515716
research-article2014
TCNXXX10.1177/1043659613515716Journal of Transcultural NursingKishi et al.
Research Department
A Model of Adaptation of Overseas Nurses: Exploring the Experiences of Japanese Nurses Working in Australia
Journal of Transcultural Nursing 2014, Vol. 25(2) 183–191 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659613515716 tcn.sagepub.com
Yuka Kishi, MN, RN1, Kumiyo Inoue, PhD, RN2, Patrick Crookes, PhD, BSc (Nursing), RGN, RNT, CertEd3, and Allison Shorten, PhD, MSc, BN, RN, RM4
Abstract Purpose: The purpose of the study was to investigate the experiences of Japanese nurses and their adaptation to their work environment in Australia. Using a qualitative research method and semistructured interviews, the study aimed to discover, describe, and analyze the experiences of 14 Japanese nurses participating in the study. Design: A qualitative study. Method: Fourteen Japanese registered nurses working in Australian hospitals participated in the study. Individual semistructured interviews were conducted from April to June in 2008. Thematic analysis was used to identify themes within the data. Results: Analysis of qualitative open-ended questions revealed the participants’ adaptation process. It consists of three themes or phases: seeking (S), acclimatizing (A), and settling (S), subsequently named the S.A.S. model. Discussion: The conceptual model of the adaptation processes of 14 Japanese nurses working in Australia includes the seeking, acclimatizing, and settling phases. Although these phases are not mutually exclusive and the process is not necessarily uniformly linear, all participants in this study passed through this S.A.S. model in order to adapt to their new environment. Implications for Practice: The S.A.S. model of adaptation helps to describe the experiences of Japanese overseas qualified nurses working in Australian hospitals. Future research is needed to examine whether this model can be applied to nurses from other countries and in other settings outside Australia. Keywords transcultural health, international educational experiences, work force diversity, Japanese, overseas qualified nurses, adaptation process, Japanese nurses, Australian hospitals, an adaptation model
Nursing workforce shortages are a global concern, such that hospitals and health care services attempt to fill vacancies through the recruitment of nurses from overseas. Studies exploring the experiences of overseas qualified nurses (OQNs) and how they adapt to a new country and health care environment may help to identify unique needs for support and professional education. The experience of Japanese nurses working in Australian hospitals has been largely unexplored in the literature. This article reports on a study that sought to better understand the perspectives of Japanese registered nurses who relocated to Australia and were working in Australian hospitals. The article describes the development of an adaptation process model for Japanese nurses working in Australia, named the S.A.S. model. It is believed that the S.A.S. model, which describes the adaptation process experienced by a group of Japanese nurses working in Australia, will contribute to future studies of OQNs who are familiarizing themselves with different environments and countries.
Review of the Literature A database search was conducted in CINAHL, Medline, ProQuest central, and ScienceDirect. The search was limited to articles written in English and published between 2000 and 2010. The key words used in the database search were “migrant or immigrant or international or overseas” and “cultur*” and “adaptation or acculturation” and “process*”. The snowballing technique of retrieving highly relevant articles from references led to the inclusion of seven qualitative articles. Of these seven, two articles examined the adaptation 1
Sougouzaitaku Medical Clinic, Hashima-gun, Japan University of New South Wales, Kensington, Australia 3 University of Wollongong, Wollongong, Australia 4 Yale University, New Haven, CT, USA 2
Corresponding Author: Yuka Kishi, Sougouzaitaku Medical Clinic, 1-180-6 Yatsurugikita Ginanchou, Hashima-gun, Gifu Prefecture, Japan. Email: [email protected]
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Journal of Transcultural Nursing 25(2)
process of OQNs. The other five focused on immigrants, immigrant families, immigrant adolescents, and international students. The two studies (Omeri & Atkins, 2002; Yi & Jezewski, 2000) focusing on the adaptation process of OQNs reported the essential aspects that emerged. One of these studies, which used grounded theory research, found five categories in the process of social psychological adjustment when Korean OQNs adapt to hospitals in the United States (Yi & Jezewski, 2000). These were “relieving psychological stress,” “overcoming the language barrier,” “accepting American nursing practice,” “adapting to American problem-solving strategies,” and “adapting to the American style of interpersonal relationships.” Yi and Jezewski (2000) identified that the first three categories largely characterize nurses’ adjustment in the initial stage, which can last for 2 to 3 years. The latter two categories were principal components of the later stage, which can take an additional 5 to 10 years to complete. These categories are not mutually exclusive and the process is not necessarily uniformly linear. This study focused on Korean OQNs in American hospitals and explained how their cultural background might affect their process of adjustment, and hence the results may not apply to OQNs from other countries. The second study was a phenomenological study (Omeri & Atkins, 2002) that explored the lived experiences of participants, focusing on the process of migration and job seeking as a graduate nurse and the gaining of registration as a nurse in New South Wales. This study focused primarily on the negative aspects of the adaptation of OQNs to their new environments, rather than the process of adaptation. Three categories of meaning emerged from the analysis: “professional negation,” experienced as a lack of support, lack of direction, and lack of recognition of skills and previous nursing experience; “otherness,” experienced as cultural separateness and loneliness; and “silencing,” experienced in language and communication difficulties. Participants in this study experienced continuing marginalization and their experiences were mostly unhappy, isolating, and negative (Omeri & Atkins, 2002). The above two studies identified the essential aspects influencing the adjustment process of OQNs; however, they did not establish a conceptual model for their adaptation process. Studies by Walsh and Horenczyk (2001) and Morrison and James (2009) established a model; however, they focused on the impact of gender and generation on the acculturation process. Walsh and Horenczyk (2001) considered the issues faced by English-speaking immigrants during their immigration process in Israel, according to gender patterns, and examined difficulties in emigrating, acculturating, and adapting as well as immigrants’ coping strategies. The women in their study tended to have issues relating to belonging, whereas the men had issues relating to competence; therefore, the investigators named their model the Belonging/ Competence Model.
Morrison and James (2009), in contrast, focused on the acculturation process among families in the Portuguese immigrant population in Canada. The authors revealed that “immigration and acculturation were stressors on the family unit,” “family members adopt different acculturative strategies,” and “as family members acculturate, discords arise and are resolved according to the cultural traits different members have adopted” (Morrison & James, 2009, p. 155). In this research, women, men, and second-generation immigrants demonstrated different characteristics during the acculturation process and when seeking discord resolution. Studies by Yeh et al. (2005) and Ajrouch (2000) addressed the identity formation of immigrant youths but did not establish a conceptual model. The Korean immigrant youth in the study by Yeh et al. (2005) had to negotiate with various cultural value systems and often faced complex issues such as “meeting parental expectations; negotiating Korean, Asian and non-Asian peer relationships; and coping with different language usage at home and at school” (Yeh et al., 2005, p. 178). These issues greatly influenced their ethnic identity and peer group formation. In the study conducted by Ajrouch (2000), second-generation Lebanese adolescents living in the United States faced issues of identity formation. They lived within a Lebanese ethnic community that continued to receive immigrants. Within this situation, the second-generation Lebanese adolescents had a significant impact on their own identity and on how they placed themselves in the context of American society (Ajrouch, 2000). The findings of the above four studies (Walsh & Horenczyk, 2001; Morrison & James, 2009; Yeh et al., 2005; Ajrouch, 2000) demonstrated the significant influence of gender and generation on acculturation patterns and suggested that support should be varied according to age and gender; however, they did not address the whole process of acculturation. Ryan and Ogilvie (2001) also focused on one aspect of acculturation, examining the acculturation strategies of overseas students in Australia and Singapore using a “place attachment framework.” This phenomenological study emphasized that it is important for overseas students to feel at home in their new country. Overseas students even attempted to substitute places and people they left behind in their home country with places and people in their new environment (Ryan & Ogilvie, 2001). The literature review did not uncover any studies proposing a conceptual model for the adaptation processes of Japanese OQNs in Australia or any other English-speaking country. The present study aims to investigate the experiences of Japanese nurses and their adaptation to their work environment in Australia.
Methods A qualitative research approach was used. The acculturation of OQNs is a topic of which little is known (Closs & Cheater, 1999; Rusinová, Pochard, Kentish-Barnes, Chaize, &
Downloaded from tcn.sagepub.com by guest on March 13, 2015
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Kishi et al. Azoulay, 2009) and the research question is “attempting to generate exploratory or descriptive knowledge” (Draper, 2004, p. 77; Sandelowski, 2004). Qualitative research assumes that the understanding of individuals based on their previous experiences and personal beliefs influences the meaning of their current experiences (Ellis & Crookes, 2004, pp. 53-54).
Sample Fourteen Japanese registered nurses working in Australian hospitals were recruited using purposive and snowball sampling. In purposive sampling, researchers select subjects who are likely to provide information about their experiences in the area being studied (Burns & Grove, 2005, p. 352; Polit & Beck, 2004, p. 306; Russell & Gregory, 2003). Snowball sampling enabled prospective participants to be introduced to the researcher by Japanese participants. The inclusion criteria used to recruit Japanese nurses as participants for this study were (a) registered nursing experience in Japan (the length of nursing experience was not a criterion), (b) study experience in Australia, (c) previous or current employment in the NSW health sector (the length of nursing experience was not a criterion), (d) ability to speak English, and (e) willingness to participate in the study.
Data Collection Individual semistructured interviews were conducted from April to June 2008 at a time and place that was mutually suitable to the participants and the interviewer (the chief researcher). Prior to the interviews, demographic data were collected using a written questionnaire on age, gender, years of nursing experience in Japan and Australia, years of residency in Australia, past and present areas of clinical experience (refer to Table 1), types of hospitals (private or public) in which participants were employed in Australia and Japan, number of beds in those hospitals, and shift work patterns in Australia. Nurses had worked or were currently working in a wide range of settings including a 300+ bed public–private general hospital in a major urban area of Australia, nursing homes, and a suburban facility for the physically handicapped. Participants were from a wide geographical area of Japan (from large cities to rural areas). Interviews were approximately 1 hour in duration, and seven prompts (refer to Table 2) formed the common core of the semistructured interview process. The seven lead questions were developed in order to broadly cover the work and study experiences of Japanese registered nurses. All interviews were conducted in Japanese, primarily because both the interviewer and the interviewees were Japanese. Providing an atmosphere that enables participants to speak in their native language is thought to give the interviewees the opportunity to clearly explain their feelings, which they might only be able to express in their native
Table 1. Demographic Characteristics of Japanese Nurses Interviewed (n = 14). Characteristics Gender Age Years of nursing experience working in Japan Years of residency in Australia Years of nursing experience working in Australia Clinical role in Australia Academic qualifications in nursing
Category
n
Female Male 30-34 years 35-39 years 40-44 years 45-49 years 55-59 years
research-article2014
TCNXXX10.1177/1043659613515716Journal of Transcultural NursingKishi et al.
Research Department
A Model of Adaptation of Overseas Nurses: Exploring the Experiences of Japanese Nurses Working in Australia
Journal of Transcultural Nursing 2014, Vol. 25(2) 183–191 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659613515716 tcn.sagepub.com
Yuka Kishi, MN, RN1, Kumiyo Inoue, PhD, RN2, Patrick Crookes, PhD, BSc (Nursing), RGN, RNT, CertEd3, and Allison Shorten, PhD, MSc, BN, RN, RM4
Abstract Purpose: The purpose of the study was to investigate the experiences of Japanese nurses and their adaptation to their work environment in Australia. Using a qualitative research method and semistructured interviews, the study aimed to discover, describe, and analyze the experiences of 14 Japanese nurses participating in the study. Design: A qualitative study. Method: Fourteen Japanese registered nurses working in Australian hospitals participated in the study. Individual semistructured interviews were conducted from April to June in 2008. Thematic analysis was used to identify themes within the data. Results: Analysis of qualitative open-ended questions revealed the participants’ adaptation process. It consists of three themes or phases: seeking (S), acclimatizing (A), and settling (S), subsequently named the S.A.S. model. Discussion: The conceptual model of the adaptation processes of 14 Japanese nurses working in Australia includes the seeking, acclimatizing, and settling phases. Although these phases are not mutually exclusive and the process is not necessarily uniformly linear, all participants in this study passed through this S.A.S. model in order to adapt to their new environment. Implications for Practice: The S.A.S. model of adaptation helps to describe the experiences of Japanese overseas qualified nurses working in Australian hospitals. Future research is needed to examine whether this model can be applied to nurses from other countries and in other settings outside Australia. Keywords transcultural health, international educational experiences, work force diversity, Japanese, overseas qualified nurses, adaptation process, Japanese nurses, Australian hospitals, an adaptation model
Nursing workforce shortages are a global concern, such that hospitals and health care services attempt to fill vacancies through the recruitment of nurses from overseas. Studies exploring the experiences of overseas qualified nurses (OQNs) and how they adapt to a new country and health care environment may help to identify unique needs for support and professional education. The experience of Japanese nurses working in Australian hospitals has been largely unexplored in the literature. This article reports on a study that sought to better understand the perspectives of Japanese registered nurses who relocated to Australia and were working in Australian hospitals. The article describes the development of an adaptation process model for Japanese nurses working in Australia, named the S.A.S. model. It is believed that the S.A.S. model, which describes the adaptation process experienced by a group of Japanese nurses working in Australia, will contribute to future studies of OQNs who are familiarizing themselves with different environments and countries.
Review of the Literature A database search was conducted in CINAHL, Medline, ProQuest central, and ScienceDirect. The search was limited to articles written in English and published between 2000 and 2010. The key words used in the database search were “migrant or immigrant or international or overseas” and “cultur*” and “adaptation or acculturation” and “process*”. The snowballing technique of retrieving highly relevant articles from references led to the inclusion of seven qualitative articles. Of these seven, two articles examined the adaptation 1
Sougouzaitaku Medical Clinic, Hashima-gun, Japan University of New South Wales, Kensington, Australia 3 University of Wollongong, Wollongong, Australia 4 Yale University, New Haven, CT, USA 2
Corresponding Author: Yuka Kishi, Sougouzaitaku Medical Clinic, 1-180-6 Yatsurugikita Ginanchou, Hashima-gun, Gifu Prefecture, Japan. Email: [email protected]
Downloaded from tcn.sagepub.com by guest on March 13, 2015
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Journal of Transcultural Nursing 25(2)
process of OQNs. The other five focused on immigrants, immigrant families, immigrant adolescents, and international students. The two studies (Omeri & Atkins, 2002; Yi & Jezewski, 2000) focusing on the adaptation process of OQNs reported the essential aspects that emerged. One of these studies, which used grounded theory research, found five categories in the process of social psychological adjustment when Korean OQNs adapt to hospitals in the United States (Yi & Jezewski, 2000). These were “relieving psychological stress,” “overcoming the language barrier,” “accepting American nursing practice,” “adapting to American problem-solving strategies,” and “adapting to the American style of interpersonal relationships.” Yi and Jezewski (2000) identified that the first three categories largely characterize nurses’ adjustment in the initial stage, which can last for 2 to 3 years. The latter two categories were principal components of the later stage, which can take an additional 5 to 10 years to complete. These categories are not mutually exclusive and the process is not necessarily uniformly linear. This study focused on Korean OQNs in American hospitals and explained how their cultural background might affect their process of adjustment, and hence the results may not apply to OQNs from other countries. The second study was a phenomenological study (Omeri & Atkins, 2002) that explored the lived experiences of participants, focusing on the process of migration and job seeking as a graduate nurse and the gaining of registration as a nurse in New South Wales. This study focused primarily on the negative aspects of the adaptation of OQNs to their new environments, rather than the process of adaptation. Three categories of meaning emerged from the analysis: “professional negation,” experienced as a lack of support, lack of direction, and lack of recognition of skills and previous nursing experience; “otherness,” experienced as cultural separateness and loneliness; and “silencing,” experienced in language and communication difficulties. Participants in this study experienced continuing marginalization and their experiences were mostly unhappy, isolating, and negative (Omeri & Atkins, 2002). The above two studies identified the essential aspects influencing the adjustment process of OQNs; however, they did not establish a conceptual model for their adaptation process. Studies by Walsh and Horenczyk (2001) and Morrison and James (2009) established a model; however, they focused on the impact of gender and generation on the acculturation process. Walsh and Horenczyk (2001) considered the issues faced by English-speaking immigrants during their immigration process in Israel, according to gender patterns, and examined difficulties in emigrating, acculturating, and adapting as well as immigrants’ coping strategies. The women in their study tended to have issues relating to belonging, whereas the men had issues relating to competence; therefore, the investigators named their model the Belonging/ Competence Model.
Morrison and James (2009), in contrast, focused on the acculturation process among families in the Portuguese immigrant population in Canada. The authors revealed that “immigration and acculturation were stressors on the family unit,” “family members adopt different acculturative strategies,” and “as family members acculturate, discords arise and are resolved according to the cultural traits different members have adopted” (Morrison & James, 2009, p. 155). In this research, women, men, and second-generation immigrants demonstrated different characteristics during the acculturation process and when seeking discord resolution. Studies by Yeh et al. (2005) and Ajrouch (2000) addressed the identity formation of immigrant youths but did not establish a conceptual model. The Korean immigrant youth in the study by Yeh et al. (2005) had to negotiate with various cultural value systems and often faced complex issues such as “meeting parental expectations; negotiating Korean, Asian and non-Asian peer relationships; and coping with different language usage at home and at school” (Yeh et al., 2005, p. 178). These issues greatly influenced their ethnic identity and peer group formation. In the study conducted by Ajrouch (2000), second-generation Lebanese adolescents living in the United States faced issues of identity formation. They lived within a Lebanese ethnic community that continued to receive immigrants. Within this situation, the second-generation Lebanese adolescents had a significant impact on their own identity and on how they placed themselves in the context of American society (Ajrouch, 2000). The findings of the above four studies (Walsh & Horenczyk, 2001; Morrison & James, 2009; Yeh et al., 2005; Ajrouch, 2000) demonstrated the significant influence of gender and generation on acculturation patterns and suggested that support should be varied according to age and gender; however, they did not address the whole process of acculturation. Ryan and Ogilvie (2001) also focused on one aspect of acculturation, examining the acculturation strategies of overseas students in Australia and Singapore using a “place attachment framework.” This phenomenological study emphasized that it is important for overseas students to feel at home in their new country. Overseas students even attempted to substitute places and people they left behind in their home country with places and people in their new environment (Ryan & Ogilvie, 2001). The literature review did not uncover any studies proposing a conceptual model for the adaptation processes of Japanese OQNs in Australia or any other English-speaking country. The present study aims to investigate the experiences of Japanese nurses and their adaptation to their work environment in Australia.
Methods A qualitative research approach was used. The acculturation of OQNs is a topic of which little is known (Closs & Cheater, 1999; Rusinová, Pochard, Kentish-Barnes, Chaize, &
Downloaded from tcn.sagepub.com by guest on March 13, 2015
185
Kishi et al. Azoulay, 2009) and the research question is “attempting to generate exploratory or descriptive knowledge” (Draper, 2004, p. 77; Sandelowski, 2004). Qualitative research assumes that the understanding of individuals based on their previous experiences and personal beliefs influences the meaning of their current experiences (Ellis & Crookes, 2004, pp. 53-54).
Sample Fourteen Japanese registered nurses working in Australian hospitals were recruited using purposive and snowball sampling. In purposive sampling, researchers select subjects who are likely to provide information about their experiences in the area being studied (Burns & Grove, 2005, p. 352; Polit & Beck, 2004, p. 306; Russell & Gregory, 2003). Snowball sampling enabled prospective participants to be introduced to the researcher by Japanese participants. The inclusion criteria used to recruit Japanese nurses as participants for this study were (a) registered nursing experience in Japan (the length of nursing experience was not a criterion), (b) study experience in Australia, (c) previous or current employment in the NSW health sector (the length of nursing experience was not a criterion), (d) ability to speak English, and (e) willingness to participate in the study.
Data Collection Individual semistructured interviews were conducted from April to June 2008 at a time and place that was mutually suitable to the participants and the interviewer (the chief researcher). Prior to the interviews, demographic data were collected using a written questionnaire on age, gender, years of nursing experience in Japan and Australia, years of residency in Australia, past and present areas of clinical experience (refer to Table 1), types of hospitals (private or public) in which participants were employed in Australia and Japan, number of beds in those hospitals, and shift work patterns in Australia. Nurses had worked or were currently working in a wide range of settings including a 300+ bed public–private general hospital in a major urban area of Australia, nursing homes, and a suburban facility for the physically handicapped. Participants were from a wide geographical area of Japan (from large cities to rural areas). Interviews were approximately 1 hour in duration, and seven prompts (refer to Table 2) formed the common core of the semistructured interview process. The seven lead questions were developed in order to broadly cover the work and study experiences of Japanese registered nurses. All interviews were conducted in Japanese, primarily because both the interviewer and the interviewees were Japanese. Providing an atmosphere that enables participants to speak in their native language is thought to give the interviewees the opportunity to clearly explain their feelings, which they might only be able to express in their native
Table 1. Demographic Characteristics of Japanese Nurses Interviewed (n = 14). Characteristics Gender Age Years of nursing experience working in Japan Years of residency in Australia Years of nursing experience working in Australia Clinical role in Australia Academic qualifications in nursing
Category
n
Female Male 30-34 years 35-39 years 40-44 years 45-49 years 55-59 years
