I decided to apply in nursing home. Trans i t ion to Pract ice 34 A l t h o u g h he d i d have some experience i n acute care pr ior to m o v i n g to Canada, it d i d not meet the pos i t ion requirements. H e had this insight into the situation: And then besides it's an irony because before the, the acute care management told me that I should attend refresher course before, before they hired me so right now I'm saving. I'm saving a lot for because I'm planning to attend a refresher course because I, I have a plan to work in acute care. This d i rec t ion p rov ided by a prospective employer may help h i m achieve his goa l o f w o r k i n g i n acute care. Others w i t h a p lan to w o r k i n a certain specialty or agency have been faced w i t h misconcept ions as to j o b stabili ty and what a pos i t ion entails. Several participants were i n v o l v e d i n hospi tal restructuring that forced them to change posi t ions. Some nurses found the pos i t ion they were recruited for not to be what they expected: /just thought these are special needs children, some of them were and, you know, had severe special needs but their seizure disorder was so bad and the problems that they were admitted with was so bad — the learning disability, the special need was not my main focus. . . . I think there was a job in [the other unit] I don't know, I don't know what their thinking was, maybe I should have asked them but. I've still got it, I've wrote down the things I was worried about and I can just remember being told, if you like special needs then you '11 like [this unit]. This nurse recognized the niche she had found i n nursing and questioned the recruiter o n the fit o f the pos i t ion offered. N o t want ing to lose an opportunity and feel ing pressured, the nurse accepted an inappropriate pos i t ion f rom w h i c h she q u i c k l y transferred. Ano the r participant described that tension develops w i t h new colleagues due to a lack o f communica t ion . "There's misinformation at times, which if the minority who are giving us a bad time get Trans i t ion to Pract ice 35 onto it, they feed that to the others, and then it's totally misconstrued and that's the unfortunate thing. " She felt that i f informat ion about her interests and areas o f expertise w o u l d have been shared on arr ival , her transit ion may have been smoother. Several o f the nurses f rom B r i t a i n and A u s t r a l i a expressed concern about Canad ian nurses be ing bitter about the posi t ions they held. "Some people felt, thought their job was in jeopardy because there's people here. So there's a lot of misinformation about the reasons we 're coming and the roles we 'replaying." T h i s nurse went on to exp la in h o w she describes the role she plays . "Well, I say I'm here because I'm a traveling tourist, I'm a working tourist. And they accept that really well." A nurse w o r k i n g i n another organiza t ion described a s imi la r experience: / think sometimes there has been a little bit of resentment sometimes felt when new grads want a job, and maybe someone experienced from outside the country comes in. But if you can work well, you soon are accepted within your, with your nursing colleagues, you know. Several participants described units as hav ing a range o f c l ique mentalities that prevented them f rom feel ing l i ke va lued members o f the nurs ing team: Some of the older foreign nurses on the ward that I was working on didn 't take to me very well. I almost resigned because of the clique mentality that was on there. I kept thinking, "Why have they got a problem with me? " I've actually come here to help address their staffing issues because they had horrendous staffing problems on the unit when we first came from [Hospital A]. Trans i t ion to Pract ice 36 A l t h o u g h the in f lux o f n e w nurses was meant to be a posi t ive measure i n addressing w o r k l o a d issues, it created w o r k i n p rov id ing orientat ion and m i n i m i z e d avai lable overt ime i n some areas. One part icipant described her experience: But it's funny how, one team in particular here has the attitude here of, "Oh, no, we don't have another one of these on our team do we? We just finished teaching one that means whipping you into shape, and then we've got another. " But little do they know, they haven't whipped us into their shape at all, we just do it to shut them up. You know, we just do it because it makes it a lot more comfortable. In adapting to their new w o r k settings these nurses personal ly recognize the knowledge and experience they have and are aware o f the standards for practice. They k n o w the pr inc ip les for care and the f l ex ib i l i t y a l l owed w i t h i n those guidel ines. Th i s was expounded by one o f the participants: It doesn't matter that you put your jars over there than over here exactly so, but this is the anal retentiveness I'm talking about. You know, I worked with an agency [back home], so I go to a different hospital every day. Do you think they 're all the same? No way. And the nurses are all different. Anothe r nurse expla ined, " / kind of had to learn to stand up for myself and say, you know what, this is the way I trained, this is the way I work, this is me, and you have to accept it" Often t imes international recruitment is thought to be synonymous w i t h generous re locat ion packages. The expense and perseverance required to complete the process o f be ing m o v e d to another country to w o r k overshadows the incentive offered by employers : Yeah, I think you really have to want to come to continue on with the process. It does take so long. And, I know a lot of people said, yes, I want to come too, and they start Trans i t ion to Pract ice 37 to look into it, and lot of work, too much work. It's very expensive to come here, not just airfares. But by the time you pay for all the RNABC all that they want, the visa, the medical, it's about $1500, the relocator, without airfares or anything. Nurses who migrate q u i c k l y d iscover that the p romised monies cover a m i n i m a l amount o f expenses. M o s t find that the cost o f rent and other basic needs o f m o v i n g is greater than the monetary incentive negotiated. A c c o r d i n g to one participant: I was only ever reimbursed $3000, and that was just like 3 months rent when I first got here. So all that did was pay for the rent. It didn't pay for any furniture that I had to buy. I couldn't ship furniture over because I didn't have enough money, because they just left me stranded. M o n e y is even further stretched when one comes w i t h a fami ly . Nurses need to real ize that the basic reason to migrate should not be based o n a re locat ion incentive alone as one participant describes be low: And recruitment when I came, there was a $2000 sort ofpayment for you. Obviously you had to stay for 12 months, but it doesn't really go very far. By the time you paid your RNABC exam, your flight, especially if you 're bringing family and your sort of first lot of rent things. So the money isn't the carrot really. I don't think the money, if you offered foreign nurses really big pay packets, I don't know that that would bring the nurses over that want to really stay, you know. And, you have to want the lifestyle, you have to want to be in the country, be willing to live the lifestyle. F o r some, the relocat ion package is confusing and not what they were expecting. A l s o , payment o f re locat ion funds is not received i n fu l l immedia te ly o n ar r iva l . One nurse shared her experience: Trans i t ion to Pract ice 38 It takes a long time for you to get your money back, your relocation money bach And when you do get it back, it's not as much as you what you expected to get. Um, they, they kind of don't tell you the truth. Um, they 're very sketchy on that, really. They, it nothing was in black and white. I'd asked for, uh, my relocation package to be in, be in my contract; it w a s n A n d , uh, Ifeel that they, they didn 't tell us the truth. I feel that they lied to us. And when you'd ask for more information, he would eventually get back to you, this [relocation assistant], but it would be, like, a week or a week and a half. Um, I've never heard from him again. Strategies set-up to assist nurses i n settling into a new locat ion have at t imes become more o f a frustration than a benefit. Further, there are many hidden costs to relocat ing and b e c o m i n g employed i n another country that are not discussed up front w i t h prospective employees: / mean no one really expects that, but there is some hidden costs that we don't know where at the time, things like the registration, the price of the union and registration is amazing. I mean we just fall over. Anothe r nurse also questioned h o w the fees col lected are u t i l i zed . "Which also means, where does the money go to? I've got no idea. And the union, where does that money go to? " M a n y o f the nurses in terviewed compared the professional fees be ing p a i d i n Canada as be ing exorbitant to what they pa id i n their home country. D i f f i cu l t y also arises when nurses educated outside o f Canada are confronted w i t h their col leagues ' misconcept ions about what they have received for c o m i n g to w o r k at the organizat ion. One o f the participants expla ined: Often people say how long are you staying, oh, I'm going home in whatever the month they came. But you only just got here, well the contract is only 12 months. Trans i t ion to Pract ice 39 They pay $100,000 to get you out here. Oh really. Where's the $100,000? I didn't see any of it. Nurses recruited to specific organizations and posi t ions often s ign a t ime l imi t ed contract, w h i c h i n most cases can be extended w i t h mutual agreement o f the employee and the employer . Nurses w h o come to Canada on a w o r k v i s a and choose to stay are required to renew their w o r k visas and eventually apply to be permanent residents or landed immigrants . The dec is ion to stay i n Canada indefini tely can be a diff icul t dec is ion , especia l ly w h e n fami ly members are s t i l l i n the home country. A l s o , the process required to be able to stay i n Canada long-term is daunting to some so they return home. Col leagues w h o have not faced the challenges o f bureaucracy related to immigra t i on are unable to empathize w i t h these nurses and the tedious applicat ions they are required to complete. P r o v i d i n g support to colleagues i n their in i t i a l stage o f transit ion to Canada is also hard at t imes. The f o l l o w i n g section w i l l further explore the challenges experienced by the participants o f this study i n adapting to Canada. Challenges in Adapting to Canada M a n y Canadians assume that m o v i n g f rom one Western nat ion to another must be re la t ively easy as our countries have so many s imilar i t ies . In m y in te rv iewing , nurses f rom B r i t a i n and A u s t r a l i a described more challenges i n their transit ion to Canada than nurses f rom the Ph i l ipp ines . There may be mul t ip le reasons for this trend i n the data; however , naivety and personali ty confl ic ts are two prominent inf luencing factors. B e i n g prepared for the adaptation one is required to undergo w h e n learning new surroundings and settling into a new j o b is essential. The process o f adaptation was explored w i t h a participant: Trans i t ion to Pract ice 40 It's not easy, um, and it's not, it's sometimes the fact that you're learning a new job, you 're settling into a new country, you've got exams looming, you 're trying to fit in courses and orientate, and you 're trying to settle your family as well. So it's quite a lot that goes on. And I think it takes six to eight months, and I would say the first six months definitely, is a period of time where you really are so on the go emotionally, physically, you know, you 're just constantly adapting and adjusting and learning and, under pressure, really. That's the hardest period. Anothe r nurse also out l ined the first s ix to eight months o f being i n a new place as the most diff icul t : But it is a really heart wrenching transition when you first come here. And I wish it didn't have to be, because it is such a beautiful place. And it is such a really good experience once you 're into it. It's a whole different way of life and it's a really good way of life, too. But you've just got to really rough it out those first six to eight months and get through it. But I'm glad I did. I'm here to stay now. T r y i n g to survive these in i t i a l months can be traumatic w i t h feelings o f isola t ion, lack o f acceptance, and loneliness. F o r some this becomes a burden that is too heavy to bear as indicated by one o f the participants: Yeah, I think, yeah, I just couldn't, couldn't take it. It was intolerable to the point that I decided, that's it. I always, when I came here I said I'd give myself six months and if I was unhappy, I would leave after six months. But as it turned out, I was so unhappy I thought enough is enough. But yeah, I think I got used to it but it was still the right decision to leave. Trans i t ion to Practice 41 This nurse d i d not leave the country as she was able to f ind a pos i t ion w i t h i n the organizat ion i n w h i c h she found greater j o b satisfaction; however , she m a y have just as easi ly chosen to return home. Participants l i ke this nurse who experienced significant trials i n their transit ion to Canada were emot ional when sharing their stories. A year or more later, the hurt is s t i l l fresh, unresolved, and not healed. Unders tanding the challenges faced by these nurses m a y help others adapt to Canada more easi ly i n the future. Differences i n pr inc ip les o f funct ion were hurdles. Several participants described their workplaces as be ing s t i f f and r i g i d w i t h l i t t le openness to change. "And they 're very, very stuck in their ways; they won't change. They don't want to change, and when change is, is put in place, they really resent it. They set up a huge barrier. " One o f the other participants compared her experience w i t h the change process she was fami l ia r w i t h i n her home country: And we do find that, at home we 're taught to challenge things all the time and ask why, and here, that's not a very popular thing to do. And when you ask why it's just because we do it, which we 're taught that's not an acceptable answer. If you come to a "it's because, " then you have to find the reason why, and if you can't find the logical reason why then it needs to be looked at, perhaps come up with a change to improve on that, but that doesn't seem to be a thing here . . . . A lot of things are just accepted as fait de compile, which is the way we 're taught is not acceptable. You know, if it's just because, may be there's a better way to do it and let's look at it. And everybody gets in and does that.... But once something is in place, nothing can shift it. It's like the Rocky Mountains, it can't be moved. And we stand by and wait and our Trans i t ion to Pract ice 42 suggestions don't go anywhere. Ifind nursing frustrating from that point of view, anyway. A l t h o u g h these nurses poignant ly out l ined systemic issues they encountered, they also were reflective and recognized personal responsibi l i ty i n the process o f adaptation. Some talked about the impact o f personal perspective and attitude o n situations: You have to actually enjoy the place where you are while you 're there, because you really don't know how long you 're going to be there for. So you have to actually embrace where you are and make the most of where you are. T r y i n g to understand h o w one 's attitude affects their colleagues is valuable as w e l l . One o f the nurses tried to empathize w i t h what it w o u l d be l i ke to gain a col league f rom another country w i t h different ideals and ideas related to practice: And I think if you 're a nurse, I don't know if it's my attitude, you know, I respect all my nursing colleagues, and sometimes we all have different personalities, we all have different strengths to bring. You know, when you have nurses come over to what is your home country, it may not always be bringing what you are used to, but sometimes they can offer something from it. But you know, you have to fit in, and when you come to a, it's like if you go to a new hospital, you know, if you 're not going to fit in, you 're not going to make an effort to you know fit in, you can question, but how you do the question and the asking is the difference. It's attitude. It's your accountability. One participant detailed a greater accountabi l i ty for addressing issues faced i n the transit ion process. She w o u l d l ike for others to be able to learn f rom her experience: Trans i t ion to Pract ice 43 People who come here, they bitched and complained about stuff, gone home and haven't sort of said, "Well, how can we fix it? " It might not be for me or you, but coming down the line, you know, it might be. Anothe r participant expla ined the need for nurses to be responsible for addressing issues internal to the profession. "It's up to us to resolve those problems in our own profession because we '11 destroy ourselves if we don't. " T h i s nurse shared the valuable lessons she has learned about supporting her colleagues and funct ioning w i t h i n a team: We 're all nurses together. We shouldn't be eating each other. We should be helping each other. And you know what, I am different to you. I nurse differently to you, but at the end of day, my goals are the same as yours. My patients are of number one importance to me. It shouldn't be the way I speak; it shouldn't be the way I make a bed. It's my nursing care, and my goals are the same as yours. So, you know, learn to live with it because I'm the same as you deep down. In sharing this w i t h her new colleagues, she was able to convey that she was "one o f them." A l t h o u g h there were outward differences, their goals i n p rov id ing nurs ing care were the same and, therefore, they c o u l d relate to each other i n their commonal i ty . A d a p t i n g soc ia l ly was another challenge described. "Ifind it hard to, like, yeah, switch your mode from nursing there to nursing here, at the same time, adjustment for myself. Like socially I, I can't talk to anybody. It's like no friends. " The need to adapt and make the most o f the environment was the impetus personal change for one nurse: /found trying to fit in very hard, as I said, in with the Canadian nurses. It took that probably about a year and, uh, I found that I had to be more open to people. I had to, Trans i t ion to Pract ice 44 um, put myself out there to be accepted, whereas in [home country] I didn't have to do that, but here it was quite hard work doing that. B e c o m i n g comfortable i n a mul t icul tura l society and soc ia l i z ing w i t h others w i t h different backgrounds was a n e w experience for some o f the F i l i p i n o participants i n this study: We, we 're not used to dealing with, um, a different culture, um, entirely different, entirely different from us. Um, just like here, if you go to the community centres, it's very multicultural. It's kind of hard because we never had friends who are Caucasian, or we never had friends who are East Indian, and, I don't know, sometimes you can offend somebody by mentioning something, and you won't even know it. So, that too, it's, it's also hard, because just learning how the cultures are here, learning ourselves and finding our identities, and our place here in Canada, too, at the same time. These nurses developed friendships w i t h people f rom various cultural backgrounds and describe feel ing more comfortable w i t h divers i ty and not being bound to their o w n cultural group. M o s t o f the F i l i p i n o participants i n this study made purposeful decisions not to be secluded w i t h i n F i l i p i n o groups. T h e y define Canada as being mul t icul tura l and desire to experience l i v i n g i n such a society. Several participants out l ined specific practices i n the workplace as challenges. The broader role o f the nurse i n the healthcare team was an adjustment for some. One participant expla ined: At home, um, Iwasn't challenged, perhaps, as much as I was here at the beginning. I had the knowledge, but I just didn't really use it, it was based on my ability in [home country], as we have doctors there that, that do everything, and you as a nurse care Trans i t ion to Pract ice 45 for the patient, and, and do, do your nursing duties. Here in Canada, you 're expected to do a little bit more, and I found. . . really paying attention to those things much harder, and 'cause I'd never done it before. In particular, the nurse 's involvement i n check ing charts and deve lop ing and mainta in ing medica t ion records was a surprise for some. "We didn't do all the, um, the thing Ifound quite shocking here with the way we check the charts and we get involved with the medication record sheet. We have nothing whatsoever to do with that in [home country]. " "Our MAR system, at the hospital, it's just deplorable. There are so much medication mistakes, " stated another nurse. These nurses described systems that appeared to be more streamlined i n the processing o f orders and l i m i t a certain amount o f human error that m a y occur when an order is processed. M u l t i p l e participants ta lked about c o m m o n , everyday items that are taken for granted, namely a dr iver ' s l icense. Obta in ing a dr iver ' s l icense is a right o f passage that many o f us pass through as w e become young adults. It was a shock to many to learn that the l icense they have had for years is no longer v a l i d after three months o f l i v i n g i n Canada: And the fact that, um, you can only use your [home country] license for three months; that's another thing we didn't know about. We thought we could drive, and be fine for a year or so, 'cause you had a working permit note. We didn't know we had to sit a driving test, we didn't know we had to do the knowledge test. These are, these are things that Ifeel they should have in a pack for foreign nurses when they come in Canada. These are basic things that we have in [home country] that you know about because you live there and you've grown up there. But when you 're coming to a different country, you don't know. Trans i t ion to Practice 46 In descr ib ing the fo l ly o f many people ' s misconcep t ion about the va l id i ty o f their d r iver ' s l icense, one nurse recognized the impl ica t ions o f not be ing informed and hav ing appropriate l icensure: People are under the impression that we can keep driving on our [home country] license for 12 months so long as we got the initial license, and that's not true. Because our [home country] license is only good for 3 months, and once our [home country] license is dead, so is our international license, 'cause you have to have a valid, I mean our license is still valid at home, but it's not valid here any more after 3 months. So people are under the misconception that they can keep doing that. And some do. But if you get into a big car accident, you will be buggered because it wouldn't be legal. But you know that's not something that we 're aware of. And until we go through the pain of it, we don't, a lot ofpeople aren't aware. The challenge i n procur ing a n e w l icense and transferring insurance can create more bumps a long the road due to people ' s lack o f knowledge o f the required processes. The expense o f vehic le registration and insurance can be a shock: I didn't know that you only had 3 months to get your Canadian license for instance. Let's take that. I've just got my Canadian driver's license in November. If I had known, I could have bought all my car insurance documents over with me. They are valid for the first year you 're here. You've got to get your Canadian's driver's license within 3 months of being here for your [home country] car insurance to be valid here for you to be able to get a discount. Trans i t ion to Pract ice 47 The nurses i n this study were frustrated w i t h hav ing to take another exam. It is an added i t em on the "to d o " list o f the international migrant i n the midst o f a busy and stressful t ime o f transition. A c c o r d i n g to one o f the participants: Having said that, for the first 12 months, you 're so busy having colds, settling down at home, sitting the RNABC exam, and then of course there's the driver's license, which is the other thing that you retake. So you have 3 months of driving and then you have to re-sit the driver's license, which is something on its own. N o t being able to dr ive or k n o w i n g h o w to access cost and t ime efficient transport i n a c i ty can have an isolat ing effect. The feelings o f i so la t ion experienced by the participants i n this study w i l l be described i n the next section. Isolation W h e n m o v i n g to a new country people often automatical ly have a sense o f i so la t ion as they leave behind fami ly , friends, and a l l that is famil iar . " We left our two daughters behind in [home country]. They were young adults. I missed my youngest daughter's 18th birthday and my eldest daughter's 21st birthday being here. It was heartbreaking leaving them behind. " There is a sense o f abandonment i n the words o f this mother as her need for a new start i n life separated her f rom her daughters causing her to miss some milestones i n their l ives . L i v i n g i n new surroundings that may be un l ike any setting one has been i n before can be frightening, especial ly when one does not have an established support network. "I'd never lived in a high rise before. I was isolated in a high rise in a big city. My family was 6,000 miles away. " A l t h o u g h this nurse was l i v i n g i n a large c i ty w i t h a m y r i a d o f resources i n close p rox imi ty , she was overwhe lmed i n her experience and was not at a l l equipped w i t h the informat ion she needed to easi ly adapt to her new surroundings. The feel ing o f i so la t ion Trans i t ion to Pract ice 48 can have a c r ipp l ing effect on one 's self-esteem and we l l -be ing . One o f the participants shared her experience o f feel ing isolated: But when you come across as a foreign nurse, you've given up everything. And you 're just kind of reaching out for help and just for contact, and there's nobody there for you. So it's really hard. And they really need to look into that. Get some really good support. Fee l ing alone and not hav ing any supportive resources can be d isabl ing . People f lounder i n situations that they describe themselves as hav ing the sk i l l s to cope. T h e y have a heightened sense o f vulnerabi l i ty related to the fact that they are outside o f their comfort zone. One participant described: And, and because I was so unhappy I couldn't really verbalize that too, at home and I, I am very good at like just taking things in their course, but at home I would have perhaps taken, taken that and said, you know what, I'm really doing my best here and this really, this is not helping, but I couldn't, I was just. . . I was just, like I said, I was just I can't find a word, I was just overwhelmed. I couldn't deal with that. People want to be able to reach out to the support they have established i n l ife when they encounter struggles; however , even m a k i n g a long distance phone c a l l was troublesome enhancing the sense o f isola t ion: / couldn't even have long distance phone calls at the time because we had no credit history so I was really isolated. I was crying out for help to Human Resources, and there was nobody there to help me from a foreign nurse's point of view. It was all about bureaucracy. It was not about let's give this girl some support. Let's put her in touch with other people who have been through the same process. Shed the same Trans i t ion to Pract ice 49 tears. Shouted at the walls, banged their head against the walls because they 're coming up against the same things - nobody to give me useful, practical information. Oh you know, this is the way you get through this. This is who you contact for this. There was no one. The support mechanisms and groups the nurses thought w o u l d be a help to them faltered and fai led. "Except none of that really happened, it didn't take off. And now it's completely gone. I think they've forgotten about us. " Th i s nurse was informed o f plans for an event to enable nurses educated outside o f Canada to connect w i t h other nurses w h o were new to Canada, but the schedule o f events and meetings never mater ia l ized. Nurses independently sought out each other and i n round about ways became acquainted w i t h nurses educated outside o f Canada that w o r k e d at other organizations. Several nurses w h o participated i n this study were l i nked w i t h an assistant to help i n their re locat ion and f ind ing accommodat ion o n arr ival . I was to ld mul t ip le stories o f nurses be ing placed i n inappropriate hous ing matched w i t h homeowners or roommates that were more antagonistic than w e l c o m i n g . W h a t was meant to be a beneficial in i t i a l soc ia l contact became a factor i n nurses w i thd rawing and isolat ing themselves. A c c o r d i n g to one o f the nurses i n this study: / think if they had, um, if the Human Resources department had said to us, you know, this is the hotel, this is the Days Inn Downtown; just book in there, and go and stay there and then phone us in a couple days once you 're more settled, and, um, come and speak to us, and we will give you a resource person, another nurse, from a foreign country. Even if she had been Canadian, it really wouldn't have mattered; as long as it had been somebody that, that lived here and had been here for a little while, and who would know where the basic things were, and help you meet people. Trans i t ion to Pract ice 50 Um, you know, I, I didn't see anybody for about six weeks; it was, like, six weeks before I started my orientation, and, um, you know, when you 're, when you 're living downtown and you 're in your room, you can't come out of the room, 'cause you don't want to go in sit in the lounge area where this woman was because then I'd be invited to go to church and I'd have to make up all these excuses. E v e n those w h o had fami ly i n Canada felt isolated. F a m i l y members that ar r ived together felt comfort i n hav ing another person w i t h them i n the same situation, but d i d not feel that they cou ld relate to the f ami ly members that were already established i n the country: When we came, we don't have friends here, we don't know anybody. We have our cousins, but they speak (family member: we didn't grew, grow up with them, they were born here) they speak straight, you know, English, you know; we can't really understand, and they 're like, yeah, we were like, so shy, we were. A sense o f isola t ion and be ing different also develops when one cannot find material i tems or entertainment that is fami l ia r to them. "The shows on TV; it's like, I can't even appreciate. And the food here, it's like, there's no Filipino food. " Participants described searching for items that reminded them o f home. One nurse had a contest w i t h her colleagues to make food f rom her home country. T h i s is an example o f the ingenuity o f people i n finding mechanisms that create a sense o f comfort and support. Nurses m a y search for support i n several arenas inc lud ing : professional bodies, such as government, nursing associat ion or un ion , or professional practice groups; workplaces ; and socia l networks. The experiences o f the nurses i n this study i n seeking support and reflecting on what support was prov ided versus their expectations w i l l be explored i n the f o l l o w i n g sections. Trans i t ion to Pract ice 51 Professional Support One o f the m a i n challenges i n obta ining support is k n o w i n g where to f ind it. Some participants learned about agencies after they had arr ived and settled w h i c h w o u l d have been helpful to them pr ior to them even m o v i n g . One nurse ta lked about the potential to connect w i t h government agencies i n her home country to assist i n the migra t ion process: Get all the information you can from your own consulates in the country where you live, and get them to help you because there's recruitment people that can help you. And find out what's required and get a work visa before you get here. In in te rv iewing the participants, it was surprising to f ind that nurses f rom the Ph i l i pp ines appear to be more proactive i n l i n k i n g w i t h government agencies than nurses f rom B r i t a i n or Aus t ra l i a . T w o nurses had a d iscuss ion about the benefits o f H u m a n Resources and S k i l l s Deve lopment Canada ( H R S D C ) : Oh, you know community resources. Like how do you call it? (Human Resources) Human Resources? Because you go to Human Resources, they provide you free advice, financial too. If you need money, they will. . . When I'm doing my review, they gave money for my babysitter so I can do it. Plus if you go there, they will give you a free bus ticket. If you find a job, they will give you $50. It's a job. You can use the computer. They can do your resume. A couple participants described Hea l th M a t c h as be ing a very important resource for them i n searching for nurs ing posi t ions: Trans i t ion to Pract ice 52 Yes, it's Health Match BC. So they were the really the first one who helped me giving me information . . . . Health Match has some more information about hiring foreign nurses. So I was able to know more about information, so that was helpful — that saves me money because they gave me resources which are free. The B r i t i s h and Aus t r a l i an nurses tended to use recrui t ing agencies more, w h i c h was problematic for some as they discovered that the agency staff d i d not t ruly comprehend the transit ion process o f m o v i n g to Canada. One participant described: They don't know a great deal. When we emailed them back or talked to them on the phone, they 're not aware of a lot of these things. They basically, their job was basically to find us, to find somewhere here to position us, or find who goes to them and says, "This is what we want, " and they find us, or we say we want to go to here, and they find the job. And then they marry us up. Once they've got us in like with the registration or licensing people, immigration and the hospital, the hospital offers, gives us a job offer. Immigration says, okay, we '11 process your stuff, and we do what we have to do with the minimum. There's no backing there. One nurse was extremely frustrated when the agency she was w o r k i n g w i t h c losed m i d - w a y through her comple t ing the process o f being able to w o r k i n Canada. "I had to finish it all off myself. She was no help to me whatsoever. I shed many tears." Nurses f rom other countries expressed confusion around the separation o f the nurs ing associat ion and the un ion . F r o m the stories I heard, no representative f rom either organizat ion took t ime to exp la in the purpose and function for two distinct bodies. T h i s led to quest ioning the value o f the organizations: Trans i t ion to Practice 53 / don't find the union helpful at all. Um, Ifeel that they get their money for nothing. Um, they never kind of come up to the units and see how things are going. Um, I don't know what they 're meant to do for me. Nurses seeking informat ion and further assistance i n the transit ion process at t imes incorrect ly contacted agencies that d i d not handle the issue o f concern and became more frustrated by the perce ived lack o f support. Several participants l i nked w i t h professional practice groups for specialties such as gerontology and the operating room. T h e y described these groups as hav ing a good support structure w i t h month ly meetings and regular newsletters. Some participants l i nked w i t h other support groups to assist i n their transit ion. "Luckily we have, we call it, Filipino nurses support group that they, for free, they give review for free. It's like a study group. We don't have a teacher, just a study group" Workshops targeted to nurses educated outside o f Canada were also thought to be helpful : And I was thankful for the RNABC because they offered a seminar to the foreign educated nurses which are very beneficial and advantage for us in giving us orientation about the health care system and the standards of practice here in British Columbia. The nurs ing registration body was useful i n p rov id ing clar i ty o n scope and standards o f nursing practice through p rov i s ion o f wri t ten materials and consultat ion w i t h practice advisors. "So there are, you know, like the RNABC, I think they're a good body. I found they sent me quite a lot of information on accountability, you know, standards and issues like that, they 're pretty good." Several nurses described the need for the nurs ing associat ion registration department and employer human resources departments to develop a greater Trans i t ion to Pract ice 54 understanding o f the experience o f the transi t ion by nurses educated outside o f Canada to w o r k i n g here: / wish they had a department that deals with foreign nurse issues and, again, get some foreign nurses working within that department that know what it's like to go through this whole process. And not just on the end of a telephone flicking through your charts and folders, saying, you haven't got enough hours in obstetrics or you haven't got enough hours in peds. This is what you've got to do. Again, I think they really could get some support groups going for foreign nurses. Just somebody there that you can talk to, that's not condescending. Somebody who can give you some really good useful information and say to you, T know what you 're going through because I've been through it myself. And hang on in there, because it does come through in the end.' And it is worth it in the end. Just that kind of support would be really good. M a n y participants described communica t ion delays f rom R N A B C that left nurses frustrated and unsure o f their status and progress i n the registration process. One participant expla ined: / mean, you know, they say ah the problem with RNABC sometimes when, when we don't follow it up, they won't reply like that. You know, I experienced that that's the first one so I waited like one month for their response so, so after one month I phoned them so you know like make me concerned about the TSE. So I'm wondering if support is enough. So I wrote a letter and then there's no response for after a month, so I kept on waiting and then I decided to phone them. You know sometimes when you left a message; you have to wait for at least one to three days for the response. Trans i t ion to Pract ice 55 One participant concluded, "You know RNABC itself, if you leave a message they don't reply. So you have to go there personally. So that makes time slower." F o r those w h o are s t i l l overseas ach iev ing efficient communica t ion can be even more diff icul t . One participant described her experience: So it was terribly, terribly slow, and terribly, terribly frustrating. And a lot of the other people have said similar things, except the others haven't some of them sort of got it going in 16 to 18 months . . . . There was a lot of silences in between there: I had to keep prompting, what's going on? And you 'd wait 3 weeks thinking, "Oh, the post. " And then you'd ring up and, "Oh, somebody hadn 't processed that, it's on somebody's table. " The college was the biggest pain in the neck. For me, that caused me the most, caused me all sorts of- 8 months ofphone calls and letters and all that sort of stuff. One cannot assume that the registration process i n another j u r i sd i c t i on w i l l be qu ick and easy s imp ly because one has a reputable educat ion and extensive w o r k experience. E v e n those recruited to specific contract posi t ions encountered lengthy delays i n obta ining their registration: It was like, every step forward seemed to be two steps backward over time. It did get frustrating. When you know you've got the job, and they ring up and say when are you coming, and you say I still haven't got a work visa and I still haven't got my letter to say I can sit the exam. And then the interim permit that was another one we had to apply for, yeah, it's just seemed they made it hard when they so desperately wanted nurses. Trans i t ion to Pract ice 56 Nurses educated outside o f Canada w h o responded to an advertised nurs ing shortage be l ieved they c o u l d be o f benefit to a Canadian organizat ion i n f i l l i n g needed posi t ions w h i l e taking advantage o f a personal opportunity for themselves. The lengthy migra t ion and registration process coupled w i t h the experience o f transi t ion to a new workp lace soon caused the nurses to quest ion their competence and personal value i n the health care system. Questioning One's Competence A n x i e t y is pervasive w h e n people start new jobs . E v e n the most experienced, w e l l educated nurses I in terviewed questioned their abi l i t ies i n beginning to practice i n Canada. " / think it's obviously when you've got experience; it's thinking, Well, will I know what I'm doing? " ' Other nurses questioned i f they had made the correct dec i s ion i n m o v i n g to Canada. "/ used to go to work on the bus thinking I can't do this. I really don't want to be here anymore. What did I do this for?" The novel ty phase o f migra t ion described i n the literature seems to end soon after ar r ival and beginning to work . Nurses repeatedly to ld o f their d is i l lus ionment w i t h their pos i t ion and doubted their abi l i t ies to succeed: As I said, the first few weeks were hell. Ijust didn't want to do it. Ijust felt like I was falling short even though I've been an ICU nurse. Sometimes I just told myself I don't know anything, why do I want to do this. It's just the difference in the transition. It's just different expectations, and it was meeting those expectations, I didn't know if I was up to it. I must be because I'm still here. One nurse described the feelings she had her first week o f work : " / can just remember being just totally overwhelmed, really frightened, like really what have I done? What have you done?" Th i s nurse had specific concerns that she had identif ied pr ior to c o m i n g to Canada: Trans i t ion to Pract ice 57 Before we came for definite, it would be said, I was worried about going into a [the specialty] because I knew nothing about. I was worried about going into acute care and I'd been at acute care for about four years. I was very concerned about IVs because I knew they did a lot of IVs and I'd done IVs but I knew it was different here and I didn't have - it wasn 't something that I had a lot of experience doing. A l t h o u g h this nurse had a sense o f one aspect o f practice that w o u l d be different for her, she d i d not understand the intricacies o f the practice change as the environment was bas ica l ly u n k n o w n to her. In i t ia l ly when beg inn ing to w o r k i n a new pos i t ion one nurse said, " / didn't even want to touch the pumps. Ifear have fear of the unknown!" One o f the other participants was able to further identify specific aspects o f practice o f w h i c h she cou ld improve her knowledge pr ior to m o v i n g : Probably the fact that, um, things would be different. Um, you do things differently here. The assessments — that was a huge concern. I was so worried about that. And, uh, I used to think oh my god, they 're going to test me, and what if I get it wrong, and I'll look like a real idiot, and look like, you know, I don't know anything, and that was the other thing that was worrying, that you'd been trained for such a long such a while. I've been qualified twelve years, and you, you think oh god, I'm supposed to know everything, but what if I don't? Well, I know I don't know everything, but I'm going to look really stupid and inadequate. And, uh, that was, probably for the first four months Ifelt like that - very inadequate. She s t i l l questioned her abi l i ty to perform certain sk i l l s and make cr i t ica l judgments ; however , she had taken t ime to identify her learning needs and implement a learning p lan that enabled her to feel more comfortable i n her transi t ion to practice i n Canada. These Trans i t ion to Pract ice 58 nurses have described differences i n practice and personal issues that caused them to personal ly quest ion their competence to practice. Several nurses to ld stories o f their experience i n hav ing their competency questioned by colleagues. W h e n descr ib ing hav ing their competency chal lenged, the participants i m p l i e d this to be a demeaning experience especia l ly as quest ioning was often done inappropriately i n the presence o f others and not framed as constructive feedback. One participant expla ined: There was a group of people who particularly gave me a hard time wouldn't appreciate that just because I couldn't do what they've been doing for the last five, six, or fifteen years, did not mean that I was crap at my job - it just meant that I was from a different country and had different background from they had and just a little patience would have gone a long way. T h i s nurse longed for someone to take a moment to empathize w i t h her and help her understand her role and h o w she c o u l d succeed. The stress o f the transit ion and constant pressure i n the workp lace she recounted made her "feel like a crap nurse, feel like I knew nothing and which is true enough, I didn't know about [the specialty]. I was terrified. I think some people didn't understand how difficult it was." T h i s nurse equated the lack o f mutual understanding between her and her colleagues to speaking different languages: Who said, 'For one minute never think cause you 're going to an English speaking country that you 're going to know what they 're talking about or they '11 know what you 're talking about because they won't.' And of course she's been to England enough; it was interesting. And sure enough, sometimes, I feel like Fm talking Japanese. Trans i t ion to Pract ice 59 N o t feel ing empowered to be able to ask c la r i fy ing questions i n a supportive environment prevented this participant f rom understanding the expectations being made o f her. B e i n g able to have an open dialogue about expectations throughout the transi t ion per iod , standards for practice, as w e l l as pol ic ies and procedures that is constructive i n b u i l d i n g knowledge and s k i l l is essential. A participant i n another practice setting shared her experience o f be ing made to feel incompetent: And when you 're being targeted everyday because you do something a little different, but when you go and look at all the books, you are well within the bounds, but because they haven't seen it, it doesn 't exist, and they will scream across the room at you, in front of surgeons and everything and make you feel big enough to crawl under the bed. It becomes that you see your name beside that person you want to go home sick. She found the department to be inconsistent and never k n e w h o w her orientat ion w o u l d be day-to-day. It does not appear that any o f those support ing her i n the orientation per iod took t ime to assess her competencies and develop a p l an for the shift that w o u l d meet her learning needs. Th i s participant commented o n her experience: I went to another where I was treated like I'd left my brain on the tarmac out at [the airport]. Then I go to another one and they treat me like, "Oh you know what to do, get on with it, " which doesn't worry me or doesn't worry most of us. So it depends where you were, what your orientation was. Prior knowledge was irrespective and if you don't know just ask me. Well, what do you know? Or it was like you 're a dummy and I have to teach you everything, to scrub your hands, to put your gloves on, stuff Trans i t ion to Pract ice 60 that you've been doing since you were qualified. So it depended on who you got and where you got, as to what happened to you. Exper i enc ing doubt f rom others related to one 's competence to practice m a y cause an ind iv idua l to become more assertive or defensive. M a n y nurses migra t ing to Canada to w o r k have been prac t ic ing for years. They are confident i n their sk i l l s and abil i t ies to nurse. One o f the older participants i n this study made the expectations she had o f her n e w colleagues clear: And I've found the best way that I've made my stamp with them is to stand my ground, and I've actually said to them in meetings, if you have a problem with the way I practice, I would really appreciate you coming to me. Don't talk about me behind my back because that is not the way to resolve problems. Come to me. I'm amenable. If we can't get it solved here, we can go see the manager. T h i s nurse was proactive i n t ry ing to prevent a b reakdown i n communica t ion between her and her colleagues by presenting herself as approachable and open to feedback. A s an ind iv idua l it can be cha l lenging and daunting to assert oneself to the regulatory body w h e n one's competence is questioned. "You recognized our experience but you're not going to recognize our qualifications. " There was a repetitive theme i n the interviews w i t h nurses f rom A u s t r a l i a and Br i t a in , i n particular, that hav ing to take the Canad ian Registered Nurse E x a m i n a t i o n ( C R N E ) questioned their competence to practice i n an insul t ing manner. A c r i t i c i sm by one nurse i n the study: Um, one thing that I suppose for me that really annoyed me was sitting the RNABC exam because before you come, it took a good 12 months to go through the RNABC to get your registration, and I don't for one minute think they should be lax in checking Trans i t ion to Pract ice 61 out your qualifications and things like that. But actually when you have gone through and, like myself I've done nursing, midwifery. I've done a neonatal intensive care recognized course, I've done public health nursing course, I've got my degree and my Masters, and it was all within, you know, the [college in home country] recognized it, and you know, I've kept up to date professionally, and I was experienced. To come over and sit the RNABC exam is a little bit insulting, a little bit unnecessary, I think in some cases. I mean, I found the exam very easy. I was most unimpressed. And actually, when you 're an experienced nurse and sit that exam, you've then got to go back and think, well, what would I have done if I was just newly qualified, because some of the questions we would do some thing, whereas, in fact, what you had to put was call for help, when you would do two things, which were on there, but you know, you 'd be marked on that. So, for me, I was a bit annoyed about that. And I actually think, because some countries, where the standard of nursing education is considered quite good, for example, I think the UK, Australia, Canada, you know, some of these countries do have a good standard of nurse training. I think yes you should always check out references, you should always make sure that they are registered, but to sometimes have to come and re-sit that basic exam is ridiculous. Especially if you are, you know, well qualified and you are in a specialist area. And I think it would be more sensible to may be sit the more specialist exam, rather than have to do the whole gamut again. A s this infers, the C R N E is a basic test o f knowledge that does not recognize a nurse 's expertise and depth o f specia l ized knowledge . The idea o f be ing examined based o n their Trans i t ion to Pract ice 62 specialty area and hav ing registration restricted to w o r k i n g i n that area was proposed several t imes. One participant recal led: / would rather have had, I remember mom ringing. She thought it was, she didn't believe I actually sat that exam. She thought like I had a test in the theatre to see, like to use all the equipment in there. Like she didn't believe that that's what I had to go through. She thought like I'd work there for a little while and then they'd give me a test to see if I could sort of stay in the theatre. Even if they did make it based on the department you did go and work in, it would make more sense. The nurses acknowledged the need to ensure that nurses are qual i f ied, but thought that for experienced candidates w i t h reputable educat ion and good references a more streamlined process c o u l d be implemented. "And I know that the nurses registration has to be very careful getting back to that, of who they accept. But surely to goodness, they can look at the specific overall training of specific countries" T h i s caused them to question the purpose i n them wr i t i ng the C R N E . "So that's what we just were, what are we doing this for? We saw it quite cynically as a revenue getting thing" Some felt that they were be ing used for the benefit o f creating revenue for the regulatory body. The nurses I in terv iewed f rom Aus t r a l i a expla ined w h y they especial ly had di f f icul ty i n appreciat ing the need for a registration exam. "In Australia, you don't sit the exams, so all we have to do is to prove your past experience, your education, etc." Ano the r nurse expounded on this wonder ing w h y in te r im permits c o u l d be granted on the basis o f education, experience, and references: And then when we found we had to do the exam, we couldn't understand that, and felt that was an insult because Canadians going to Australia don't have to do any exams. Trans i t ion to Pract ice 63 And we felt, most of us, the New Zealanders and myself and Australians felt that why weren't our qualifications good enough when you give us an interim permit to work here, and you recognized our experience but you 're not going to recognize our qualifications. We found that quite professionally an insult to our colleges and our abilities. The nurses d i d not feel that the exam was a reflect ion o f their experience and knowledge and left the exam wonder ing what purpose it served. One o f the nurses remembered her thoughts: So I thought, it's either really ridiculously easy or else I've just failed. So I just didn't even think twice about that. What the hell was that.... And this exam here it is such a laugh. It was just ridiculous. And so I thought that was pretty futile. The C R N E d i d not validate the nurses' advanced competencies or demonstrate value for specia l ized knowledge and experience. Feeling Valued The sense o f be ing va lued as a professional begins pr ior to setting foot i n the workplace . A nurse 's registration is extremely va lued as it grants the abi l i ty to practice. In the province o f B r i t i s h C o l u m b i a , registration cards are distr ibuted annual ly i n paper format. I never thought that people w o u l d associate their value as a nurse w i t h the fo rm o f a registration card. One participant expounded: But for registration and licensing I don't get the, for the life of me, see where . . . I didn't even get a badge! Where's the money go? What do I get from the $300 whatever dollars? I get a little piece ofpaper. Not even a laminated piece ofpaper. It's not even a plastic card. It's just a piece of something that you can lose so easily. One participant even shared his ideas for i m p r o v i n g the l ook o f the card w i t h the associat ion: Trans i t ion to Pract ice 64 My frustration here professionally so like little things like the ID, registration, renewal the license, the registration ID. So I wrote RNABC regarding that because you know like um some of us won't be RNs for a long time, some of us will stay for five years, two years as an RN. So I recommend I suggested I wrote a letter I suggested to RNABC to make it like a credit card I mean like BC ID or like a credit card like that to make it more presentable because right now our IDs just a piece of paper ordinary ones. Anyways, I didn't receive ah um a response from them. So I wrote in our journals about it so I did receive but only just a minor one like I told them it won't cost like $20 a year for the membership, you know it would like a lifetime like a ATM card, you know what I mean, like a better card. The nurses i n this study described mul t ip le examples o f h o w their perseverance throughout their transit ion to practice i n Canada has resulted i n them feel ing va lued and presented w i t h further opportunities. Several ta lked about being mentors and preceptors. " / fought really hard, and I have now been nominated and been working as a ward mentor for the last six months. I was actually nominated from other nurses on the unit, unbeknown to me." Some had previous experience as a mentor and were happy to be able to further their experience here: lam a mentor in my ward, and, um, I was a mentor in [home country], um, a preceptor. So, I was used to looking after students, and looking after newly qualified nurses, so when I came here, and um, my manager decided to, um, to do this, um, along with [a professor], um, I was really pleased, and what happened was the people were given you, you had to be nominated by your peers, and I was nominated, and uh, I had an interview, and, uh, I was successful. Trans i t ion to Pract ice 65 Ano the r participant described being entrusted w i t h students as a h ighl ight o f her experience. The abi l i ty for the nurses to be i n v o l v e d i n the unit and have opportunity to provide feedback created a sense o f being valued. One participant shared her experience: They would thank me. Um, at the end of a day, or they'd say, "You 're doing really well; we 're really pleased with you. " Um, my opinion would be warranted on some things. I would be invited to join committees. And, my input is quite important, I would say. Um, people come to me to ask advice, and, um, I'll, I'll give my opinion. Opportunit ies to take o n greater responsibi l i ty and f i l l advanced roles were a posi t ive experience. "Yeah, so that's really one of the good experiences. Like, you know, you get to be promoted, in a way. And being charge nurse, it's, like, a new thing for us, too." Con t inued posi t ive performance has promise to lead to further advancement. One participant expla ined: You know, that my boss told me she '11 give me more opportunities. For example, when I was registered nurse she told me if I can if I can do the, the function of [Director of Care], so after that maybe I can I can think about the position of like manager or administrator till my employer is giving me more opportunities. . One participant was supported to obtain specia l ized education to be able to w o r k i n the area o f her interest: In my case, here, because in [this hospital], they hired me first in the long-term care. And they ask me, "What is your dream? " "Oh, I want to be operating room nurse here in Canada. " And now I got OR nurse. It's really happy, it's really my joy — OR nurse. The investment i n m a k i n g the transi t ion to practice i n Canada is great both o n the part o f the nurse educated outside o f Canada and the employer . F o r those nurses recruited to Trans i t ion to Pract ice 66 specif ic posi t ions, a one year contract is standard. The nurse has no ob l iga t ion to the employer after the contract has expired; however , i f the nurse has had a successful t ransi t ion and is feel ing settled i n the practice setting, the dec i s ion to leave can be diff icul t . There are means for the employer to support nurses to extend their ab i l i ty to w o r k i n Canada . One participant commented: The other thing, when people have been here 6 months or 12 months, or not quite 12 months, maybe if someone backed up and said would you be interested in staying on, and how to go about renewing, that's sort of a pain. But you know there's no explanations for those things, like half way through our time would you consider extending. Some people need to be appealed to, and would stay if they were appealed to. E m p l o y e r s can support nurses ' appl ica t ion to renew w o r k permits. F o r those want ing to stay i n Canada long-term support can be p rov ided i n obta ining permanent residency. Work Support Network Starting to w o r k i n a new setting is anxiety p r o v o k i n g i n itself; w o r k i n g i n a new country the anxiety can be exponential . Several participants had been h i red into posi t ions pr ior to their a r r iva l , yet came to the organizat ion w i t h litt le informat ion about it and their colleagues k n o w i n g li t t le about them. "Yeah, probably, like I said, to have been greeted and sort of orientated to the hospital a little bit before we actually had to start work. Actually feel like you 're being appreciated for sort of coming all this way" Shar ing an i nd iv idua l ' s sk i l l s and experience that are be ing brought to the new workplace m a y a id i n extending a w e l c o m i n g attitude. B a s e d o n the experience o f one participant: Trans i t ion to Pract ice 67 The senior staff are often unaware of our expertise or the terms of their employment. Meaning, the team leaders don't seem to get information to say this is [Nurse A], here is her CV, read it, and know where she is coming from. The information is there, but they don't get given it. It's all seems to stay in another office or they are not privy to it. R e c o g n i z i n g the s k i l l and experience that a nurse brings to the workplace demonstrates value for the ind iv idua l and what the person has to offer. The participants described needing to prove themselves and be ing treated as i f they had no knowledge and experience: And I was treated like - / was told by one of the newly qualified nurses that a handover, somebody had said, 'Let's be careful [with participant] because she's a -we need to treat her like . . .' what do they call it here? A new grad. 'We need to treat her like a new grad.' Which one I think said the nicest possible attention, but I don't really think it was. I think it was just another way of undermining me. Anothe r nurse cou ld not understand w h y her expertise was not recognized. "You know, I didn't just walk in here and shuck everything off that I knew [from home], because the flight across [to here] doesn't suck my brains out" She chal lenged people to take t ime to learn about her and not make assumptions about what she d i d and d i d not k n o w : One of the girls said, I said something to her, why don 'tyou ask me. She said, well I don't know what you know. I said but why don 'tyou ask. And that seems to be a problem. No one asks us, and they just assume we don't know, and then it becomes an insult and we just go on, okay. A l t h o u g h one o f the participants tr ied to adapt to the new w o r k setting, it seemed to become increasingly more di f f icul t for her. She described: Trans i t ion to Pract ice 68 I'm good at putting my hand up and saying, you know I'm struggling here with this, and when I did that I felt it actually got worse. It became like I say a self-fulfilling thing for me and it was safe for them - it was like you know what, she can't do this, or no, she can't do this: Well, no, I couldn 't but I know I can't and you having this crumby attitude is really not helping. Again, I normally I would have verbalized that, but I couldn't, I just sat there and I have to admit I was stupid and I just cried. O v e r t ime this nurse reflected o n the sk i l l s she had that she c o u l d have appl ied i n this si tuation that may have assisted her i n ach iev ing a different outcome. She was able to learn f rom her experience, recognize the expertise she has, and apply her knowledge i n cha l lenging environments. She shared that she felt va lued i n her new w o r k setting. "I had people coming up to me saying, 'Oh, I'm so glad that you 're here; it's so nice when you 're here. "' "And, you know, you go to work and enjoy yourself because you 're there for a long time, more than you are at home," described one participant w h e n emphas iz ing the need for co l l eg ia l relationships. W h e n settling into a new place it is comfor t ing to have some things that are famil iar f rom home. F o r some o f the nurses i n this study hav ing colleagues f rom their home country p rov ided that l i n k to home: I was lucky I supposed that there were 3 other nurses [from home country] there. They were kind of like my lifeline, hearing [those] accents again. Having to start all over again, at least there were . . . girls there who understood me. One nurse expla ined the benefit o f hav ing a preceptor w h o was also educated outside o f Canada: Trans i t ion to Pract ice 69 / was quite lucky that my preceptor was English for two of my shifts so Ifound working with her just great. She was like, oh you won't believe what we have to do with this and that was good cause she knew that I was going to go, 'What?' The preceptor was able to anticipate what w o u l d be surprising and potent ial ly diff icul t for the new hire. The participant was at ease as she k n e w she c o u l d ask questions and relate her current experience to that o f her home country and the preceptor w o u l d understand her perspective. K n o w i n g that a person has someone to empathize w i t h is a comfor t ing feel ing. A nurse i n another organizat ion felt embraced more by other nurses who were educated outside o f Canada than she d i d by Canad ian nurses: /found, um, the Canadian nurses here, um, Caucasian nurses unfriendly, not welcoming at all, very stand-offish, um, whereas the Filipino nurses and Asian nurses were, were more welcoming. As one had put it to me, that she had been an immigrant, too, and knew how, how it felt. Others described hav ing better relationships w i t h their Canadian colleagues than they had expected. One o f the participants expounded: / think Canada has been everything I expected it would be, perhaps a bit more. I didn't expect the Canadian girls that I would work with to be as helpful, as supportive and as friendly as Ifound them. And it's not just the nurses. The unit clerks, the porters, you know, everybody in the hospital I work. You know I can't speak for anywhere else because my experience is in the one place, but generally I think they 're an excellent group ofpeople to work with. I admire some of their skills. Fve learned new skills. Trans i t ion to Pract ice 70 Several o f the participants were able to connect w i t h new graduate nurses and found the experiences o f their transit ion to practice i n Canada benef ic ia l . The leadership w i t h i n the unit, manager and educator, etc., was also instrumental i n creating a supportive environment, described one participant: We had an educator on the unit. She was very good. She was always really amenable to me as a foreign nurse. My colleagues were great once they kind of got used to me and the way I spoke. They were great. They were a big help. Because I was working with a lot of new grads that hadjust taken their Canadian nursing exam, just graduated, and they were a big help just chatting to them. They were really supportive, the girls here. And my manager at [Hospital A] was really nice, really good. She was almost, she kind of took me under her wing like a surrogate mother. But everybody was really supportive. F o r those w h o were displaced f rom posi t ions soon after a r r iv ing i n Canada, feel ing supported through a second j o b transi t ion was cr i t ica l . B e i n g a part o f a group o f nurses i n v o l v e d i n a displacement and transferring to a new unit helps alleviate feelings o f i so la t ion and be ing alone i n the transit ion. One participant recal led her experience: But when we talked to the manager there, she was very welcoming. She seemed to be flexible. She seemed to be really accommodating, and to be understanding of our situation, coming from extended care. And also, the good thing is, um, the staff on our floor from the extended care, we were all together in looking for the wards. We were approximately five nurses, and we all went to that ward. So that, um, made the transition also easier, having familiar people, you know, to adjust to the ward. Trans i t ion to Pract ice 71 R e c e i v i n g support and understanding f rom people i n the workp lace w h o have had s imi la r experiences o f t ransi t ion as the nurse educated outside o f Canada was stated as a need by several participants. A c c o r d i n g to one o f the nurses i n this study: They need some kind of support link within their own group for foreign nurses, people that have been through the process. People who know how it feels. And workers that are actually nurses themselves. They know the difficulties that people are up against. Some nurses took upon themselves to develop support structures for other nurses educated outside o f Canada. "I have a habit of looking out for my colleagues, particularly southern colleagues. Hook out for the Aussies and Kiwis a lot mainly because I'm a single person and older" A t t imes the co l l eg ia l support desired was found i n a nurse at another organizat ion. One participant offered to be a resource to others: Need a Kleenex, come to me. Yeah, we, we do support each other and I met a nurse just by chance who worked at [another hospital], who was in the same boat as me -she was struggling big time. Again she was in an area she knew but again she couldn't figure out the doctor's orders, she couldn't figure out what the heck she was supposed to be doing with these MARs and the different way of working just totally threw her. W h e n facing the challenge o f adapting to new practices, po l ic ies , and procedures a nurse needs to be able to have resources that can be accessed and people that can be coaches i n the adaptation process. One part icipant 's story a l luded to the need for the assurance i n be ing able to turn to her colleagues: But um, yeah, just trying to make some kind of connection with them instead ofjust you know blinking them off and letting someone else, an educator or someone, deal Trans i t ion to Pract ice 72 with it. And maybe just standing up for that person a bit, finding out what they have done and what they are capable of doing. She appreciated the role o f the educator, but wanted to be able to trust that her colleagues w o u l d also facilitate her learning. T o improve his sk i l l s , another participant purpos ive ly used the teaching/learning strategies o f observat ion and return demonstration: If you ask them, "How can you do this? " You know some person if you approach, I'm not comfortable in doing this, I can do this, but can you watch me. You know what, if you ask them, I'm not comfortable in doing this, they will say, okay I will do that and you look. So for the next time that you will do it, it will be easy for you. It's slightly difference, if you do it first. It's hard for you to do it, it's better if somebody is watching you. B y observing first, the nurse was able to v i sua l l y understand the steps o f the procedure. T h e n when do ing the procedure in i t i a l ly w i t h another nurse present, the participant was able to validate the process and receive immediate feedback o n his s k i l l . R e c e i v i n g performance feedback, especial ly i f it is c r i t i ca l , can be di f f icul t and make people defensive. One nurse shared a story about a mistake she had made i n unwi t t ing ly f o l l o w i n g the advice o f a novice nurse. The nurse w h o recognized her error was aggressive and confrontational shock ing the participant and leav ing her somewhat embarrassed: But then, this other nurse that, when they witnessed then they said, "You know, if you need to talk, I'm here, okay. If you need any help, just let us know; we will help you. " That was a very touching moment for me from the other nurses, because I thought everybody was like that. Trans i t ion to Pract ice 73 The value o f a support network cannot be overstated. N u r s i n g is a cha l lenging profession i n w h i c h one can easi ly become d is i l lus ioned . T a k i n g t ime to acknowledge the feelings and challenges experienced by colleagues is appreciated, as expla ined by one participant: Just, you know, when you see someone in tears at work you know, not to think you know what, it's not my problem because I'm not directly involved. Just to go up to that person and say, you know, 'How are you doing? What's, what's, what are you finding hard?' Because it wasn't everything that finding hard, it was just specific things. Because m u c h o f our life is spent at work , friendships often develop w i t h co-workers that frame apart o f one 's soc ia l support network. Social Support Networks N o t k n o w i n g any or few other people i n a ci ty m a y be an impetus for nurses educated outside o f Canada to m o r p h professional relationships into friendships. One nurse p rov ided the details o f her experience: So we had to, to sum it up, we form our social relationships mostly with our work now. Like, um, you know, whether they 're young, or, you know, more senior, it's like we go to functions with them now. We go [in runs] or potlucks, like, we, we go with them. And, you know, it's, it's good, because, in a way, it's like support emotionally, and it's like away from work, you can talk to them, not as, like, nurses like as friends, too. F o r some c o m i n g to a mul t icul tura l nat ion l ike Canada has enabled the development o f relationships w i t h people f rom around the w o r l d . One participant described: Trans i t ion to Pract ice 74 And I've made some good friends. I've got friends that have come over from other countries, Australia, South Africa, you know I work well with them, they work hard; we have a good line. And I also have made some very good Canadian friends, and I have actually found my Canadian colleagues to have been most helpful, you know, advising me on all sorts of things. You know, there was a time when I had a colleague, I bought my house. I didn't know where my house was because I'd only been there twice with the real estate agent. And one of my colleagues brought me and showed me around where I lived and, you know. B e i n g able to connect w i t h people outside o f w o r k to share experiences and explore new things is a blessing. F o r those w h o came to Canada o n their o w n they felt isolated i n their in i t i a l per iod o f transit ion. A c c o r d i n g to one o f the participants: And of course you know you have, you know nobody and you know not a soul, nobody knows you either, they don't anything about you so it's hard. I don't just mean in work; I mean outside of work. If work's crap and then you go home, you've got your friends and whoever, you can deal with it a bit better. You go home to people who don't know you either. O n her ar r iva l , this nurse was fortunate i n obtaining accommoda t ion w i t h two other nurses w h o were also educated outside o f Canada. She found it helpful i n k n o w i n g there were other people i n the same pos i t ion as her. One o f her roommates had been i n Canada for an extended t ime and was able to reflect on her experience at the same stage and provide advice to the new migrant: If you hadn't by chance happen to live with someone or met someone through someone else who happened to be in the same position as you and I think to make the Trans i t ion to Pract ice 75 connection with someone who is struggling too, cause a lot of people take it's like, you know they 're not as sensitive as everybody else and don't take it to heart. So to meet someone like you that is really missing home and really struggling, not that it's a good thing that I'm struggling, but I think that's what helped me and you know, so having people to meet that are in the same boat as you for definite. The participants descr ibed just hav ing someone to be w i t h w h o understands the other person as a c o m m o n aspect o f soc ia l support. T h i s may be to have t ime to vent about w o r k experiences and relat ionships or to participate i n activit ies that provide a distraction f rom the reali ty o f current challenges and frustrations. One participant expla ined: You know it's so important like when you 're finished work and you've got nobody, like nobody, it was so nice just to go out to dinner with somebody or just meet them for a drink or go to the cinema or just do something for just for maybe two hours to take your mind off the fact that you 're on your own. One participant had a system o f support arranged w i t h another nurse: We'd get down to her place and eat food and have a really deep fall out about it all. And then we'd laugh our heads off and that was that. And then next week it was either her turn or my turn. And if something was extremely badfor us one week, we'd go out that evening and get it off our chest and go back to work the next day. So we found that helped us a lot, it helped both of us. T h i s structure a l l owed the nurses to have a routine debrief ing that p rov ided opportunity to reflect o n their experiences and compare them to the stories o f other nurses. It a l l owed the nurses to put their experience i n perspective and l ook forward to the future, described one participant: Trans i t ion to Pract ice 76 And other girls have similar stories and we just, this is what I'm saying to you, we just both laugh about it and move on. Now it's become a joke in our repertoire. We never mentioned who the person was. Some people don't even know where the story came from. But they know the story's out there. A l t h o u g h it seems that some stories may evo lve into what seems l i ke my th i ca l legends as they pass f rom one nurse to another, each story facilitates a learning opportunity. A story enables one to relay informat ion i n a non-threatening manner. "We try to pass it on to one another without being too intrusive for one another, but I think it should be in some sort of information that's given so we understand when we get here." People can learn f rom each other's experiences - what to do, what not to do - i n order to make more informed personal decisions. A n interesting f inding i n this study was that some participants had no desire to socia l ize w i t h people f rom their home country. One participant expla ined that he had extended fami ly that l i v e d near h i m , so he d i d not need to be a part o f other soc ia l groups. The comment o f one nurse about her soc ia l iza t ion needs stood out to me. "If I'd never seen another ex-pat I could still have been happy. So I didn't have a personal need that I had to have other foreign nurses to give me group support. That wasn 't something Ifelt I needed." This nurse came to Canada w i t h her f ami ly and intended to move here o n a permanent basis. She also was older and had a variety o f experiences as a nurse. These factors combined w i t h the fact that the f ami ly chose to move to Canada for the l ifestyle and dynamics o f the country may have inf luenced this decis ion . F a m i l y members p rov ided cr i t ica l elements o f soc ia l support for the 10 participants w h o had immediate f ami ly w i t h them; however many d i d not expound on their experiences Trans i t ion to Pract ice 77 i n relat ion to be ing i n Canada w i t h their fami ly . One participant expla ined the role her f ami ly members p layed, "Yeah, that yeah, social aspect, too, um, but the emotional aspect, we have, you know, lots of support from our mom with each other, our brother, um, and from our aunt here" It seems to be the support o f fami ly that helps ind iv idua ls the most i n getting through diff icul t t imes. F o r fami ly that came together to Canada, they share a c o m m o n dream o f what l ife w o u l d be l ike i n their new home. One nurse 's spouse was her l i fe l ine i n what she described as months o f he l l . "But my husband was really supportive through those 8 months. But he was really supportive. I think he must have shed as many tears as I did just, you know, everything we had given up." T h e y consoled each other as they questioned their dec i s ion to m o v e to Canada and shared s imi la r experiences i n the transit ion to l i v i n g i n a new c i ty and f inding work , "we often sort o f sat and he ld each other, " 'Oh my god, what did we do this for?' We left everything behind. So it was equally as hard for him, even though he is Canadian." Summary The nurses educated outside o f Canada who participated i n this study openly shared their experiences i n m a k i n g the transit ion to practice w i t h i n the Canad ian health care system. F o r most this was an emot ional reflection o n their expectations and the reali ty o f h o w their journey unfolded. F r o m their stories nine c o m m o n experiences emerged and were explored to increase understanding o f the transit ion process. A summary o f the f indings w i l l be discussed i n the next chapter fo l l owed by conclus ions and result ing recommendat ions. Trans i t ion to Practice 78 < Chapter 5 > Summary o f F ind ings , Conc lus ions , and Recommendat ions A s a nurs ing leader w i t h i n an organizat ion I had observed and heard stories o f the struggles o f nurses educated outside o f Canada i n m a k i n g the transit ion to practice i n Canada. T h i s study was designed to describe and understand the experiences o f nurses, educated i n a country other than Canada, as they make the transit ion to practice w i t h i n the Canad ian health care system. R i c h descriptions o f the experiences o f nurses were obtained w i t h the use o f the in-depth interviews. Interviews were completed w i t h 13 nurses, 11 w o m e n and 2 men, w h o m o v e d to Canada i n the past f ive years. Th i s method was valuable i n be ing able to identify unanticipated issues o f importance. E m p l o y i n g in-depth interviews enabled me to develop an understanding o f their experiences that caused me to reflect and evaluate m y personal conceptions and ideas about the transi t ion experience. I was cont inual ly chal lenged to be ref lexive and identify personal subjectivity i n interviews and interpretation. Ques t ioning m y assumptions and interpretations through notes, analyt ical wr i t ing , and d iscuss ion w i t h colleagues, m y supervisory committee, and participants a l l owed me to c lar i fy and redefine m y perspective o n the experiences o f nurses educated i n other countries related to their transit ion to practice i n Canada. The part icipants ' descr ipt ion o f their experiences i n m a k i n g the transi t ion to practice i n Canada led to a better understanding o f w h y nurses choose to move , misconcept ions that occur related to relocat ion, and challenges nurses have i n adapting to Canada. Other themes identif ied i n the f indings inc lude: isolat ion, professional support, quest ioning one 's o w n competence, feel ing va lued , and the s ignif icance o f w o r k support and socia l support networks. A summary o f the f indings w i l l be presented w i t h a section for each theme Trans i t ion to Pract ice 79 fo l l owed by conclus ions o f the study. The recommendat ions result ing f rom the f indings w i l l be discussed w i t h respect to government sectors o f human resources, customs, and immigra t ion , regulatory bodies, health care organizat ions, future immigrant nurses, and research. Summary of Findings In this study it was found that for these nurses c l i n i c a l issues i n the p r o v i s i o n o f care were not the p r imary concern. The focus o f their reflect ion related to the dynamics o f interactions at w o r k and w i t h professional organizations as w e l l as the basic needs and costs associated w i t h l i v i n g i n Canada. I d i d not f ind the experiences o f nurses to vary s ignif icant ly based o n gender. A difference was noted i n the response to an extended struggle o f securing permanent employment as a nurse. A male participant emphat ica l ly described this as affecting his pr ide. A female participant attempted to cont inual ly d isplay understanding for the bureaucratic process and w h i l e frustrated, she tried to remain opt imis t ic . Reason to move. The reasons p rov ided by the nurses i n this study as to w h y they m o v e d to Canada echo what was wri t ten i n the literature: better economic , w o r k i n g , and l i v i n g condi t ions; improved learning and practice opportunities; and novel ty o f t ravel and employment abroad ( I C N , 2002a; K i n g m a , 2001) . These same factors may attract nurses educated i n Canada to m o v e to other countries. A l s o , nurses educated outside o f Canada m a y seek opportunities elsewhere after hav ing spent a per iod o f t ime here. Some o f the nurses wanted to come to Canada because they and/or their spouse had prev ious ly v is i ted or l i v e d here. H a v i n g f ami ly or friends i n the c i ty to w h i c h they m o v e d was also an inf luencing factor. It was interesting to f ind that those w h o fo l l owed other f ami ly members to Canada s t i l l had significant challenges i n the transit ion process. S i m i l a r to other participants they Trans i t ion to Pract ice 80 described di f f icul ty i n obta ining w o r k that matched their professional interests, m a k i n g n e w friends, and f ind ing their w a y around a new ci ty . Some participants felt that their f ami ly members who had l i v e d i n Canada for an extended t ime c o u l d not relate to them being f rom another country as the f ami ly was too enmeshed i n Canad ian society. Rather than p r o v i d i n g the support envis ioned by the n e w immigrants , these f ami ly members heightened the participants ' sense o f be ing different and feel ing isolated. Other significant f indings related to misconcept ions when relocat ing w i l l be discussed next. Relocation misconceptions. F r o m the experiences o f the nurses i n this study the issue o f c redib i l i ty o f recrui t ing agencies has been highl ighted. Repeatedly the participants described a lack o f understanding o n the part o f the recruiters as to the t ransi t ion process and the requirements. Several also experienced agencies c los ing business and be ing left alone part way through the transi t ion o f m o v i n g to Canada. W i t h the predicted increasing need to recruit nurses f rom other countries it m a y be essential that assessment and moni to r ing processes o f recrui t ing agencies be implemented to ensure that the nurses are p rov ided t imely , accurate informat ion and are supported across the con t inuum o f their t ransi t ion to practice i n Canada. In the next section f indings l i nked to the challenges i n adapting to Canada w i l l be explored. Challenges in adapting to Canada. F r o m the descr ipt ion i n the f indings I bel ieve that the novel ty o f m o v i n g to a new country ends for nurses before they actual ly complete the m o v e or soon after a r r iva l . U p o n arr ival n e w immigran t nurses are ba lancing a new job , new country, exams, and orientation courses w h i l e t ry ing to settle their f ami ly . Several participants c lear ly described the process o f adaptation to last s ix to eight months. Nurses are often surprised by bureaucracy associated w i t h immigra t i on and expense o f m o v i n g , l i v i n g , Trans i t ion to Pract ice 81 and w o r k i n g i n another country. The participants tended to forget about the i tems and resources used every day that when i n place are taken for granted. A c q u i r i n g a d r iver ' s l icense, insurance, ut i l i t ies, and credit q u i c k l y became major frustrations for many. The literature described the potential for the stressors o f migra t ion to manifest as phys i ca l symptoms ( B o y l e , 2003; L i p s o n et a l . , 1997; Pilette, 1989). I a m aware that some o f m y previous colleagues f rom other countries suffered var ious phys i ca l a i lments; however , none o f the nurses i n this study described this as an issue. E a c h o f them d i d describe experiences o f psycho log ica l distress that has had a last ing impact . Nurses f rom the Ph i l i pp ines used more resources i n preparing to move to Canada and to a id their t ransi t ion to practice here. These nurses expected to face certain challenges and, therefore, m a y have adapted w i t h more ease than nurses f rom A u s t r a l i a or Br i t a in . N o matter where one l ives there are basic needs and costs associated w i t h l i v i n g . F o r those w h o do not move often or have little knowledge o f what it is l ike to l ive i n different countries, it is easy to take these items for granted and not to th ink about the need to learn h o w to obtain basics such as ut i l i t ies , insurance, and l icense to dr ive on ar r iva l . Further understanding o f the cost o f l i v i n g i n another country w o u l d also be valuable . Some o f the participants wanted detai led informat ion about month ly l i v i n g expenses such as rent and food w i t h a compar i son to s imi la r expenses i n their home country as w e l l as professional fees, i nc lud ing annual registration fees and u n i o n dues. In the next section f indings o f the experience o f i so la t ion w i l l h ighl ighted. Isolation. A sense o f isola t ion developed for participants as they felt that they were alone and overwhe lmed w i t h adapting to a new environment . Some had problems i n be ing able to make long distance phone cal ls due to a lack o f access to a personal phone in i t i a l ly Trans i t ion to Pract ice 82 and no established credit history i n Canada; this added to the sense o f distance f rom what was fami l ia r and comfortable. A relocat ion assistant was hired by a few organizat ions to help nurses i n settling into a new ci ty . Unfortunately, most o f the participants felt that this assistant was more o f a hindrance to them and d i d not provide the service they expected. Aspec ts o f professional support d iscovered i n the f indings w i l l be explored i n the next section. Professional support. I f the impending nurs ing shortage is as great as predicted by R y t e n (1997) and others should changes be made to government po l ic ies to enable more f l ex ib i l i t y i n the h i r ing o f nurses? W h y is there so m u c h frustration amongst nurses educated outside o f Canada when m a k i n g the transit ion to practice i n Canada? Current ly nurses o n a w o r k permit are restricted to ho ld ing permanent ful l - t ime posi t ions only . M a n y vacancies i n nursing are r e l i e f posi t ions due to leaves o f absence for maternity or med ica l issues. M a n y units have ongoing r e l i e f needs that cou ld be met by nurses educated outside o f Canada. Co l l abora t ion between the government, regulatory bodies, and health care organizat ions w o u l d lead to greater f l ex ib i l i ty for employers to be able to u t i l i ze nurses educated outside o f Canada to meet the current vacancies. M a n y o f the nurses in terv iewed i n this study d i d not access government resources that m a y have been o f assistance i n their transit ion to Canada. Some o f the participants rea l ized afterwards that us ing these agencies w o u l d have benefited them. It was surpris ing to learn that some people d i d not even realize they needed a w o r k permit or residency status to w o r k i n Canada. T h i s then begs the question what occurs when one proceeds through immigra t i on when entering Canada. I f a person states that he or she is c o m i n g to w o r k i n Canada, should a request not then be made to rev iew appropriate documentat ion to permit employment? Trans i t ion to Practice 83 Perhaps some o f the frustration experienced by those w h o were delayed i n beginning employment cou ld have been m i n i m i z e d o n arr ival . A c c e s s i n g government informat ion m a y prevent delays and some frustrations altogether. A g e n c i e s that the participants va lued inc luded Canad ian consulates, H u m a n Resources and S k i l l s Deve lopment Canada, and Hea l th M a t c h . I f these services were h ighl ighted to nurses as they ini t iated the process o f m o v i n g to Canada and at points throughout the appl ica t ion process, perhaps there w o u l d be opportunity to better prepare nurses as to what they w i l l encounter w h e n l i v i n g i n Canada. F o r example , the nurses i n this study felt it was important to have basic informat ion about taxes, ut i l i t ies, insurance, d r iver ' s l icenses, and renewal o f w o r k permits. These organizat ions c o u l d provide this type o f informat ion o n a summary page w i t h the inc lus ion o f specific resource contact informat ion. M u l t i p l e issues were raised by the participants i n this study i n relat ion to registration i n Canada. The requirement to write the C R N E , a basic cert if icat ion exam, was par t icular ly contentious. Some questioned whether a restricted registration for those nurses on a w o r k permit m a y enable recogni t ion o f their expertise and specialty w h i l e not requir ing them to wri te the exam i f they are not p lanning to stay i n Canada permanently. A query was also made as to whether the C N A special ty cert i f icat ion exams were sufficiently v a l i d and rel iable for one to be registered i n a specific area o f practice. Nurses i n special ty areas, such as the operating r o o m and maternity, bel ieve that the C N A specialty cert i f icat ion exams w o u l d better test the knowledge and expertise they br ing to the c l i n i c a l setting. The C R N E provides a baseline assessment o f the knowledge required to practice as an entry- level nurse; w h i l e a cer t i f icat ion exam tests specia l ized, expert knowledge i n a part icular area o f nursing. T o be registered wi thout comple t ing the C R N E w o u l d require a restricted registration, w h i c h may Trans i t ion to Pract ice 84 be feasible for those nurses w i t h a w o r k permit o n a one-year contract to w o r k w i t h i n a specific pos i t ion . I f these nurses choose to become permanent residents and/or w o r k i n other areas then a requirement to wri te the C R N E w o u l d be essential. It w o u l d be beneficial for the regulatory body to provide informat ion to the experienced nurses as to w h y the C R N E is necessary and the benefit it provides i n the assessment o f nurses' core competencies. C o m m u n i c a t i o n between the R N A B C and applicants/members was also described as frustrating and needing improvement . The participants stated that often t imes there were delays i n response f rom R N A B C . M a n y t imes w h e n c a l l i n g i n , people were forced to leave a message as they were unable to speak w i t h someone direct ly about their issue. Some o f the participants felt that their wri t ten letters were ignored altogether. W h e n i n the appl ica t ion process, several participants described hav ing a sense o f ambigui ty as to their status w i t h the regulatory body. T h e y were not informed i f their appl ica t ion had been received or i f addi t ional informat ion was required. W i t h some o f the participants there was d iscuss ion about i m p r o v i n g an appl icant ' s ab i l i ty to check the status o f their appl ica t ion and approval for registration. One idea proposed was to be able to access a personal f i le onl ine that w o u l d indicate registration status. Support ive resources offered by the regulatory body were appreciated by nurses. In 2003, R N A B C Pract ice A d v i s o r s facili tated a workshop for nurses educated outside o f Canada that p rov ided an orientation to the health care system and standards for practice. Nurses that I in terv iewed w h o attended this workshop felt that the session was valuable and hoped that s imi la r sessions w o u l d be scheduled i n the future. M a n y o f the participants connected w i t h professional practice groups or other nurs ing networks that were benef ic ia l to them o n a professional l eve l . The nurses often described seeking out these groups Trans i t ion to Pract ice 85 independently. A basic l ist o f such resources w o u l d be useful for n e w registrants to receive w i t h their in i t ia l registration. N e x t f indings f rom the theme o f quest ioning one 's competence w i l l be presented f o l l o w e d by a section o n feel ing valued. Questioning one's competence. Nurses educated outside o f Canada need to develop an understanding o f h o w their education and experience fits w i t h i n the Canad ian health care system. Nurses app ly ing to tertiary or quaternary care settings are frustrated w h e n they are dec l ined and informed that they need to have w o r k experience i n Canada . T h e y need to recognize that their competencies m a y be better suited to secondary l eve l care and that they w o u l d benefit f rom in i t i a l ly w o r k i n g i n a less acute environment. Feeling valued. W h i l e nurses need to feel connected and supported, they also described the need to feel valued. A surprising issue that was raised i n some o f the interviews w i t h nurses i n this study was the format o f the registration card. There is pride associated w i t h being able to use the title Registered Nurse , but a paper registration card is not demonstrative o f the value related to the pos i t ion . One participant suggested a more durable format s imi la r to a dr iver ' s l icense. F ind ings related to support i n the workplace w i l l be expounded on i n the next section. Work support network. E m p l o y e r s have identif ied challenges i n the immigra t i on restrictions related to the need to have permanent ful l - t ime posi t ions to offer ind iv idua l s o n a w o r k permit . Organizat ions need to implement f lex ib le h i r ing practices to enable them to fill their vacancies and increase the potential to hire nurses educated outside o f Canada. F o r units that have ongoing vacant temporary posi t ions, some organizat ions have successfully u t i l i z ed an over-hire strategy to meet the demands. T h i s enables the h i r i ng o f nurses into permanent ful l - t ime posi t ions to meet the staffing needs o f a unit. Trans i t ion to Pract ice 86 W h e n recrui t ing new staff it is important that organizations be clear i n the offer presented. Some o f the participants described the need for j o b stabil i ty and security. T h e y accepted posi t ions without k n o w i n g the future direct ion and plans for the organizat ion. It w o u l d have been appreciated i f the employer w o u l d have been upfront and honest about the potential for restructuring. C la r i t y on relocat ion stipends and h o w they w o u l d be pa id was also needed. It was clear i n the interviews that not a l l o f those w h o had been recruited to posi t ions understood that they were on ly to receive assistance w i t h their costs, not that their entire re locat ion w o u l d be pa id for. Some negotiations were completed verba l ly and not specif ied i n wr i t ing , w h i c h caused nurses to become distrustful w h e n what they be l ieved had been agreed upon d i d not come to fruit ion. There was a repetitive theme i n some o f the interviews related to desired improvement o f networks o f nurses educated outside o f Canada w i t h i n an organizat ion and loca l area. Some were informed o f plans for ne twork ing events, but the promise never came to pass. D a v i s and M a r o u n (1997) note that it is beneficial for organizations to have support programs that address the transit ion process w i t h a focus on the culture and customs o f the setting and region. Several participants w o u l d have va lued be ing able to l iaise w i t h another nurse who had been educated outside o f Canada, or w i t h someone w h o was at least very fami l ia r w i t h the experience. One nurse felt that it w o u l d be advantageous to have a nurse w o r k w i t h i n H u m a n Resources speci f ica l ly to assist nurses from other countries. The literature shows that the health care system and its professionals do not funct ion i n a supportive role i n rece iv ing and addressing the stresses and concerns o f peoples ' everyday l ives (Anderson , 1985; Ande r son , 1987; A n d e r s o n et a l . , 1993; D y c k , L y n a m , & Ande r son , 1995). Hea l th care needs to be more effective i n understanding the socia l context and cul tural Trans i t ion to Pract ice 87 values o f people ' s l ives to enable the p rov i s ion o f and connect ion to meaningful resources -(Ander son et a l . ; L y n a m , 1985; Schreiber et a l . , 1998; Yahes & Dune , 1996). Wi thou t supportive networks and resources, nurses felt isolated and forgotten. T h e y d i d not feel that their role i n the organizat ion was valued. L i f e i n Canada immerses people i n a mul t icu l tura l society. Several participants described an appreciat ion for be ing able to experience other cul tural traditions and develop relationships w i t h people f rom a broad cross-section o f backgrounds. T h i s enabled them to learn f rom others and develop a socia l network outside o f the w o r k setting. A s a new employee one wants to feel received and w e l c o m e d into the organizat ion. S m a l l gestures have a b i g impact w h e n a person is feel ing lost and ove rwhe lmed i n a new environment. One nurse described h o w she struggled to f ind her w a y to var ious departments i n the maze o f a hospi tal . Af ter be ing recruited f rom thousands o f mi les away and relocat ing her f ami ly , her sense o f value suddenly decreased when no one met her o n ar r ival or took t ime to show her the bu i ld ing . Besides k n o w i n g the phys i ca l layout, it is also important to understand the professional organizat ion and learn the " w h o ' s w h o " i n an agency. In a mult ifaceted approach, s imple contact lists can be one method used to a id a new employee i n learning this information. W h i l e a l l o f the participants appreciated the orientat ion they received when beginning to w o r k i n Canada, some highl ighted improvements that c o u l d be made. In their in i t ia l shifts, nurses are matched w i t h a nurse w h o is a preceptor to assist them i n their transit ion to the new practice setting. It was noted that educat ion is needed for preceptors as to h o w to support an experienced nurse f rom another country versus a new graduate. Con t inu i ty o f preceptors was also valued. Participants that were paired w i t h different nurses each shift felt that this Trans i t ion to Pract ice 88 contributed to a disruptive and inefficient learning process. Nurses need to be assertive i n expressing their personal learning needs to enable a successful transit ion. Once a preceptorship is complete , nurses w o r k independently and m a y feel alone i n the practice setting. The development o f a mentor relat ionship can assist the transit ion to independent practice as nurses feel comfortable i n approaching a specific colleague for assistance and feedback. F r o m the descr ip t ion o f experiences o f the nurses i n this study it was noted that w o r k setting may have an impact o n the abi l i ty o f nurses to adapt w e l l to a new w o r k environment. W h i l e the basic pr inc ip les o f nursing do not change regardless o f where nurses work , some areas are more structured w i t h defined routines and procedures. In this study nurses that w o r k e d i n L a b o u r and D e l i v e r y , O n c o l o g y , and the Operat ing R o o m described be ing able to more readi ly assimilate into their posi t ions. The experience people br ing to a n e w pos i t ion may invoke learning opportunities for others. One o f the participants described feel ing demora l ized when others made assumptions that she d i d not k n o w anything about var ious procedures. She yearned for someone to take t ime to ask her, " W h a t do y o u do where you ' re f rom?" T h i s nurse is an expert practitioner. She recognized that there m a y be var ia t ion i n po l ic ies f rom one organizat ion and country to another, but the basic pr inc ip les o f nurs ing remain the same. The ab i l i ty to provide constructive feedback that enables learning w h i l e b u i l d i n g o n one 's foundational knowledge is key for nurses to create a supportive, cha l lenging w o r k environment. It is recognized that each ind iv idua l brings a certain s k i l l set and area o f expertise to the practice setting. It is valuable for n e w staff to learn w h i c h people are resources for var ious subspecialties. L i k e w i s e , it is important to recognize the experience that nurses Trans i t ion to Practice 89 educated outside o f Canada br ing to the workp lace . S u c h informat ion may be presented i n staff biographies that are posted on the unit. W i t h i n a mul t icu l tura l team there needs to be recogni t ion o f others' values and priori t ies for the use o f t ime as be ing legit imate (Giger & M o o d , 1997). Informal socia l gatherings also provide opportunity for staff to learn more about each other. One participant suggested hav ing a po t luck o f international food as a we lcome gathering for nurses f rom other countries. Other key f indings related to socia l support w i l l be h ighl ighted i n the next section. Social support network. Those nurses that m o v e d to Canada w i t h their f ami ly noted greater expenses i n m o v i n g and l i v i n g ; however , they benefited f rom sharing a c o m m o n dream o f l i v i n g and w o r k i n g i n Canada. T h e y also va lued the soc ia l support p rov ided by their f ami ly members. Nurses w h o came o n their o w n were forced to b u i l d new soc ia l support networks. There is an impress ion that single nurses m a y be less l i k e l y to stay i n Canada permanently as they lack the fami ly ties. Conclusions There are f ive key conclus ions that can be d rawn f rom this study: • Nurses immigra t ing to Canada often lack informat ion about the bureaucratic processes o f settling i n a new country and the resources that are avai lable to them to facilitate the settlement process. • Despite m u c h publ ica t ion o f a nurs ing shortage i n Canada, nurses have d i f f icu l ty securing nurs ing posi t ions that match their professional interests. • W h e n beginning to practice i n a new pos i t ion a l l people have a certain sense o f anxiety. A l l o f the nurses i n this study at var ious t imes questioned their o w n competence and whether they had made correct decis ions i n m o v i n g to Canada. Nurses educated outside Trans i t ion to Pract ice 90 o f Canada w h o had years o f w o r k experience pr ior to m o v i n g encounter constant pressure to perform at advanced and expert levels w i t h little insight into the regression to be ing a novice when in i t i a l ly beginning a new posi t ion . • Nurses w i t h experience i n other countries struggle w i t h the requirement to wri te an entry leve l exam upon in i t i a l registration i n Canada. The need to write the C R N E frustrated and annoyed nurses. T h e y felt that this indicated a lack o f recogni t ion o f their s k i l l and experience and was a personal insult to them. • The stress o f migra t ion has a last ing impact . Participants to ld me about events that happened over a year ago f rom w h i c h they s t i l l had not healed. T h e y hesitated to participate and openly share because o f the depth o f emotions attached to their experience. A t the conc lus ion o f each interview, though, each participant appreciated being able to share their experiences as they made the transi t ion to practice i n Canada. In-depth in te rv iewing is valuable i n descr ibing issues o f a topic and exp lo r ing associated factors to make recommendat ions to address them. Recommendations Recommendations for Government. The f o l l o w i n g recommendat ions for government resulted f rom the f indings o f this study. • E x p a n d options for types o f posi t ions i n w h i c h a nurse w i t h a w o r k permit may be employed . • H i g h l i g h t services p rov ided by consulates, H u m a n Resources and S k i l l s Deve lopment Canada, and Hea l th M a t c h to nurses as they initiate the process o f m o v i n g to Canada and at points throughout the appl ica t ion process. Trans i t ion to Pract ice 91 • P rov ide basic informat ion about the costs associated w i t h l i v i n g i n Canada (e.g., taxes, ut i l i t ies, insurance, d r iver ' s l icenses, and renewal o f w o r k permits) upon expression o f interest i n m o v i n g to Canada and upon receipt o f an appl ica t ion for a w o r k permit or landed immigrant status. • Improve screening at customs for reason o f entering the country and appropriate documentat ion. • Assess and moni tor the c red ib i l i ty o f health care recrui t ing agencies. Recommendations for Regulatory Bodies. Recommendat ions for regulatory bodies that were identif ied f rom the f indings w i l l be presented i n this section. • D e v e l o p mechanisms for applicants and members to self-check their registration status. • Improve communica t ion as evidenced by t ime ly and direct access to appropriate staff and better response t ime w i t h acknowledgement o f communica t ion received. • U p o n expression o f interest i n m o v i n g to Canada and w i t h each appl ica t ion package, provide detailed informat ion on costs associated w i t h registering and w o r k i n g as a Registered Nur se w i t h i n the province inc lud ing : appl ica t ion fee, examinat ion cost, med ica l requirements, c r im ina l record checks, annual registration, and u n i o n fees. • P rov ide informat ion about the C R N E to nurses educated outside o f Canada, i nc lud ing w h y the examinat ion is required and the benefit it provides i n assessing competency to practice. • Facil i tate a workshop for new nurses to provide orientat ion to the Canad ian health care system and the standards for practice. • P rov ide a l ist o f resources, such as professional practice groups and other nurs ing networks, to nurses w i t h in i t i a l registration. Trans i t ion to Practice 92 • E x p l o r e options for formal recogni t ion o f registration and its ongoing renewal . Recommendations for Health Care Organizations. Recommendat ions for health care organizations are out l ined i n this section. • Create regular ful l - t ime over-hire posi t ions to facilitate the h i r ing o f nurses educated outside o f Canada to meet staffing needs. • D e v e l o p a wri t ten contract i nd iv idua l i zed for each nurse recruited f rom outside o f Canada ou t l in ing the amount o f the relocat ion stipend and a payment schedule. • A s s i g n a nurse to w o r k w i t h the H u m a n Resources department speci f ica l ly to assist nurses f rom other countries. • M e e t new employees at the entrance w h e n they first arrive o n the site and provide a basic orientation to the phys i ca l space. • P rov ide contact lists o f important contacts w i t h i n the organizat ion o n arr ival to assist nurses i n r ecogn iz ing the resources that are avai lable . • P rov ide ne twork ing opportunities for nurses educated outside o f Canada. T h i s m a y be planned soc ia l events or dis t r ibut ion o f a contact l ist o f other nurses educated outside o f Canada w h o are w i l l i n g to support or mentor new immigrant nurses. • D e v e l o p mentorship programs to support new hires beyond the orientation and preceptorship periods. • P rov ide cont inui ty o f preceptor(s). • Educate preceptors o n h o w to support nurses w i t h various levels o f experience. • W i t h i n each unit post staff profi les that are ini t iated when hi red and regular ly updated to h ighl ight each nurses area o f expertise and spec ia l ized sk i l l s . Trans i t ion to Pract ice 93 Recommendations for Future Immigrant Nurses. The recommendat ions presented thus far have been associated w i t h the impact that po l ic ies and w o r k environments have o n the experiences o f nurses educated i n other countries i n their t ransi t ion to practice i n Canada. The f o l l o w i n g recommendat ions are directed to future immigran t nurses. • People w h o immigrate need to develop awareness and be prepared for challenges they w i l l encounter when m o v i n g to and beg inn ing to w o r k i n another country. • P r io r to m o v i n g it is essential to have a clear understanding o f the potential to f ind w o r k and the legal requirements to w o r k i n another country. • H a v i n g realist ic expectations o f the transi t ion process and the length o f t ime it takes to relocate m a y assist i n preventing frustration. • C o m p l e t i n g some research as to h o w to t ime the different components o f re locat ion is also beneficial i n strategizing to m i n i m i z e delays. Depend ing o n whether a nurse is c o m i n g to Canada o n a w o r k permit or as a landed immigrant or i f a j o b is be ing sought i n a specific region, there is var iab i l i ty i n the best order to obtain a j o b offer, complete the registration process, and fu l f i l l immig ra t i on requirements. • D e v e l o p an understanding o f the cost o f l i v i n g i n another country. Ob ta in detailed informat ion about month ly l i v i n g expenses such as rent and food as w e l l as taxes and professional fees, i nc lud ing annual registration fees and un ion dues. Recommendations for Research. A s a result o f this study, recommendat ions for further research have been developed. • A n assessment o f the type o f shortage needs to be completed to enable appropriate communica t ion o f the needs and recruitment o f nurses that w i l l best meet the demand. Research is needed to define the nursing shortage and determine the s k i l l sets required. Trans i t ion to Pract ice 94 There are a m y r i a d o f advertisements i n magazines and newspapers for nurs ing posi t ions i n Canada. I f the vo lume o f advertisement is an accurate reflect ion o f nurs ing vacancies one may assume that there is a nursing shortage i n Canada. I f the shortage is specific to a subspecialty then it is not necessary to attract nurses who do not have appl icable experience. A h igh demand for nurses i n a broad range o f areas m a y require the need for adjustments i n p o l i c y to increase opportunities for nurses w i t h a w o r k permit . N u r s i n g is a g loba l profession; nurses are needed everywhere. Research o n g loba l i za t ion trends may assist i n predic t ing needs and creating strategies for recruitment and retention. The issue o f g loba l iza t ion applies to health care i n general. M a n y other health care professions are impacted by the effects o f migra t ion . Phys ic ians , for example , m o v e to different centres to encounter a variety o f educational experiences i n their residency and fe l lowship . Inter-professional research w o u l d enable a c o m m o n understanding to be developed as to the experience o f health care professionals educated i n other countries as they make the transit ion to practice i n Canada. T h i s may enable the format ion o f col laborat ive systems to improve support mechanisms and pol ic ies for immigran t professionals. F r o m the interviews w i t h nurses i n this study it was clear that there is a cont inual need to demonstrate that care is p rov ided according to best practice. O n g o i n g research is required to demonstrate that the best care is being p rov ided i n the best setting. W h e n nurses beg in to w o r k i n a new organizat ion they often encounter po l ic ies and standards that are different to those at their previous workplace . Some examples that the participants i n this study h ighl ighted include medica t ion administrat ion, check ing o f charts, and transcription. D i s c u s s i o n o f variations i n practice, that is , nurses' experiences i n their Trans i t ion to Pract ice 95 home country versus their experiences i n Canada, c o u l d lead to research as to what is best practice, w h i c h cou ld result i n organizat ional improvements or reaffirm current practice. Nurses educated i n countries other than Canada m a y provide the impetus for new, innovat ive practice ini t iat ives through sharing their experiences f rom another practice setting. Summary This study has p rov ided insight into the experiences o f nurses, educated i n a country other than Canada, as they make the transit ion to practice w i t h i n the Canad ian health care system. D e v e l o p i n g an understanding o f these experiences led to an explora t ion o f the interactions o f the immigrant nurse w i t h government, regulatory bodies, organizations, staff nurses, and other nurses educated outside o f Canada. The participants ' descr ipt ion o f their experiences o f m a k i n g the transit ion to practice i n Canada p rov ided the opportunity to identify systematic improvements for government human resources and immigra t ion sectors, regulatory bodies, and health care organizat ions to consider and future directions for research. Trans i t ion to Practice 96 References Ande r son , J . M . (1985). Perspectives on the health o f immigrant w o m e n : A feminist analysis. Advances in Nursing Science, 8(1), 61-76. Ande r son , J . M . (1987). M i g r a t i o n and health: Perspectives on immigrant w o m e n . Sociology of Health & Illness, 9(4), 410-438. Ande r son , J . M . (1991). R e f l e x i v i t y i n f ie ldwork: T o w a r d a feminist epis temology. Image: Journal of Nursing Scholarship, 23(2), 115-118. Ande r son , J . M . , B l u e , C , H o l b r o o k , A . , & N g , M . (1993). O n chronic i l lness: Immigrant w o m e n i n Canada ' s w o r k force - A feminist perspective. Canadian Journal of Nursing Research, 25(2), 7-22. A r o i a n , K . J . (1990). A mode l o f psycho log ica l adaptation to migra t ion and resettlement. Nursing Research, 39(\), 5-10. A r o i a n , K . J . (2001). Immigrant w o m e n and their health. In J . J . F i tzpat r ick (Ed.) , Annual review of nursing research: Focus on women's health (pp. 179-226). N e w Y o r k : Springer. A r o i a n , K . J . , N o r r i s , A . E . , Patsdaughter, C . A . , & Tran , T . V . (1998). Predic t ing psycho log ica l distress among former Sovie t immigrants . International Journal of Social Psychiatry, 44(4), 284-295. B a r r y , J . , Sweatman, L . , L i t t l e , L . , & Dav ies , J . (2003). International nurse applicants. Canadian Nurse, 99(8), 34-35. B a u m a n , L . J . , & Greenberg, E . (1992). The use o f ethnographic in te rv iewing to in fo rm questionnaire construct ion. Health Education Quarterly, 19(1), 9-23. Berns te in , J . H . , & Shuva l , J . T . (1998). The occupat ional integration o f former Soviet Trans i t ion to Pract ice 97 physic ians i n Israel. Social Science Medicine, 47, 809-819. Bever idge , S. (2003). Sampling in qualitative research [On-line]. Available: ht tp : / /www. i schoo l .wash ing ton .edu /har ryb /courses /LIS570Winte r03 /THING.doc B o y l e , J . S. (2003). Cul ture , f ami ly , and communi ty . In M . M . A n d r e w s , J . S. B o y l e , & T. J . Car r (Eds.) , Transcultural concepts in nursing care ( 4 t h ed., pp. 315-360). Ph i lade lph ia : L ipp inco t t . B r a n s w e l l , H . (2003). More nurses working full time, a major shift from casual work, report shows [Onl ine] . A v a i l a b l e : http: / /mediresource.sympatico.ca/heal th_news_detai l .asp?channel_id=0&news_id=22 97 Burner , O . Y . , C u n n i n g h a m , P . , & Hattar, H . S. (1990). M a n a g i n g a mul t icu l tura l nurse staff i n a mul t icu l tura l environment. Journal of Nursing Administration, 20(5), 30-34. Burns , N . , & G r o v e , S. K . (1997). The practice of nursing research: Conduct, critique, & utilization ( 3 r d ed.). Ph i lade lph ia : W . B . Saunders. Canadian Nurses Assoc i a t i on . (2002a). Highlights of2001 nursing statistics [On- l ine] . A v a i l a b l e : http:/ /www.can-nurses.ca/pages/bookstore/catalogue/index.htm ( R - Z ; Registered Nurses Statist ical High l igh t s ) Canad ian Nurses Assoc i a t i on . (2002b). Planning for the future: Nursing human resource projections. Ot tawa, O N : Au tho r . Coyne , I. T . (1997). S a m p l i n g i n quali tat ive research. Purposeful and theoretical sampl ing ; merg ing or clear boundaries? Journal of Advanced Nursing, 26(3), 623-630. Cravener , P . (1992). Es tab l i sh ing therapeutic a l l iance across cul tural barriers. Journal of Psychosocial Nursing, 30(12), 10-14. Trans i t ion to Pract ice 98 Das Gupta , T . (1996). A n t i - B l a c k r ac i sm i n nurs ing i n Ontar io . Studies in Political Economy, J i ( F a l l ) , 97-116. D a v i s , C . R . , & M a r o u n , V . M . (1997). Immigrant nurs ing personnel: The v i e w f rom C G F N S . In J . A . D ienemann (Ed.) , Cultural diversity in nursing: Issues, strategies, and outcomes (pp. 13-19). Washington , D C : A m e r i c a n A c a d e m y o f N u r s i n g . D i j k h u i z e n , S. R . (1995). M e e t i n g the basic and educational needs o f foreign nurses. Journal of Continuing Education in Nursing, 26(1), 15-19. D y c k , I., L y n a m , J . M . , & Ander son , J . M . (1995). W o m e n ta lk ing: Crea t ing knowledge through difference i n cross-cultural research. Women's Studies International Forum, 18(5/6), 611-626. Fetterman, D . M . (1998). Ethnography: Step by step ( 2 n d ed.). Thousand Oaks , C A : Sage. F i n l a y , L . (2002). " O u t i n g " the researcher: The provenance, process, and practice o f ref lexivi ty . Qualitative Health Research, 12(4), 531-545. F o x , P . G . (1991). Stress related to fami ly change among Vie tnamese refugees. Journal of Community Health Nursing, 8, 45-56. Franks , F . , & Faux , S. A . (1990). Depress ion , stress, mastery, and socia l resources i n four ethnocultural w o m e n ' s groups. Research in Nursing & Health, 13, 283-292. Gige r , J . N . , & M o o d , L . H . (1997). Cu l tu ra l l y competent teamwork. In J . A . D ienemann (Ed.) , Cultural diversity in nursing: Issues, strategies, and outcomes (pp. 33-43). Washington , D C : A m e r i c a n A c a d e m y o f N u r s i n g . Godfrey , K . (1999). Fo re ign affairs. Nursing Times, 95(48), 32-33. Hammers l ey , M . (1992). What's wrong with ethnography? N e w Y o r k : Rout ledge. H u r h , W . M . , & K i m , K . C . (1990). Correlates o f K o r e a n immigran ts ' mental health. Journal Trans i t ion to Pract ice 99 of Nervous and Mental Disease, 178, 703-711. International C o u n c i l o f Nurses . (2001). Ethical nurse recruitment [On- l ine] . A v a i l a b l e : ht tp: / /www.icn.ch/psrecruitO 1 .htm International C o u n c i l o f Nurses . (2002a). Career moves and migra t ion: C r i t i c a l questions [On- l ine] . A v a i l a b l e : h t t p : / /www. i cn . ch /Ca ree rMovesMigang l . pd f International C o u n c i l o f Nurses . (2002b). I C N develops pr inciples for ethical recruitment o f nurses. International Nursing Review, 49, 69. Jackson, D . (1996). The mul t icul tura l workplace : Comfor t , safety and migrant nurses. Contemporary Nurse, 5(3), 120-126. K i n g m a , M . (2001). N u r s i n g migra t ion: G l o b a l treasure hunt or disaster-in-the-making? Nursing Inquiry, 5(4), 205-212. Koerner , J . G . (1997). Cocrea t ion o f culture through choice . In J . A . D ienemann (Ed.) , Cultural diversity in nursing: Issues, strategies, and outcomes (pp. 63-69). Washington , D C : A m e r i c a n A c a d e m y o f N u r s i n g . L e C o m p t e , M . D . , & Schensul , J . J . (1999). Designing and conducting ethnographic research. Wa lnu t Creek, C A : A l t a m i r a Press. L i p s o n , J . G . , M c E l m u r r y , B . , & L a R o s a , J . (1997). W o m e n across the life span: A w o r k i n g group o n immigrant w o m e n and their health. In Global migration: The health care implications of immigration and population movements (pp. 47-65). Wash ing ton , D C : A m e r i c a n A c a d e m y o f N u r s i n g . L y n a m , M . J . (1985). Support networks developed by immigrant w o m e n . Social Science Medicine, 27(3), 327-333. M a c k e n z i e , A . E . (1994). Eva lua t ing ethnography: Considerat ions for analysis . Journal of Trans i t ion to Practice 100 Advanced Nursing, 19, 774-781. M a t u k , L . C . (1996). Hea l th status o f newcomers . Canadian Journal of Public Health, 87(1), 52-55. M e l e i s , A . (2003). Theoret ica l considerations o f health care for immigrant and minor i ty w o m e n . In P . St. H i l l , J . G . L i p s o n , & A . I. M e l e i s (Eds.) , Caring for women cross-culturally (pp. 1-10). Ph i lade lph ia : F . A . D a v i s . M e l e i s , A . I., & Im, E . O . (1999). Transcending marg ina l iza t ion i n knowledge development. Nursing Inquiry, 6(2), 94-102. M e l e i s , A . I., & Rogers , S. (1987). W o m e n i n transit ion: B e i n g versus becoming or be ing and becoming . Health Care for Women International, 8, 199-217. M o r s e , J . M . (1989). Qualitative nursing research: A contemporary dialogue. R o c k v i l l e , M D : A s p e n . M o r s e , J . M . , Barrett, M . , M a y a n , M . , O l s o n , K . , & Spiers, J . (2002, Spr ing) . V e r i f i c a t i o n strategies for establishing re l iab i l i ty and va l id i ty i n qualitative research. International Journal of Qualitative Methods [On- l ine serial], 1(2), A v a i l a b l e : http:/ /www.ualberta.ca/~ijqrn/englsih/engframeset.html M o r s e , J . M . , & F i e l d , P . A . (1995). Qualitative research methods for health professionals ( 2 n d ed.). Thousand Oaks , C A : Sage. N o h , S., W u , Z . , Speechley, M . , & Kaspar , V . (1992). Depress ion i n K o r e a n immigrants i n Canada II: Correlates o f gender, work , and marriage. Journal of Nervous and Mental Disease, 180, 578-582. Pacquiao, D . F . (2002). Fo re ign nurse recruitment and workforce divers i ty . Journal of Transcultural Nursing, 13(2), 89. Trans i t ion to Practice 101 Pearce, L . (2002). W o r l d o f difference. Nursing Standard, 16(32), 14-16. Pilette, P . C . (1989). Recrui tment and retention o f international nurses aided by recogni t ion o f phases o f the adjustment process. Journal of Continuing Education in Nursing, 20(6), 277-281 . Regis tered Nurses A s s o c i a t i o n o f B r i t i s h C o l u m b i a . (1998). Standards for nursing practice in British Columbia. Vancouver , B C : Au tho r . Registered Nurses A s s o c i a t i o n o f B r i t i s h C o l u m b i a . (2001). R N A B C membership. Vancouve r , B C : Author . R e i m e r K i r k h a m , S., Smye , V . , Tang , S., A n d e r s o n , J . , B l u e , C , B r o w n e , A . , Co le s , R . , D y c k , I., Henderson, A . , L y n a m , M . J . , Perry, J . , Semeniuk, P . , & Shapera, L . (2002). Re th ink ing cul tural safety w h i l e wa i t ing to do f ie ldwork: M e t h o d o l o g i c a l impl ica t ions for nurs ing research. Research in Nursing & Health, 25, 222-232. Roper , J . M . , & Shapira , J . (2000). Ethnography in nursing research. Thousand Oaks , C A : Sage. Ry ten , E . (1997). A statistical picture of the past, present and future of registered nurses in Canada. Ot tawa, O N : Canad ian Nurses Assoc i a t i on . Sande lowsk i , M . (1995). Sample size i n quali tat ive research. Research in Nursing & Health, 18, 179-183. Schreiber, R . , Stern, P . N . , & W i l s o n , C . (1998). The contexts for managing depression and its s t igma among b lack Wes t Indian Canad ian w o m e n . Journal of Advanced Nursing, 2 7 , 5 1 0 - 5 1 7 . S h i n , K . R . , & S h i n , C . (1999). The l i v e d experience o f K o r e a n immigrant w o m e n Trans i t ion to Pract ice 102 acculturating into the U n i t e d States. Health Care for Women International, 20, 603-617. Tabone, S. (2000). 2000 update: Fo re ign nurse recruitment. Texas Nursing, 74(8), 9, 15. W i l l i a m s , J . (1992). Or ien t ing foreign nurse graduates through preceptors. Journal of Nursing Staff Development, 8(4), 155-158. W i t c h e l l , L . , & Ousch , A . (2002). M a n a g i n g international recruits. Nursing Management, 9(3), 10-14. Yahes , E . , & D u n n , A . K . (1996). Encul tura t ion o f foreign nurse graduates: A n integrated mode l . Journal of Continuing Education in Nursing, 27(3), 120-123. Trans i t ion to Pract ice 103 A p p e n d i x A : Summary o f L i terature R e v i e w e d Researcher & D a t e Project T i t l e Purpose Study D e s i g n F ind ings Anderson (1985) Perspectives on the health of immigrant women: A feminist analysis To identify the primary concerns of women surrounding their health; to understand the experiences of women surrounding help-seeking; to explore if women have perceived any discriminations toward themselves as immigrant women. Phenomenology Sample: 14 women; 6 Indo-Canadian 8 Greek Location: Canada - Health care system not viewed as a potential source of support for emotional concerns (IC) - Perception that Canadians are not approachable - Belief that health care professionals would not understand their problems (IC) - Loneliness and depression not perceived as health problems - Need for more effective health care Anderson (1987) Migration and health: Perspectives on immigrant women To explore women's health and the ideological structures within the health care system that shape women's experiences. Phenomenology Sample: 36 women; 27 Indo-Canadian 19 Greek Location: Canada - Housework and childcare women's responsibility - Language training beyond reach - Feelings of loneliness, depression, and isolation most overwhelming - Women see health professionals as not understanding their situation Anderson, Blue, Holbrook, & Ng (1993) On chronic illness: Immigrant women in Canada's work force - A feminist perspective To understand how the process of migration and the status of "immigrant woman" structure life experiences. Ethnography Sample: 30 women; 15 Chinese 15 Euro-Canadian Location: Canada - Keep illness secret due to fear of losing job - For health professionals, medical management takes precedence over concerns of everyday life - Knowledge of life circumstances needs to be utilized on a day-to-day basis in clinical practice Aroian (1990) A model of psychological adaptation to migration and resettlement To explore the conditions under which migrants experienced psychological distress and the sources of their well-being. Grounded Theory Sample: 25 Polish; 15 men, 10 women Location: USA (Seattle) - Migration extremely stressful - Positive aspects of experience: self-growth, financial opportunities, freedom - Central categories to process of migration and resettlement: loss and disruption, novelty, occupation, language, subordination, feeling at home Aroian, Norris, Patsdaughter, & Tran(1998) Predicting psychological distress among former Soviet immigrants To investigate whether age, gender, marital status, education, employment, length of time in the U.S. and immigration demands are predictors of psychological distress in a sample of former Soviet immigrants. Quantitative -correlational Tools: Demands of Immigration Scale (DI), Symptom Checklist 90-R (SCL-90-R) Sample: 1647 Russians; 706 men, 934 women Location: USA (Boston) - Difference in psychological distress as a function of age, gender, level of education; not marital status - Suggested interventions toward increasing language skill, knowledge about novel situations, alleviate feelings of loss, not feeling at home, feeling discriminated against Bernstein & Shuval(1998) The occupational integration of former Soviet physicians in Israel To investigate the dynamics of occupational status persistence and psychosocial well-being of physicians who immigrated to Israel from the former Soviet Union during their first five years in Israel. Quantitative - cohort follow-up Sample: 333 Russians; 146 men, 187 women Location: Israel - Soviet physicians have better relationships with patients and their families - Support through rigid licensing procedure - Occupational status persistence: young people have more success than older - Time plays an independent role in psychosocial well-being Trans i t ion to Practice 104 Das Gupta (1996) Anti-black racism in nursing in Ontario To describe the experience of racism in nursing in Ontario. Case study Sample: 2 Black female nurses Location: Canada (Ontario) - Selection of nurses for leadership positions ad hoc - Outreach strategies to fill positions not consistent - Subjectivity and bias in decision-making when pre-screening, checking of references, interviews, and internal transfers left to individual discretion - Pattern of segmentation of work along racial lines Dyck, Lynam, & Anderson (1995) Women talking: Creating knowledge through difference in cross-cultural research To describe the research process of a cross-cultural study investigating the health care experiences of Chinese Canadian and Indo-Canadian women. Ethnography Sample: 29 women - The organization of health care institutions and practices, based on a biomedical model, act against gaining information about the social phenomena within which women's health experiences and needs are contextualized. - Class positioning of researchers important throughout research process. Power shifts between researchers, research assistants, and participants. - Women positioned within society as members of racialized groups frame their interactions; experiences fragmented by social divisions, such as class. - Reliance on others to access and interpret health care information. Fox (1991) Stress related to family change among Vietnamese refugees To identify changes in the structural and functional dimensions of family life and assess their impact on spousal relations. Ethnography Sample: 30 Vietnamese women Location: USA (Chicago) - Nuclearization of the family - Increased affectivity, spousal interdependency, and emotional involvement related to being separated from family and friends - Perceived decrease in spousal affectivity led to women feeling lonely and isolated and having a decreased ability to cope in unfamiliar setting - Women had increased participation in decision-making when having income of their own; also increased self-worth Franks & Faux (1990) Depression, stress, mastery, and social resources in four ethnocultural women's groups To examine the interrelationships of depression, stress, mastery, and social resources in four ethnocultural women's groups. Cross-sectional survey Sample: 212 women Location: Canada (Ontario) - Stressors: Housing and transportation major concerns; medical expenses the least concern - Asians most reluctant to ask for assistance - High depression scores consistent throughout all groups - Best model for predicting depression among the collective groups included perceived stress and mastery Hurh & Kim (1990) Correlates of Korean immigrants' mental health To investigate major structural and situational variables related to Korean immigrants' Quantitative Tools: Center for Epidemiologic Studies Depression Scale (CES-- Better mental health associated with satisfactory family life, marriage, employment - Ethnic attachment variables are Trans i t ion to Practice 105 mental health and theoretically explore the meaning of the empirical findings. D), Health Opinion Survey (HOS), Memorial University of Newfoundland Scale of Happiness (MUNSH) Sample: 622 Koreans; 334 men, 288 women Location = USA (Chicago) significant mental health correlates for women - Most employed wives have double burden of performing household tasks and working outside the home combined with strong adherence to Korean gender-role ideology; may explain increased somatic impairment in those with higher individual earnings Jackson (1996) The multicultural workplace: Comfort, safety and migrant nurses To generate a clearer understanding of the lived experiences of nurses from culturally diverse backgrounds as they enter and become part of the nursing workplace Phenomenology Sample: 9 female nurses Location: Australia - Need to belong and to have a place is compelling and important - Stress often described as stemming from communication problems - Loneliness is uncomfortable and disturbing; presence of strong network outside of nursing did not assuage the effects of loneliness with the working environment - Finding a place relates to belief that one has a stake in work environment - Realization that hostility/violence not only the domain of nurses from other countries, but experienced by local nurses as well; leads to more support and warmth towards new staff Lynam (1985) Support networks developed by immigrant women To investigate how women with young children who have immigrated to Canada and settled in an English speaking region defined their needs; and to identify who the women perceived as sources of support in meeting their needs. Ethnography Sample: 12 women Location: Canada (BC) - Need to feel that they belong. - Sense of isolation related to a lack of a mutual basis of understanding - Sources of support [sequential pathway] = kin (family), insiders (people who have common understanding, usually from ethnic community), outsiders (unfamiliar people, agencies, resources) - Outsiders lack understanding of cultural values guiding social interactions or cultural context within which social resources or services developed; leads to misunderstood intentions and avoidance of contact - Beneficial if professional assists in developing community contacts; resources to be described in terms meaningful to the women Matuk(1996) Health stats of newcomers To develop an understanding of the health status of the new immigrant population. Survey Tool: Newcomers Health Survey Sample: 548; 307 men, 241 women Location: Canada - Most newcomers have no difficulty accessing needed care or services for health problems - Most rate health as good to excellent and are happy; these levels decline with age Trans i t ion to Pract ice 106 (Windsor, Ontario) - Most report life to be very to fairly stressful; women more stressed than men - Common stressors: employment, language barriers, securing affordable housing - Many have low level of social support Noh, Wu, Speechley, & Kaspar(1992) Depression in Korean immigrants in Canada II: Correlates of gender, work, and marriage To test competing explanations generated by the double burden and power perspectives in Korean immigrants. Quantitative -epidemiological survey Tool: CES-D Sample: 860 Koreans; 455 men, 405 women Location: Canada (Toronto, Ontario) - Female immigrants more likely to be depressed than male related to role overload/demand - Unmarried immigrants have higher depression rate than married - Men capitalize better on the mental health benefit of social resources such as education, marriage, employment, and income Schreiber, Stern, & Wilson (1998) The contexts for managing depression and its stigma among black West Indian Canadian women To discover the basic social process by which black West Indian women in Canada manage depression and move toward recovery. Grounded Theory Sample: 12 Black West Indian women Location: Canada (Ontario) - "Being strong" is the basic social process to resolve or ameliorate depression; four stage process that includes dwelling on it, diverting myself, regaining my composure, trying new approaches - Being strong occurs within overlapping social contexts: cultural stigma of depression, male-female roles and relationships, and belief in Christian doctrine - Racism part of their existence, but choose to rise above it Shin & Shin (1999) The lived experience of Korean immigrant women acculturating into the United States To reveal and understand the true meaning of the acculturation experience of Korean women immigrants. Phenomenology Sample: 6 Korean women Location: USA (New York) - Experience evolves through four interrelates stages: dreams (of a better life), conflicts (dichotomy between life in Korea and U.S.), renunciation (will not return to Korea), remorse (longing for life in Korea) Yahes & Dunn (1996) Enculturation of foreign nurse graduates: An integrated model To identify the continuing education needs of foreign nurse graduates. Cross-sectional survey Sample: 7 Directors of Nursing Location: USA - Need to address cultural variance related to: verbal style, non-verbal communication characteristics, culturally determined gender roles, and assertive behavior - Assessment of speech mechanics for clarity and coherence - All staff to be educated on issues of pluralism and cultural diversity; recognition of individuals as resources Trans i t ion to Pract ice 110 A p p e n d i x D : Nurse Demograph ic F o r m (Confident ia l ) N a m e : Site: U n i t : Educa t ion : Count ry where education was completed Emplo ym en t : F u l l - t i m e T i t l e o f current pos i t ion: Part-t ime Hours /week H o w long have y o u been i n this nurs ing pos i t ion? Previous experience i n nurs ing: C o d e #: C o d e #: (diploma/degree) Casua l Hours /week Where were y o u born? W h a t is your country o f c i t izenship? Where d i d y o u l i ve pr ior to m o v i n g to Canada? H o w long have y o u l i v e d i n Canada? W h a t is your current immigrant status? A g e at last birthday: • (years) CONTACT INFORMATION Telephone number: M a i l i n g address: Trans i t ion to Pract ice 111 A p p e n d i x E : Interview Quest ions T e l l me about your experience m o v i n g to Canada. Descr ibe your experiences as a nurse educated outside o f Canada i n m a k i n g the transit ion to practice i n Canada. W h a t were your greatest concerns when beginning to practice i n Canada? Wha t have been some o f the highl ights o f your experience? T e l l me about your experiences these past months. • T e l l me about what y o u d i d for yourself. • T e l l me about what y o u have been do ing w i t h other people. • T e l l me about your experience w i t h the organizat ion and the support it has provided . • T e l l me about the professional resources y o u have used. • T e l l me about the commun i ty resources y o u have used. H o w important were these resources/supports i n he lp ing y o u transit ion to practice i n Canada? • E x p l o r e the meaning or s ignif icance o f resources/supports. Wha t other services or supports that y o u w o u l d have va lued i n this t ransi t ion process? Please describe them. Prompts C a n y o u te l l me more . . . In what w a y . . . - So what you ' re saying is . . . W h a t was that l ike for you? Trans i t ion to Pract ice 112 A p p e n d i x F : T i m e l i n e Phase Date A c t i v i t y Preparation M a r c h - October 2003 October 2003 N o v e m b e r 2003 January 2004 W r i t e proposal Commi t t ee accepted proposal Proposal submitted to Behav ioura l Research Eth ics B o a r d Gatekeepers have been identif ied and their support garnered A p p r o v a l received f rom Behav iou ra l Research Eth ics B o a r d Recrui tment o f sample; P rov ide study informat ion to potential participants F i e l d W o r k February 2004 M a r c h - A p r i l 2004 M a y - June 2004 Ju ly - A u g u s t 2004 Informed consent obtained f rom participants Firs t interviews comple ted Recrui t more participants O n g o i n g transcript ion and analysis o f the narratives P r imary analysis and interpretations o f the data completed and submitted to supervisors for r ev iew Informed consent obtained f rom participants Firs t interviews completed O n g o i n g transcript ion and analysis o f the narratives A n a l y s i s September - October 2004 N o v e m b e r 2004 - January 2005 February - M a r c h 2005 A p r i l 2005 A n a l y s i s and interpretations o f the data completed and submitted to supervisors for rev iew A n a l y s i s and interpretations o f the data comple ted Deve loped first draft o f thesis and submitted to supervisors for r ev iew Participants contacted for c lar i f ica t ion as needed Comple t ed draft o f thesis and revis ions Thesis accepted Dissemina t ion o f results 

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