The quantitative data profiling the IENs were tabulated (Table ) and the qualitative data was organized and classified into seven key themes including (the dominant Phase which generated the data is indicated):
• Motivation and Decision to Relocate (Phase 1)
• Expectations versus Actual Personal Experiences of Recruitment, Reception, Salary & Support on Arrival (Phase 1)
• The Health Care System Nursing Work Environment (Phase 1 & 2)
• Discrimination in the Professional Lives of IENs (Phase 2)
• Qualifying as a Registered Nurse (Phases 1 & 2)
• Life Beyond the Nursing Setting (Phase 1 & 2)
• Strategies IENs Learned to Overcome Challenges (Phase 2)
Profile of the Participating IENs
The collected details present an interesting profile of the participating IENs (Table ). The nurses had diverse ethno-cultural origins in the Philippines, Australia, New Zealand, England, Scotland, Barbados and Ghana. Time from completion of their nursing qualifications ranged from 4-19 years and their average age was 36.4 years. Almost all were educated to first degree level with some holding master's degrees. No participant had acquired a Registered Nurse (RN) qualification within Canada and they were largely employed as graduate nurses with a small number being employed as nursing aides.
Motivation and Decision to Relocate
This study reveals that the motivations of the IENs for migrating into Canada were wide-ranging. These can be broadly categorized as personal and professional motivations. Personal motivations included the search for better economic opportunities and a generally better life (particularly for their families), for a place different from the IEN's home country, or the desire to join relatives already in Canada, among others. Several IENs desired financial gains to help fulfill family financial needs in their home country. Other personal motivations included adventure and the experience of a new ethno-cultural context. Professionally, the IENs relocated to western Canada largely due to their desire to learn new skills, to widen their work experience, or to access further education. Some stated that they were leaving unfavourable former working conditions:
"What brought me to Canada is [that] I always like to experience a different climate of nursing."(Participant 9)
Findings also demonstrate that the motivation to relocate to Canada for better economic opportunities and improvements in quality of life was mediated by the IEN's country of origin. Only those IENs who migrated originally from developing countries or low income nation states referred to the above as the main motivation for their migration. On the other hand, those from the more affluent, high income countries were motivated primarily by the desire to travel, be away from home, or to experience Canada. Indeed, some of these IENs perceived Canada to have more affordable living standards. The following quotations, from Filipino and European participants respectively, exemplify this:
"Honestly we are earning here A LOT compared to my home country. So that's one of the main reasons because I really want to support my family back home.... Well, a staff nurse in the Philippines is earning 6000 pesos[approx $130 CD] and if here, well I could say that our salary here for one month could be the equivalent of one year's salary in the Philippines."(Participant 18)
"We worked in the United Kingdom a few years ago, and we just wanted to have another travel work experience. We like the outdoors and things like that so we wanted to have a look at the mountains and animals, and I like fishing and things like that so. Really, other than that, there was no real intention." (Participant 10)
Expectations versus Actual Personal Experiences of Recruitment, Reception, Salary & Support on Arrival
Whereas personal factors were the main motivator for the IENs' desire to pursue a nursing career in Canada, their expectations were by and large related to their careers. When asked about what she thought of Canada prior to relocation, one participant noted:
"I think Canada is a better place because I can learn more here especially with my profession. In the Philippines we are lacking of supplies. I must admit that we are not doing good in procedure or something because we are lacking of supplies. We let [patients'] relatives buy supplies. Let's say we are going to do one dressing. We will ask relatives to buy supplies, like gauze. And even syringes...."(Participant 13).
Some of the IENs' expectations were met while in other cases reality fell short of expectations. In fact, IENs' negative experiences of recruitment, reception and support on arrival stemmed largely from these unmet expectations. A great deal of IENs' negative experiences related to absence of appropriate or sufficient supports on arrival. Some perceived their experiences upon arrival to Canada to be positive, appreciating collection at the airport, arranged accommodation for a period of six-weeks, and the provision of necessary information, while others had negative experiences including failure to receive arranged transportation, difficulties navigating the process of obtaining a Social Insurance Number (essential for payment of salary), and displeasure with the dormitory-type accommodations (offering the bare necessities, a shared kitchen, bathroom and lounge). The IENs also repeatedly complained about the geographical location of their accommodations which were thought to be assigned without regard to proximity to their work location:
"My first accommodation was in W. That is near X Mall. That's at the back of Y (Hospital). I wasn't pleased at all when they put me there and I will work here. So during the briefing I told them my concerns that we came here in Canada because of these benefits or this offer - that $5000 relocation package, free accommodation and stuff like that. But it seems that your accommodation is quite inconvenient for the people, you know, like me who will work in Z Hospital but I live in W [geographically distant]." (Participant 7).
As related to the IENs' work contracts with and financial reimbursement from the health authority, significant discontent was expressed by many IENs particularly with regard to their expectation of working in their area of specialty. For example, several IENs thought that prior to relocation they were not given sufficient or accurate information about their job positions or their job tasks in Canada. However, many were recruited by agencies in the country of origin rather than directly by the employing authority, therefore it is difficult to establish whether accurate information was provided which reflected the actual employer perspectives. Some IENs commented that their contracts were changed just prior to their move:
"We were told that ... you will always work in your area of specialty which has turned out to not be true. They guaranteed that you would always, if you are specialized in an area, then that is where you go. ... they kept changing what they wanted to do with me every five minutes. And then two weeks before I left to come over here, like I was supposed to go to Emergency (I'm trained in Emergency and that is all I have ever done) they say 'oh, there is no positions anymore. You have to work on a medical ward.'" (Participant 10)
Others thought that after their arrival the nurse manager in charge of their placements failed to discuss with them details of their specialty and instead placed them in different areas. The following comment is reflective of the views of many of the participants:
"To me it was more suicidal than anything... the contract was that um, temporary full-time for one year... almost all Internationally Educated Nurses who came, who didn't really understand what that entailed until we got here... given all those years of experiences of working in the NHS no one would have swapped that for a temporary one year position...then because they used an agency, the people that they employed at the agency themselves didn't really understand that." (Participant 14)
Many IENs also had difficulty reconciling the fact that they were recruited as RNs by the health authority but the regulatory body did not allow them to practice as RNs (see section on Qualifying as a Registered Nurse). Moreover, because of employment at graduate nurse level, not RN, many IENs stated that their actual salary entitlements were lower than those included in their signed contract. An additional financial challenge faced by many IENs were the long-wait times (up to eight weeks was claimed) for receiving their reimbursement of expenses.
When asked about their experiences of reception once starting work, many IENs were surprised that they were not introduced to their co-workers on their first day as might be considered courteous. Moreover, although their co-workers of similar ethno-cultural background were friendly, fellow Canadian workers were typically viewed as friendly in a capricious manner. One IEN described a substantial incongruity between previous experiences in another country where staff members were informed in advance of newly recruited staff and where introductions on arrival were commonplace.
The Health Care System Nursing Work Environment
When asked to share their general perspectives on the working within the provincial health care system, the overwhelming sentiment towards the system was negative. Only occasionally did the IENs feel positive about the system. In one such case an IEN felt that the system was generally supportive of IENs.
"What I appreciate with them [the health authority] is that they just don't throw you into the job. They orientate you as best as possible. And even here, they don't just say 'okay, you're in theatre today.' They try to sensitive you to the things that you're supposed to know except for those little bit flaws that I had just say." (Participant 9).
While many of the IENs were enrolled in a six-week long orientation/retraining session, many felt that there were several negative aspects of its implementation and content. Several felt that there was no new information provided to them and that there was an overall lack of consistency within the program particularly with respect to continuity of preceptorship. Others were left without assignment of a preceptor and were trained at a task by watching a staff nurse perform it once or twice.
Some IENs felt disillusioned after relocation to Canada, having realized that the system was not as comparatively advanced as they had expected:
"I thought that the [Canadian] health care system would be really advanced. Like I thought it would make Australia's health care system look really old-fashioned? But I don't think that's true. Like that's just what I thought in my head. I thought I would come over here and there would just be all this whiz/bang technology, and all these different practices and I wouldn't understand and I thought I'd have lots and lots to learn. But that hasn't ended up being a really accurate idea that I had." (Participant 11).
Others regretted what they perceived as a belief among Canadian health care decision makers and practitioners that their way is always the right way. The IENs particularly pointed out Canadian co-workers' consistent aversion to change (where the IEN was the change agent), a tendency that some IENs considered self-destructive:
"I think they are a little bit foolish doing what they're doing. I think they are chopping themselves off at the head by doing it. As an educator in New Zealand ... we had lots of international nurses come through the unit. And I loved the fact that they brought skills to New Zealand that we didn't have in New Zealand. You know, and everybody brought something. Canada's not about that unfortunately, or not so far. It's about their way is the right way. ..." (Participant 4).
While the above findings are in respect of IENs working directly for the health authority, some nurses were recruited to work in privately-owned continuing care facilities with the services of these facilities being contracted by the health authority. Indeed it is this cohort who appeared to experience the most dissatisfaction. The extent to which the health authority was fully aware of the work environments of these nurses is not clear.
"We were sent there by [the health authority] because they're adult clients that was funded [through the provincial health care plan] so we can work there. They said that we're just going to be added staff. So what we're going to do is assist with the medication administration. But then when we get there, the Health Care Aide is the one who gave us the orientation. She oriented us where the kitchen is. Where the cleaning cart is. So the moment I get home, it was already 11 p.m. and I can't call my supervisor... And the [senior] supervisor told her [junior supervisor] that it is part of our job. That as Community nurses, it is different from working in an acute setting and that we should be enthusiastic about, you know, our job. We should be...we should be ready to do, to do those stuff for the resident, to keep them safe, to have the environment tidy. But after doing it for two weeks or three weeks, I've been repeatedly telling them that no this is not what I'm supposed to do here. I just thought that I would just go home if they don't stop that." (Participant 19).
The IENs we interviewed made observations concerning clinical nursing practice differences between their home countries and Canada. While some IENs stated that nursing remains nursing and patients are patients, some observed major changes to their nursing practice in their home country:
"My biggest challenge. Like knowing that for example, most women here, way over 90 percent of women here, deliver in stirrups, in the lithotomy position. It has been proven time and time again through research that that is a very bad position for her comfort as well as for tearing. It increases tearing risks of the perineum. And they just, they're just like this is the way we've always done it so we'll just keep doing it. And I'm like, that's that woman's body, that's her life, it's her self-esteem, it's her choice, it's her sexuality, it's her relationship with her partner when she goes home. Not just, it's not just about you and the way you've always done it. It should be about that woman and how many aspects of her life this can negatively impact because she's having an unnecessary third degree tear whereas if you let her deliver in an up-to-date position, she might only get a first degree tear... That's a big challenge for me because I'm very passionate about women being looked after in the best possible way. And then I see its old fashioned here and that really, it's upsetting." (Participant 11).
Some IENs also commented on the many ways and reasons for charting (recording of nursing notes and observations) on the wards. Charting for some required learning to use much more objective language (e.g. measurements) and waiting until the end of shift, rather than using more descriptive language in an immediate fashion. Clinical practice varied in other ways beyond patient care extending into professional (interdisciplinary) relationships.
"Communications for, between the... disciplines between the doctors and the nurses and the Physios and the Occupational Therapists, there's not a feeling of collaboration. There's a feeling of competition. There's a feeling of, far more solid than I experienced. In New Zealand, everybody appreciates what everybody is doing." (Participant 4).
Discrimination in the Professional Lives of IENs
IENs also shared perspectives on issues of fairness and equity. Some IENs felt that being assigned tasks that were unrelated to nursing, such as dishwashing and vacuuming was reflective of employer/supervisor discriminatory practices based on country of origin. Others felt that the IEN's country of origin determined whether or not they were able to relocate with their family members. Other perceptions of discrimination or unfair treatment mainly related to credentialing and are addressed in the next section.
Some IENs described their perceptions of discrimination in the form of overt racism:
"Well, what people will talk about, you know, racism. Racism is a big word. Right? People wouldn't come you know and tell you in your face, straight to that because you know, you are black or this or that, I'm doing this to you. Right? It can be very subtle. Very covert." (Participant 14)
Qualifying as a Registered Nurse
All of the IENs we interviewed were recruited by the health authority as RNs but once in Canada were required to work in different capacities such as a Graduate Nurse, a Licensed Practical Nurse, or a Nursing Aid. For this reason, although this study was not designed to focus on credentialing we found this issue too persistent and troubling to avoid reporting. The main concerns of the IENs focused on being informed that they were here (Canada) to work as a Licensed Practical Nurse and that they could not apply to take the national Canadian Registered Nurse Exam to become an RN. (Registration of nurses in Canada is a provincial matter, yet each province uses the national board exam as part of their credentialing process. Obtaining a practice permit with the regulatory body related to this study is a three-step process which starts with an eligibility assessment requiring that the applicant is currently registered as an RN in the country where they obtained their education and considering whether their education was of generalist nursing at a baccalaureate level. Evidence of English competency [using one of two examination methods] and various practice competency information is also required with the cost of all translation incurred by the IEN). Many of the IENs were not well informed of the criteria used when appointing IENs to the entry level of nursing (i.e. Graduate Nurse) at which they could expect to commence their employment in the province. Some IENs stated their expectation that the regulatory body would adjust credentialing criteria according to the IEN's country of origin, with their perceived reality to be that there were unclear guidelines on the criteria used to assign IENs to the different nursing levels.
"But we never expected that it [credentialing process] will be so long. And it's really different. Yeah, one thing that was really, that was really promised us is that being an RN right? They didn't tell us about the SEC, that's the Substantial Equivalent Competency Exam that we have to go through for like 5 days. That's written and oral. And then after that, you, um, they're going to assess us as to how many courses are we going to take. So never, never in our wildest dreams."(Participant 22).
To some extent the inconsistencies in professional status on arrival may represent a degree of naivety on the part of the IENs, in that perhaps more research and investigation might have been initiated by them at the point of recruitment. Indeed some IENs acknowledged this as an issue. However, many had received RN designations from multiple countries, the United Kingdom and Saudi Arabia for example, which had similar criteria for nursing qualification, and therefore they assumed they would become an RN on arrival without taking a qualifying exam. One participant's comment reflects the overall responses related to dissatisfaction with what the IENs' perceived to be stringent rules of the regulatory body relating to requirements for practicing nursing in the province.
"It [regulatory body] has put up lots of barriers along the way and you know, if I may pass another exam and stuff, it [regulatory body] is like, "no, you just need to do this, and do this, and do this." It's incredibly pedantic about qualifications you need and stuff like that. I'm sure it must frighten people away.... The hoops they make you jump through are above and beyond what is necessary. I know they have got to be safe with who comes through here but it's too much." (Participant 4).
The findings demonstrate that many IENs were not informed during recruitment of the different stages and qualifying procedures the provincial regulatory body required before one is able to take the national board exam to become an RN. The IENs often questioned whether the regulatory body and employer credentialing decisions were made on a case-by-case basis or based on existing stereotypes, e.g. country of origin or practice of IENs. Many IENs stated their discontent with their perceived inconsistency with decisions related to which IEN writes which credentialing exam; many thought that only considering the last country and position where they worked, rather than their skills and competency, was short-sighted and unfair. Moreover, the content of the national board examination is essentially bound by Canadian ethno-cultural conventions and many IENs are not fully familiar with these conventions which may have lead to disadvantages.
Life Beyond the Nursing Setting
When we asked the nurses how they were experiencing living in Canada, responses generally considered the financial, health and education institutions they with their families were required to utilize during their stay. In many cases, the IENs could not afford to bring along immediate family members, yet if they were fortunate to do this, many of their spouses experienced difficulty securing employment in their area of specialty. There was a lack of familiarity with the public school system which IENs having young children encountered. Accessing or obtaining vital services including health services, banking, communications (i.e. phone contract), and acceptable and affordable food, was felt to be challenging. Several IENs experienced delays in obtaining an appointment with a family physician. The cost of living was seen as relatively expensive, especially costs of food and other necessities like housing. Many IENs expressed that many of their negative views were shaped by their being paid lower salaries that they were expecting and the uncertainty of reimbursement for their expenses.
"So I've come here and I've been kind of told, well you can't, you won't be paid as a Registered Nurse until you sit the exam. In the meantime you'll be a graduate nurse. So you're paid at a graduate nurse level. And then your pay goes up once you sit the exam." (Participant 6)
Strategies IENs Learned to Overcome Challenges
The participants reported a wide variety of strategies for coping in their environment, sometimes related to family and friend supports, communication, reliance on previous experiences, and previous and gained knowledge and perceptions. Many IENs commented on the role played by family members, whether living in their country of origin, living with them in Canada, or being additional family members with whom they joined in Canada. Many IENs were required to start work early upon their arrival, thus they greatly appreciated assistance of supporting family members in shopping, maintaining the living space (cleaning, cooking etc), or locating a more permanent place of residence. One participant mentioned relying upon family members to help supply documents require for their credentialing. More helpful for many, family members were those with whom to "vent to and relax with" whenever working conditions were not favourable.
"Our two daughters are coming at Christmas with our new grandson and my mom and dad are coming next year. And our youngest son and his girlfriend are hopefully coming next year". (Participant 16)
"Yeah, we, and the church we go to it's brilliant because we've made a lot of good friends there and so we socialize with them as well". (Participant 12)
Communicating issues was an important way for some IENs to have their issues known. This was likely more productive for those who had a fully fluent command of English, as it has been noted by many investigators that communication abilities may be associated with better chances of becoming employed in the IEN's area of specialty and more expeditious migration and credentialing processes [23
Gained knowledge and knowledge from past experiences were recognized as importance means to facilitate transitioning. IENs who had previously relocated for nursing employment knew that obstacles would need to be faced, and that having an open-mind to learn "their way" would ease the adjustment of the foreign system. Continual learning was one way the IENs found to enhance their assimilation into the Canadian health care system and social environment. Some thought it okay to "learn and practice the Canadian way of doing things even though they go against 'your' practice and beliefs".
"You have to fend for yourself. And you do whatever it takes to survive. And in a sense, that's the reason why, as I've said, lots and lots of the staff, over half of them, and some are even in the process of leaving". (Participant 16)