1 NURSE MANAGER PERSPECTIVES ABOUT INTERNATIONALLY EDUCATED NURSES (IENs) AND HIRING PRACTICES IN LONG-TERM CARE by KATRINA HAYNES B. S. N, Trinity Western University, 2010 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES We accept this thesis as conforming to the required standard Dr. Barbara Astle, Supervisor Dr. Margery Hawkins, Second Reader Dr. Sheryl Reimer-Kirkham, Third Reader TRINITY WESTERN UNIVERSITY August 2017 © Katrina Haynes, 2017 Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 2 Abstract Internationally Educated Nurses (IENs) are an integral part of Canada’s workforce. In a qualitative study, seven Nurse Managers from long-term care facilities in British Columbia were interviewed about their perceptions and experiences with IENs, and how these influenced their hiring practices. Three themes emerged: Acknowledging the Complexities, Finding the “Right Fit”, and Navigating Differences. Conclusions were that Nurse Managers: 1) Compared IENs to newly graduated nurses in support required, 2) Preferred hiring Canadian educated nurses over IENs, however, some preferred hiring IENs as they perceived them to be more hardworking, 3) Perceived IENs as being ready to practice, but failed to acknowledge their previous nursing education and experience, 4) Perceived IENs as a homogenous group, 5) Preferred hiring IENs with positive attitudes, clear communication skills, Canadian nursing experience, and a background in caring for older persons, 6) Were unware of current licensing guidelines, 7) Used no established hiring guidelines, and 8) Possessed a positive ‘gut feeling” about selected new hires. Recommendations for nursing education, management, and research are made based on these conclusions. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 3 Acknowledgements Thank you to my husband without whom I would never have embarked on this journey, and who provided faithful support to me throughout the process. Thank you to my supervisor, Dr. Barb Astle whose unwavering dedication, support and commitment to her student’s success is without rival. Her guidance and mentorship was invaluable to the entire process. Thank you to my second reader, Dr. Margery Hawkins for her insightful comments and advice. Thank you to those that participated in this study for taking the time to share your perspectives with me. Finally, I would like to thank God for his faithfulness to me in all situations and for equipping me with the ability to complete my Master’s studies. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 4 Table of Contents ABSTRACT……………………………………………………………………………………....2 ACKNOWLEDGEMENTS……………………………………………………………………….3 CHAPTER ONE: INTRODUCTION AND BACKGROUND…………………………………...9 Background………………………………………………………………………………………10 Rationale for Research…………………………………………………………………………...11 Definition of Terms………………………………………………………………………………12 Purpose and Research Questions………………………………………………………………...13 Study Method…………………………………………………………………………………….13 Outline of Thesis…………………………………………………………………………………14 CHAPTER TWO: LITERATURE REVIEW……………………………………………………15 Search and Retrieval Strategies for Literature Review………………………………………......15 Literature Review………………………………………………………………………………...17 Background Knowledge………………………………………………………………….18 Communication…………………………………………………………………………..19 Workplace Integration…………………………………………………………………...20 Barriers to Career Advancement…………………………………………………………23 Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 5 Recommendations for Nurse Managers………………………………………………….25 Research Gaps……………………………………………………………………………27 Chapter Summary………………………………………………………………………………..27 CHAPTER THREE: RESEARCH DESIGN, METHODOLOGY, AND PROCEDURES……..29 Study Design and Methodology………………………………………………………………….30 Sampling………………………………………………………………………………....30 Sample.…………………………………………………………………………………...31 Data Collection…………………………………………………………………………..32 Data Analysis…………………………………………………………………………….33 Scientific Quality…………………………………………………………………………35 Ethical Considerations……………………………………………………………………36 Limitations……………………………………………………………………………….36 Chapter Summary………………………………………………………………………………..36 CHAPTER FOUR: FINDINGS………………………………………………………………….38 Theme One: Acknowledging the Complexities………………………………………………….39 Sub-theme A: Giving Everyone a Chance………………………………………………….39 Sub-theme B: Constraining Elements……………………………………………………..41 Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 6 Theme Two: Finding the “Right Fit”……………………………………………………………44 Sub-theme A: Possessing the Right Attitude and Values…………………………………..44 Sub-theme B: Possessing the Right Experience……………………………………………47 Sub-theme C: Possessing Adequate Communication Skills……………………………….49 Sub-theme D: Determining Long-term Intentions…………………………………………51 Sub-theme E: Gaining an Innate Feeling…………………………………………………..53 Theme Three: Navigating Differences…………………………………………………………..55 Sub-theme A: Variations in Education and Clinical Practice………………………………55 Sub-theme B: Country Specific Variations………………………………………………...59 Sub-theme C: Variations in Culture……………………………………………………......61 Chapter Summary………………………………………………………………………………..63 CHAPTER FIVE: DISCUSSION………………………………………………………………..65 Comparison with Existing Literature…………………………………………………………….65 Theme One: Acknowledging the Complexities………………………………………….65 Theme Two: Finding the “Right Fit”…………………………………………………….67 Theme Three: Navigating Differences…………………………………………………...73 Chapter Summary………………………………………………………………………………..78 Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 7 CHAPTER SIX: CONCLUSIONS AND RECOMMENDATIONS……………………………80 Summary of the Study…………………………………………………………………………...80 Conclusions………………………………………………………………………………………80 Implications & Recommendations……………………………………………………………….82 Implications for Nursing Education……………………………………………………...83 Implications for Nursing Management…………………………………………………..83 Recommendations for Nursing Research………………………………………………...84 Chapter Summary………………………………………………………………………………..85 REFERENCES…………………………………………………………………………………..86 APPENDICES…………………………………………………………………………………...94 Appendix A: Table Outlining the Literature Search Strategy…………………………...94 Appendix B: Literature Review Matrix of Selected Articles……………………………96 Appendix C: Recruitment Letter of Introduction for Potential Study Participants…….104 Appendix D: Demographic Table of Study Participants……………………………….105 Appendix E: Demographic Information/Interview Questions………………………….106 Appendix F: Research Ethics Board Consent Form……………………………………108 Appendix G: Debriefing Script…………………………………………………………111 Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 8 Appendix H: Code Book………………………………………………………………..112 Appendix I: TWU Research Ethics Board Approval…………………………………...115 Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 9 CHAPTER ONE: INTRODUCTION AND BACKGROUND Internationally educated nurses (IENs) are an integral part of Canada’s nursing workforce (Jeans, Hadley, Green, & Da Prat, 2005; McGillis-Hall, Jones, Lalonde, Strudwick, & McDonald, 2015). However, when nurses immigrate to Canada, they often encounter many barriers in their journey from being a newcomer to successfully practicing nursing in the Canadian context (Covell, Neiterman, & Bourgeault, 2016; Hawkins & Rodney, 2015; Tregunno, Peters, Campbell, & Gordon, 2009). These barriers have been well documented and include hurdles at every step of the process of becoming a Registered Nurse (RN) in Canada (e. g. , with immigrating; obtaining nursing recertification, which may involve taking a language test, writing the RN Licensing exam, or upgrading their skills and taking additional courses, prior to finding employment; and lastly, with successfully integrating into a new workplace) (Canadian Health Human Resources Network[CHHRN], 2013; Covell, Neiterman, & Bourgeault, 2014; Hawkins & Rodney, 2015; Moyce, Lash, & de Leon Siantz, 2016; Newton, Pillay, & Higginbottom, 2012; Primeau, Champagne, & Lavoie-Tremblay, 2014). Much of the literature regarding IENs focuses only on the various issues from their perspective (BabenkoMould & Elliot, 2015; Higginbottom, 2011; McGillis-Hall, et al., 2015; Moyce, Lash, & de Leon Siantz, 2016; Salma, Hegadoren, & Ogilvie, 2012; Singh & Sochan, 2010). Minimal literature is available that addresses the perspectives of Nurse Managers regarding IENs, and nothing was found that specifically discusses the hiring practices of Nurse Managers. The purpose of this qualitative research was to explore the perceptions and experiences that influence the hiring practice decisions of Nurse Managers in long-term care settings who employ IENs with Canadian RN credentials. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 10 Background Many Canadian scholars have written extensively about the nursing shortage. They predict that the situation will be further compounded as the number of Canadian nurses approach retirement age and exit the workplace (Armstrong & Armstrong, 2008; Canadian Institute for Health Information [CIHI], 2017; Covell, Neiterman, & Bourgeault, 2015; Covell, Neiterman, & Bourgeault, 2016; McGillis-Hall et al., 2015). As a result of this ongoing nursing shortage, IENs continue to be a welcome addition to the Canadian health care system by ensuring an adequate number of RNs. IENs are a valuable source of human capital; not only do they augment the Canadian work force, but they also provide an invaluable store of knowledge and expertise that can potentially advance Canadian nursing through exposure to new epistemic strands and modes of praxis (Baumann, Ross, Idris-Wheeler, & Crea-Arsenio, 2017; Njie-Mokonya, 2014; Primeau, Champagne, & Lavoie-Tremblay, 2014). In 2016, IENs represented 9% of the RN workforce in Canada with the majority of these nurses working and residing in British Columbia, Ontario and Alberta (CIHI, 2017). Despite accounting for a relatively small percentage of Canadian nurses, IENs continue to remain an integral component of the nursing workforce within these provinces. Ensuring that IENs successfully transition into the Canadian nursing workforce is crucial to maintaining appropriate staffing levels as well as ensuring patient safety (Covell et al., 2015; McGillis-Hall et al., 2015). It is essential that appropriate support is provided to IENs during their transition period as they immigrate to Canada in order to ensure their successful integration into the nursing workforce (International Council of Nurses [ICN], 2007; World Health Organization [WHO], 2010), and to maintain the safety of the Canadian healthcare system. However, IENs often face additional barriers such as negative, racist, and discriminatory attitudes and behaviors from Canadian nurses, managers, and employers (Babenko-Mould & Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 11 Elliot, 2015; Covell et al, 2016; Hawkins & Rodney, 2015; Ramji & Etowa, 2014; Tregunno, et al, 2009; Tuttas, 2015). Nurse Managers are often unaware of the unique needs of IENs as they transition to practicing within a Canadian nursing context (Baumann, Blythe, Idris-Wheeler, Fung, & Grabham, 2013; Baumann, et al., 2017; Njie-Mokonya, 2014). This lack of knowledge on how to support IENs, coupled with negative attitudes and behaviors can create additional difficulties for the IEN who is attempting to integrate into the Canadian workforce (McGillisHall, et al., 2015). In addition, it is implied that some Nurse Managers might not hire IENs because they perceive their educational credentials as substandard, and their work experience to be of less value than those of Canadian nurses (Covell et al, 2016; Covell, Primeau, Kilpatrick, & St. -Pierre, 2017; Jeans, et al, 2005; Prendergast, 2014; Pung & Goh, 2017; Tuttas, 2015). While some of these issues have been documented from the perspective of IENs, very seldom are they explored from the perspective of potential employers of IENs. In order to better understand the unique situation facing these IENs in finding employment and successfully integrating into the workplace, this study was conducted primarily from the perspective of Nurse Managers responsible for hiring IENs. Rationale for Research Scholars exploring the ability of IENs to successfully transition to the Canadian workplace revealed that IENs face multiple challenges as they pursue the RN licensure process in their quest to be gainfully employed. Nurse Managers responsible for hiring IENs can be described as the gatekeepers capable of granting IENs access to practice in Canada. Therefore, it is critical to have their perspectives in order to better understand their impressions of IENs as well as the criteria used in the decision-making process of the recruitment phase. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 12 This study explored how a Nurse Manager’s perceptions and experiences shape the capacity of IENS to acquire RN employment. As well, the findings from this study offer insights into how stakeholders, such as, nurse administrators, nurse educators, immigrant serving organizations, and nursing professional associations and unions, can better support and facilitate IENs with their transition and integration into the nursing workforce in Canada. This study addressed a gap in the literature by having Nurse Managers, from long-term care settings, reflect upon their hiring practice decisions with regards to IENs. Thus, a better understanding of these hiring practices of Nurse Managers may shape the capacity of IENs with successfully acquiring RN employment into the Canadian workplace. Definition of Terms Nurse: “Nurse” refers to any regulated nurse – Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Registered Psychiatric Nurses (RPNs) – regardless of where they were educated. Internationally Educated Nurse: An Internationally Educated Nurse (IEN) is a nurse in Canada who has received his/her nursing training/education in a country outside of Canada. Other terms that may be used interchangeably would be foreign educated or foreign trained nurses. Nurse Manager: A Nurse Manager is a nurse in a position that allows him/her to hire, manage, and supervise employees (specifically nurses) in a long-term healthcare setting. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 13 Purpose & Research Questions The purpose of this research was to explore the perceptions and experiences that influence the hiring practice decisions of Nurse Managers in long-term care settings who employ Internationally Educated Nurses (IENs) who have Canadian RN licensure. My primary research questions were as follows: Research Questions: 1. What perceptions do Nurse Managers have about the performance and readiness of Internationally Educated Nurses (IENs) to practice as a nurse? 2. How do Nurse Managers perceive the performance and readiness of Internationally Educated Nurses (IENs) to practice in comparison to nurses educated in Canada? 3. How do Nurse Managers’ perceptions and experiences with Internationally Educated Nurses (IENs) influence their hiring practice decisions? 4. What elements do Nurse Managers take into consideration when deciding to hire Internationally Educated Nurses (IENs)? Study Method A qualitative research method was used to gather an in-depth understanding of the perceptions and experiences of Nurse Managers in long-term care settings as they relate to IENs and their hiring practice decisions. Thorne’s (2016) Interpretive Description method was used to gain in-depth inductive insights into the experiences of Nurse Managers. This method was selected due to its roots in nursing research, and its potential to provide a fully developed interpretation of the data, allowing for the generation of new nursing knowledge to inform this Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 14 topic. Seven Nurse Managers in long-term care settings were interviewed about their hiring practices of IENs. Data collection included semi-structured, individual, face-to-face interviews. Data analysis involved an iterative process of coding the transcripts followed by in-depth immersion in the data and identification of emerging themes. Outline of Thesis This thesis is comprised of six chapters. In this first chapter, the rationale for the study was discussed, as well as the study definitions, purpose, research questions, and method. In Chapter Two, the search retrieval strategies for the literature will be reviewed, and a description of the literature relevant to the study will be presented. Chapter Three delineates the research method, sampling, data collection and analysis along with the ethical considerations, scientific quality, and limitations. Chapter Four describes the findings and in Chapter Five, the findings are analyzed in comparison to the current literature. Finally, Chapter Six provides a summary, conclusions, implications for nursing education and nursing management, and recommendations for nursing research. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 15 CHAPTER TWO: LITERATURE REVIEW In this chapter, the search and retrieval strategies used to conduct the literature review for this study will be described. A description of the findings from the literature review related to the topic, and accompanying gaps will also be identified, in order to support the need for this study. Search and Retrieval Strategies for Literature Review This literature review consisted of a preliminary and a secondary search. A preliminary review of the literature was undertaken to ascertain the current scope of the literature on IENs, and to determine the need for a study focusing on hiring practices from a Nurse Manager’s perspective. The Matrix Method was used to search, organize, and synthesize relevant literature on this topic (Garrard, 2017). The search was refined through consultation with an academic librarian and was further aided by suggestions by both the supervisor and second reader as to sources or authors to include in the search. After this input, it was decided to conduct a systematic search using the following databases: CINAHL, Biomed, Medline, and Social Sciences index. The key words used in the searches were as follows: “Internationally educated nurse*” OR “foreign nurse*” OR “migrant nurse*” OR “overseas trained nurse*” OR “internationally recruited nurse*” OR “immigrant nurse*” (See Appendix A). This search was combined using the Boolean operator “AND” with the following terms: hiring OR experiences OR perspectives. Originally this was going to be combined with a third search utilizing the terms employer OR manager, however this narrowed the results significantly and thus the reference to employers and managers was removed from the search and instead was used as selection criteria. Selection criteria for the literature review was as follows: Research about Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 16 IENs from the last 12 years (2005-2017), to be most relevant to the current context; specific mention of manager/employer perspectives or Nurse Manager interactions with IENs in the article; and written in English due to author limitations. The following results were obtained from the search. CINAHL resulted in 338 articles whereupon a search of the titles and abstracts was conducted. This then narrowed the results to 27 articles. After a scan of the articles, only 12 were found to be relevant. Biomed resulted in 104 articles of which 12 were selected for in depth review. Of these none were applicable to the topic of this study. Medline resulted in 120 articles of which 10 were selected to be reviewed. Of these, four articles were determined to be relevant. Social sciences citation index resulted in 127 articles, of which none were relevant to the current study that had not been previously found in other database searches. At this point, the reference lists of selected articles were hand-searched for other studies. The specific sources and authors suggested previously by both the supervisor and second reader were also explored. These hand-searches and explorations resulted in the discovery of the Canadian Health Human Resources Network (CHHRN) which has a library with a searchable online bilingual database of peer-reviewed literature, grey literature, and data resources related to health human resources within and concerning Canada. Using the search term “internationally educated nurse”, this database resulted in 39 articles, of which six were determined to be relevant. A further hand-search of these bibliographies resulted in 6 more articles. Similar to the method in which the CHHRN was found, the Nursing Health Services Research Unit (NHSRU) was discovered and searched using the term “internationally educated nurse”. This resulted in one additional article to be used in the literature review. Of the final 29 studies that were included for the literature review, 11 were qualitative research studies, one was a quantitative Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 17 research survey, nine were literature reviews, four were reports on knowledge translation or demonstration projects, two were discussion papers, one was a doctoral dissertation based on a qualitative study, and one was a Master’s of Nursing thesis based on a qualitative study. The Matrix method was used to organize the relevant studies and create a comparison table (Garrard, 2017) (See Appendix B). During the data analysis process of the study, a secondary search of the literature was conducted in order to locate other studies related to the emerging themes and to seek additional literature that was pertinent to the findings. The same databases were searched as were utilized in the initial search. During the editing of the final draft of the study, a final search was conducted that mirrored the original two searches. The results of all searches and the resulting articles can be reviewed in the table outlining the search strategy in Appendix A. Literature Review This literature review provided an overview of the available literature as it relates to IENs who immigrate to a new country. Most of the literature on IENs focused primarily on the following areas: Ethical recruitment of IENs, Pre-immigration, Motivations and challenges of immigration, Credentialing barriers, Bridging Programs, Transition/Integration into healthcare, and Racism/Discrimination against IENs. The majority of these studies provided the “point of view” of the IEN, describing their experiences and perceptions. The following literature review discusses the following headings regarding IENs: communication, workplace integration, barriers to career advancement, recommendations for Nurse Managers, and Research Gaps. It describes these areas of emphasis from the reviewed literature. The literature review will begin with describing in the background knowledge, a seminal study that included Nurse Managers’ Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 18 perspectives on IENs (Jeans, Hadley, Green, & Da Prat, 2005). This seminal study along with some recent literature reviews on IEN experiences, provided context and comprehensive background knowledge for the study. Further background knowledge was provided in studies examining the importance of communication for IENs. This review then highlighted several studies that focus on how IENs could be better integrated into the workplace. Also explored were some studies and literature reviews that looked at barriers to IEN career advancement such as racism and discrimination in the workplace and lack of recognition of IEN qualifications and credentials. Finally, the review described the gaps in the literature as it related to a Nurse Manager’s perspective. Background Knowledge One seminal study that sought to understand the experiences and challenges related to employing and integrating IENs, and that is frequently cited in the literature, was by Jeans, Hadley, Green and Da Prat (2005). This qualitative study was particularly relevant as it included the perspectives of employers and Nurse Managers. Jeans et al (2005) found that IENs’ communication ability was a key hiring criteria used by Nurse Managers as they perceived nurses from non-English/French speaking countries to be less competent than their Canadian counterparts. Similarly, Covell, Neiterman, and Bourgeault (2014) in a scoping review of Canadian literature, found that employers often do not hire IENs as they believe that they lack nursing knowledge, expertise, or language skills necessary for providing safe practice. Moyce, Lash, and de Leon Siantz (2016) in their systematic review on the migration experiences of IENs had similar findings, in which they found IENs often faced increased scrutiny of their nursing skills and tasks from managers, patients and host country nurses. As well, in a literature review conducted by Pung and Goh (2017) in which they examined the challenges IENs face in Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 19 migrating to another country, they found that IENs were scrutinized more closely than native nurses. Pung and Goh (2017) described how IENs often felt mistrusted by their Nursing Managers and that they felt they must prove themselves before their skills were acknowledged. Newton, Pillay and Higginbottom (2012) found similar results when they studied the migration and transitioning experiences of IENs. They found that Nurse Managers often did not recognize or value the skills and experiences of IENs and thus often passed them over for career advancement opportunities. They further concluded that having a supportive Nurse Manager was key to easing the transition of IENs into the workplace (Newton et al., 2012). Communication A number of studies, in the literature, closely examined the barriers for IENs in gaining employment and transitioning into the workplace, and found that language and communication were two significant barriers (Baumann et al., 2017; Blythe, Baumann, Rheaume, & McIntosh, 2006; Blythe, Baumann, Rheaume, & McIntosh, 2009; Jeans et al, 2005; Lum, Dowedoff, & Englander, 2016; Njie-Mokonya, 2014; Pung & Goh, 2017; Sherman & Eggenberger, 2008). Similarly, Lum, Dowedoff, and Englander (2016) in their qualitative study examining IENs reflections on communication in the nursing workplace, in Canada, found that a lack of language proficiency was a serious impediment to IENs chances of gaining employment. Sherman and Eggenberger (2008) in their qualitative study on the transitioning experiences from both IEN and Nurse Manager perspectives, noted that Nurse Managers perceived IENs competency as being directly related to their ability to speak English fluently. Similarly, Jeans et al. (2005) found that employers in their study thought language ability was related to the nurse’s capabilities. Nurse Managers in both studies stated that difficulties with language and communication often led to Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 20 frustration for both staff and patients that could potentially lead to misunderstandings and compromising patient care (Jeans et al., 2005; Sherman & Eggenberger, 2008). Workplace Integration Workplace Integration of IENs has been one of the primary foci of more recent publications. Covell et al. (2017) conducted a cross-sectional, descriptive, correlational survey which aimed to describe the demographic and human capital profile of IENs in Canada in order to identify predictors of successful workplace integration. They found that the two most indicative predictors to finding employment were participating in an IEN bridging program and utilizing social networks to assist them in securing their initial job. Primeau, Champagne, and Lavoie-Tremblay (2014), in their literature review centering on best practices for socioprofessional integration of IENs, found that decision makers and Nurse Managers often lacked knowledge on how to effectively integrate IENs into the workforce. In another literature review on IEN integration into the healthcare workforce, Ramji and Etowa (2014) noted the challenges IENs often face with workplace integration and proposed that both IENs and employers are responsible to partner together to ensure better transitioning experiences. Similarly, in a demonstration project designed to build the capacity of Nurse Managers to better support IENs, Hoxby, Fortier, Brown, Yardy, and Blythe (2010) found that in order to better integrate IENs into the workplace, that mentors, educators, and nurses all need to be involved in collaborative networking to create interventions to aid workplace transitions. Babenko-Mould and Elliot (2015) in their qualitative study on IEN integration suggested that Nurse Managers required additional education as a means to address the lack of support, racism, and discrimination demonstrated by Nurse Managers towards IENs. Njie-Mokonaya (2014) in her qualitative study on IEN integration experiences also noted the importance of educating and Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 21 supporting Nurse Managers to acknowledge and support the contributions that IENs make to the healthcare team in order to better facilitate workplace integration. Much of the Canadian literature that has discussed IENs has originated from Ontario. The Nursing Health Services Research Unit (NHSRU) located in Ontario has supported multiple qualitative studies from both IEN and Nurse Managers perspectives on IEN integration into the workplace (Blythe et al., 2006; Blythe et al., 2009), and more recently sponsored projects focused on moving research into action to better support IEN integration into the healthcare workforce in Ontario (Baumann & Blythe, 2009; Baumann & Blythe, 2015, Baumann et al., 2013; Baumann et al. 2017). In addition, in recent years in British Columbia (BC), Hawkins and Rodney (2015) studied the processes and structures that challenge IENs from the Philippines as they seek RN licensure in Canada, and found that IENs in BC needed support programs similar to those available in Ontario. The authors recommended that IENs should be included in transition programs similar to those offered to Canadian educated nurses (Hawkins & Rodney, 2015). Blythe et al. (2006) conducted a qualitative study interviewing multiple stakeholders that work with IENs, focusing on issues related to IEN integration. They found that employers had varying perceptions of IENs, but agreed that it can be difficult to compare their skills and experiences relative to Canadian educated nurses. They concluded that employers need to create specific orientation and mentoring programs for IENs comparable to those for new graduate nurses. In a similar study, Blythe et al. (2009) explored factors that allow or inhibit IENs to reestablish their professional careers by interviewing managers, educators and others that interact with IENs. They also noted the need for adequate orientation specific to IEN needs in order for successful workplace integration. They proposed that “Bridging and Orientation programs” for IENs should be focused on communication and establishing familiarity with the Canadian Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 22 healthcare system, as these are two of the most significant barriers IENs have to obtaining employment and transitioning into the workplace (Blythe et al., 2009). In a discussion paper based on literature reviews and interviews with stakeholders that work alongside IENs in Ontario, Baumann and Blythe (2009) found that IENs faced challenges related to uninformed employers and bias in hiring practices. Managers were more likely to hire Canadian educated nurses as they required less education and support. Similarly, Hawkins and Rodney (2015) found that employers were often reluctant to hire IENs unless they had Canadian education or experience, even though they had met the requirements for Canadian RN licensure. In an effort to educate employers about the benefits of hiring IENs, the unique support needs of IENs, and the challenges they may face in practice, Baumann et al. (2013) and Baumann et al. (2017) with the support of the NHSRU initiated a knowledge translation project to create, implement, and evaluate a web-based practice guide to support employers to hire and integrate IENs into their workplace. They developed products, such as a quick reference flipbook (Ontario Hospital Association, 2013), employer workshops, and a website (McMaster University, 2017), that provided employers and stakeholders with successful strategies to recruit, retain, and integrate IENs into their workforce, and that could be utilized to facilitate IEN orientation and mentorship. In another project, Baumann and Blythe (2015) initiated a multifaceted collaborative research intervention involving multiple employers and stakeholders that was designed to assist IENs find employment and integrate into the nursing workforce. They supported IENs and Canadian nursing graduates with English as second language (ESL) from Ontario via multiple initiatives such as webinars, workshops, job coaching/mock interviews, learning plans, and Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 23 networking programs. Over the course of the project, IENs were able to gain employment and most attributed success in securing employment to participation in the project. Barriers to Career Advancement One critical issue that prevented IENs from integrating into the workplace is experiences of racism and discrimination based on ethnic stereotypes. IENs often experienced racial discrimination from their supervisors, and felt mistrust from employers which was a barrier to promotion and career advancement (Allan, 2010; Likupe, 2015; Pendelton, 2016; Pung & Goh, 2017; Tuttas, 2015). Tuttas (2015) in her literature review exploring experiences of discrimination among minority migrant nurses, found that IENs from minority ethnic backgrounds often face racial and ethnic prejudice in the workplace which can further hinder their integration into the nursing team. Similarly, in Pendleton’s (2016) literature review on the experiences of black and minority ethnic nurses in the UK, he found that Nurse Managers viewed hiring black and minority ethnic IENs as a necessity rather than an opportunity. These negative and discriminatory attitudes often led to a lack of respect for IENs from their colleagues on the unit and create divisiveness among nursing staff. Likupe’s (2015) study of African nurses and their managers in the UK revealed that Nurse Managers voiced uninformed stereotypes about black African nurses comparing them to other groups of overseas nurses and created an ethnic hierarchy of IENs with black African nurses at the bottom of the racial hierarchy. An ethnographic interpretive study by Allan (2010) focused on identifying barriers to effective and non-discriminatory mentoring of IENs in the UK by interviewing 93 IENs and 37 managers and mentors of IENs. Allan found that managers lacked awareness of the unique learning needs of IENs. The managers interviewed in this study tended to demonstrate a lack of Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 24 cultural awareness and perceived British nursing education and techniques to be superior to those of other countries. Newton et al. (2012) described the lack of promotion and career advancement of IENs due to discriminatory practices, and the unspoken requirement that individuals meet culturally specific criteria to advance to leadership positions. Prendergast (2014) supported these conclusions in her doctoral dissertation and described how promotion in nursing tends to be based not on merit or qualifications, but rather on fitting into the “ideal type” which is a white Canadian that subscribes to certain cultural norms. Lack of recognition of nursing qualifications, skills, and experience even after obtaining nursing licensure was found to be a problem for IENs when seeking employment, transitioning into a workplace, or advancing their careers by several authors (Allan, 2010; Babenko-Mould & Elliot, 2015; Blythe et al., 2006; Covell et al., 2014; Hawkins & Rodney, 2015; Jeans et al., 2005; Moyce, Lash, & de Leon Siantz, 2016; Newton et al, 2012; Pendlton, 2016; Prendergast, 2014; Primeau et al., 2014; Pung & Goh, 2017; Salma, Hegadoren, & Ogilvie, 2012; Sherman & Eggenberger, 2008; Xiao, Willis, & Jeffers. , 2014). When IENs education and experience is not recognized or valued, it results in limiting their employment opportunities and prevents them from promotion and career advancement (Likupe, 2015; Njie-Mokonya, 2014; Pendleton, 2016; Primeau et al., 2014; Pung & Goh, 2017). IENs stated that when a Nurse Manager failed to recognize their skills and credentials, they were more likely to experience marginalization in their workplace by other nursing colleagues as well (Pung & Goh, 2017; Sherman & Eggenberger, 2008). Prendergast (2014), in her doctoral dissertation on multiculturalism policies in Canadian nursing, found that the questioning of foreign credentials of IENs, even after they have been approved by Immigration Canada and Provincial Regulatory bodies, is perpetuating racism and Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 25 discrimination in Canadian nursing. By failing to recognize IENs credentials, employers and managers can justify the promotion of Caucasian Canadian nurses above IENs who have more education and experience. In this manner, IENs are effectively prevented from entering policymaking positions of leadership and continue to occupy more menial positions with very limited influence (Prendergast, 2014). Salma et al. (2012) had similar findings in their qualitative research study examining IEN perceptions of career advancement and educational opportunities in Alberta. IENs often found that their Caucasian Canadian peers were more likely to be groomed for leadership positions and promoted to management roles even if their qualifications and experience were equal to or less than an IEN who applied for the same position. These IENs came to the conclusion that connections and networking were more important than skills, education and experience when it comes to career advancement and promotion (Salma et al., 2012). These findings are echoed in Pendelton’s (2016) literature review as black and minority ethnic nurses were often passed over for promotion in favor of less experienced white colleagues. Similarly, black African nurses in Likupe’s (2015) study found that they were being more closely scrutinized than their Caucasian co-workers, being disciplined more harshly than peers for similar errors, and being passed over for promotions even when they had more education and experience than their peers. Nurse Managers in Likupe’s study mirrored the experiences of these IENs in their interviews by voicing stereotypes about IENs of various ethnic origin and justifying overlooking certain IENs for promotion as they perceived them to be lacking desire or motivation to advance in their nursing careers (Likupe, 2015). Recommendations for Nurse Managers In the literature, there were several recommendations of how Nurse Managers could facilitate a smooth transition and integration of IENs into the workplace. Several studies found Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 26 that one key strategy is to educate managers on how to recruit, hire, provide ongoing support, and address the potential for racism and discrimination (Allan, 2010; Babenko-Mould & Elliot, 2015; Baumann et al., 2013; Baumann et al., 2017; Covell et al., 2014; Sherman & Eggenberger, 2008; Xiao et al., 2014). It was emphasized that Nursing Managers have a powerful influence on the environment and culture of their units and can ease or inhibit and IENs integration by how they address or fail to address challenges as they arise. Once managers were aware of the needs of IENs, they were better equipped to support IENs through fostering a unit culture that celebrates diversity and facilitates positive interpersonal relationships (Babenko-Mould & Elliot, 2015; Hoxby et al., 2010; Likupe, 2015; Newton et al., 2012; Njie-Mokonya, 2014; Pendelton, 2016;Primeau et al., 2014; Ramji & Etowa, 2014; Sherman & Eggenberger, 2008; Xiao et al., 2014). Another key element identified by several researchers was that Nurse Managers recognize that crucial to IENs success in the workplace was the introduction of an in-depth orientation program adapted to meet their needs (Allan, 2010; Baumann & Blythe, 2009; Baumann et al., 2013; Baumann et al., 2017; Blythe et al., 2006; Blythe et al., 2009; Hawkins & Rodney, 2015; Jeans et al., 2005; Newton et al., 2012; Njie-Mokonya, 2014; Primeau et al., 2014; Sherman & Eggenberger, 2008). Once IENs had adequate orientation programs put in place, the next step suggested is ongoing mentorship or preceptorship programs to assist them as they transition to practicing on their own. Several authors, for example, found mentoring and preceptorship programs, similar to those offered to new graduate nurses, were a key element in ensuring IEN success in the workplace (Allan, 2010; Baumann et al., 2013; Baumann et al., 2017, Blythe et al., 2006; Newton et al., 2012; Primeau et al., 2014). While many Nurse Managers supported the implementation of orientation programs and ongoing mentorship for Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 27 IENs, the reality is that employers often do not have the funds or the time to create supportive programs. As a result, Baumann et al. (2013) and Baumann et al. (2017) recommended that health authorities be provided with additional funding in order to provide programs that ease IEN transition into the workplace, and ultimately increase the safety and quality of patient care. Research Gaps There is a gap in the literature regarding the perspectives of Nursing Managers and the employers who hire IENs (CHHRN, 2013; Covell et al., 2014; Neiterman, & Bourgeault, 2013). The CHHRN in their discussion paper on internationally educated healthcare professionals (IEHPs) identified the employer perspective as being an area that required more research (2013). Covell, Neiterman and Bourgeault (2016) in their scoping review about the professional integration of IEHPs also identified a research gap with regards to employers hiring decisions as they relate to IEHPs. Lum, Dowedoff and Englander (2016) in their qualitative study concluded that more attention should be directed towards providing IENs with quality information about employer expectations. Covell et al. (2014) recommended that an exploration of hiring practices, from an employer’s point of view, be undertaken to address such a gap in evidence. More recently, there has been some literature from Ontario that has begun to focus on these gaps by educating employers on the needs and concerns of IENs to better assist transition of IENs into the workplace (Baumann et al. 2017; Covell, et al., 2014; Covell et al., 2016; Covell et al, 2017). Chapter Summary This chapter covered the search strategy for this study, reviewed the selection criteria for articles, and gave an overview of the process of article selection and the types of articles used to write the literature review. Some of the key issues that can be found in the literature relating to Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs IENs and Nurse Managers were discussed. Issues explored were those of communication difficulties, workplace integration of IENs, racism and discrimination against IENs, and how these issues can be exacerbated by Nurse Managers who are unaware of the concerns unique to IENs. Some recommendations for how Nurse Managers can better assist IENs were explored, and finally, research gaps in the literature were discussed. The description of the research design, methods, and procedures for data collection and analysis will be addressed in Chapter Three. 28 Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 29 CHAPTER THREE: RESEARCH DESIGN, METHODOLOGY AND PROCEDURES The purpose of this research was to explore the perceptions and experiences that influence the hiring practice decisions of Nurse Managers in long-term care settings who employ Internationally Educated Nurses (IENs) who have Canadian RN licensure. Research questions: 1. What perceptions do Nurse Managers have about the performance and readiness of Internationally Educated Nurses (IENs) to practice as a nurse? 2. How do Nurse Managers perceive the performance and readiness of Internationally Educated Nurses (IENs) to practice in comparison to nurses educated in Canada? 3. How do Nurse Managers’ perceptions and experiences with Internationally Educated Nurses (IENs) influence their hiring practice decisions? 4. What elements do Nurse Managers take into consideration when deciding to hire Internationally Educated Nurses (IENs)? This chapter specifically describes the research process conducted in this study including: study design, sampling, sample, data collection, data analysis, scientific quality, limitations, and ethical considerations. Study Design and Methodology A qualitative research method was used to better understand the perceptions and experiences of Nurse Managers who employ IENs in long-term care settings about their hiring practice decisions. An Interpretive Descriptive (ID) method as described by Thorne, ReimerKirkham, and MacDonald-Emes (1997) was utilized to explore this topic. Interpretive Description Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 30 (Thorne, 2016) allowed the researcher to analyze thematic elements and patterns and generate new nursing knowledge to address the research topic. ID utilizes inductive reasoning by starting with specific observations and moving to broad generalizations (Thorne, 2016). This approach allowed for the formation of new insights as specific data points from participant interviews were analyzed and broad conclusions were derived from the data. This method goes beyond mere description and allowed for a fully developed interpretation of the data received. ID was suitable for this research study as it allowed for a more in-depth analysis of interview data obtained from Nurse Managers. By carefully analyzing concurrent patterns and themes that emerged from the interviews, broad categories were generated that provided insight into how an individual’s perceptions and experiences impact their decision-making in the hiring of IENs. This information informed the research questions and served to highlight the challenges IENs face in finding employment as newly licensed nurses in Canada. Sampling Participants were recruited from a Nurse Manager group, as well as long-term care institutions within BC. The researcher connected with a Nurse Manager with whom she already had a working relationship and she assisted with recruitment. A Recruitment Letter of Introduction (See Appendix C) outlining the purpose of the study, research questions, the methodology used, and the interview process, was e-mailed by this Nurse Manager to other Nurse Managers in long-term care sites in the surrounding urban areas. Letters were also mailed to the Nurse Managers at other long-term care sites in the area and in several nearby cities within the Lower Mainland of BC. Nurse Managers who were interested in participating in the study voluntarily contacted the researcher directly. As this round of recruiting only yielded four participants, a second round of recruiting took place in which Nurse Managers were e-mailed an Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 31 invitation to participate in the study along with the recruitment letter of introduction. E-mails were obtained from a publicly available database that listed various long-term care facilities and the contact information of Directors of Care. The Nurse Manager who assisted with initial recruitment was re-contacted, and she sent out a reminder e-mail to her group of contacts. This second round of recruitment added 3 more participants to the study. The goal for participants in this study was eight to ten with a minimum of six participants. The recruitment period ended at three months when no more participants responded, yielding a total of seven participants who comprised the sample for this study. Sample The sample was a convenience sample of seven Nurse Managers who were involved in the hiring and supervising of IENs who had Canadian RN licensure in urban long-term care settings. Long-term care settings often are the primary employers of IENs and thus Nurse Managers in these settings were more likely to have firsthand experience in the hiring of IENs. Nurse Managers who did not work in Long-term care facilities or were not in BC were excluded from this study. Of the seven Nurse Managers who agreed to participate, six were female, one was male; all were Caucasian, and one was an IEN. Three Nurse Managers were from the same organization that had multiple facilities, and the rest were from different organizations. Of the five organizations represented, all were privately funded, with two being non-profit organizations. All had between 24-36 years of nursing experiences and had been Nurse Managers for 6-18 years. With regards to education, two participants were diploma RNs, three had baccalaureate degrees in Nursing, and two had obtained Masters Degrees (one in Healthcare Leadership and another in Public Management) (See Appendix D for Demographic Table of Study Participants). Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 32 Data Collection Consistent with the chosen research design, semi-structured, individual face-to-face interviews were conducted with seven Nurse Managers from various long-term care sites within BC. The interviews were approximately between 30-45 minutes in length, and the location for each interview was mutually agreed upon between the participant and researcher. A list of interview guide questions and prompts assisted the researcher in directing the interviews (See Appendix E). Each interview was recorded using a password protected smart phone, the recordings were then transferred to a password protected computer. Once the recording was transferred to the computer, it was deleted from the smartphone. Field notes and reflexive notes were written after each interview and then later reviewed to examine emerging thought patterns. These were then typed up prior to transcribing the interviews. The researcher transcribed all the interviews verbatim and reviewed the transcripts to ensure accuracy. After the initial interview, the researcher consulted with her supervisor to review the interview questions, and revisions were made to the questions. For example, in the initial interview guide, question 2 regarding IENs readiness to practice, had a generic prompt “ask them to tell you more specifically about the situation”. While this portion was kept, and slightly adapted, two additional prompts were added to the question: “What would be an indicator an IEN is ready to practice?” and “What would be an indicator that an IEN is NOT ready to practice”. Each interview followed the same basic pattern. After introductions were made, the purpose of the study and research questions were reviewed with the participant, the consent form (See Appendix F) was read through with the participant, highlighting the importance of Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 33 confidentiality and their rights to withdraw from the study at any time. The consent form was then signed by both the participant and the researcher and a copy of the consent form was provided to the participant. The interview was then conducted by the researcher following the interview guide questions and prompts. This interview portion was recorded by a digital recorder for transcription at a later time. At the conclusion of each interview, a short debriefing session was conducted with the participants (See Appendix G). Participants were then given a 5 dollar coffee card as thank you for participating in the study. Reflexivity is a critical portion of any qualitative research endeavor as it assists the researcher to reflect on personal beliefs and values and how they could influence the findings of the research project (Jootun, McGhee, & Marland, 2009; Patton, 2015; Streubert & Rinaldi Carpenter, 2011). To facilitate reflexivity, reflexive field notes were written by the researcher after each interview and used to supplement the interview data. Field notes were then later reviewed and typed out. Data Analysis Data analysis was completed by using qualitative interpretive analysis following guidelines as outlined by Thorne (2016). This approach was an intricate process that involved comprehending and synthesizing data and then theorizing and contextualizing the information (Thorne, 2016). Once the transcripts of the interviews were ready, the researcher immersed herself into the data by repeatedly going over reflexive notes and interviews and making notes about patterns and themes that emerged. “Memo” notes were made in the margins of the transcripts with thoughts on what was seen in the interviews (Thorne, 2016). This was also an iterative process whereby data analysis was completed concurrently with data collection. Each Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 34 transcript from the interviews was individually coded to form broad categories for further data analysis. A codebook was developed in consultation with the Thesis Supervisor (See Appendix H). After the iterative process of repeated immersions into the data, the findings were conceptualized by further analyzing the categorical data and identifying themes and patterns as they emerged from the research. Codes were refined after in-depth discussions with the thesis supervisor, and again with the second reader to ensure accuracy of coding and thematic development. For example, one code that originally was entitled as “reasons to hire” was reconstructed as “finding the right fit” as it better represented the findings. After the preliminary themes for the data had been identified, the thesis supervisor and second reader reviewed them again. One code, “determining long term intentions” that was originally under theme one, “Acknowledging the complexities” was moved to theme two, “finding the right fit” as it better represented the findings and flowed better structurally. Multiple changes were made to condense, clarify, and structure the themes organizationally so that the findings would be represented clearly as a whole rather than as disjointed pieces (Thorne, 2016). One theme that had been originally titled “providing opportunity” was altered to “acknowledging the complexities” as it was noted that Nurse Managers expressed a desire to provide opportunity, but discussed barriers that prevented them from doing this as often as they desired. This change was made after discussion with the second reader. As described in the previous example, each portion of data analysis was reviewed with the supervisory committee to verify the researcher’s analysis and interpretation of the research to ensure accuracy of thematic concepts. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 35 Scientific Quality The quality of the research was enhanced by various techniques to ensure authenticity, credibility, and insightful interpretation of the data. An audit trail was created to document the methodologic decisions made both personally and in conjunction with Dr. Astle and Dr. Hawkins (Polit & Beck, 2017; Thorne, 2016). This was kept in the form of a Research log with all the meetings and discussions between the researcher and the supervisory team recorded promptly. Data was checked, confirmed, and rechecked with the original transcriptions conducted by the researcher herself, to verify that the interpretation of the data was accurate and to prevent errors in data analysis (Polit & Beck, 2017). The data and transcripts were also checked by both Dr. Astle and Dr. Hawkins to ensure the researcher’s interpretations were authentic and trustworthy. As is often the case in qualitative research, the researcher recognized that her own uniqueness as an individual undoubtedly impacted the research process (Streubert & Rinaldi Carpenter, 2011). Thus, field notes, and reflexive notes were written after each interview, in order to analyze researcher biases and presuppositions about the research and to strive to prevent them from impacting the integrity of the study (Jootun, McGhee, & Marland, 2009). While some qualitative researchers suggest “member checks” to enhance the confirmability of findings, this process can often lead to false confidence (Polit & Beck, 2017) and is not recommended by Thorne (2016) due to the potential to “derail you from good analytic interpretations” (p. 175). Also, as participants had already expressed how busy their schedules were and often had to reschedule in order to find time to initially meet with the researcher, due to their expressed time constraints, the researcher refrained from conducting member checks. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 36 Ethical Considerations Ethics approval for this study was sought and received from the Trinity Western University Research Ethics Board (REB) (see Appendix I). The purpose of the study was outlined for each participant of the study, they were informed of their right to withdraw from the study at any time, and they were made aware of the efforts made to ensure participant anonymity. Consent forms were signed by each participant after they were informed of the above information (See Appendix F). Each participant was given a copy of the consent form for their records. Privacy and confidentiality was ensured as all data collected was stored on a password protected computer and any paper copies were stored in a locked filing cabinet. A pseudonym was assigned to each interviewed participant and only this pseudonym appeared on recorded or transcribed data. The electronic data obtained from this study will be kept for five years after study completion. Access to data was exclusive to the thesis committee. Limitations Limitations of this study are a small sample size and data collection from Nursing Managers in long-term settings only. While a small sample size is not necessarily a limitation in qualitative research, a larger sample size would have possibly captured a broader range of experiences from Nurse Managers. A small sample size and the single setting will limit the transferability of the findings to other areas of nursing practice as many of the concerns of theses Nurse Manager were specific to the long-term care setting and working with older persons. Chapter Summary This chapter reiterated the purpose of the study to highlight the suitability of the chosen qualitative methodology of Interpretive Description. Data collection through means of semi- Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs structured interviews was described in detail, and the participant recruitment process was elucidated. The demographics of the sample of seven Nurse Managers were listed and steps taken to ensure the security and accuracy of the data were explained. The iterative process of data analysis was described and the steps taken to ensure the scientific quality of the findings was reviewed. Finally, this chapter reviewed the ethical considerations and limitations of the study. The next chapter will describe the findings from the interviews conducted with the Nursing Managers from long-term care settings. 37 Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 38 CHAPTER FOUR: FINDINGS The purpose of this study was to explore the perceptions and experiences of Nurse Managers with regards to IENs and examine how these impacted their hiring practice decisions. Research questions were focused on what a Nurse Manager’s perceptions and experiences are regarding IENs performance and readiness to practice, and how these compared to nurses educated in Canada. Another focus of the research questions was looking at the various criteria that influence a Nurse Manager’s decisions when deciding to hire IENs. This chapter describes the findings from interviews conducted with seven Nurse Managers working in long-term care settings who hire IENs. Emerging from the data analysis were three primary themes: Acknowledging the Complexities, Finding the “Right Fit”, and Navigating Differences. Theme One, Acknowledging the Complexities included two subthemes: Giving everyone a chance, (in which Nurse Managers expressed a willingness to give IENs a chance to be employed, mentored, and supported in the long-term care setting), and constraining elements (in which Nurse Managers described factors that inhibit them from providing IENs with adequate support). Theme Two, Finding the “Right Fit”, contained five subthemes that explored what “the right fit” meant for Nurse Managers in the long-term care setting: Possessing the right attitudes and values, possessing the right experience, possessing adequate communication skills, determining long-term intentions, and gaining an innate feeling. The third and final theme, Theme Three, Navigating Differences, revealed characteristics, as perceived by Nurse Managers that distinguish IENs during the hiring process. These differences were highlighted in three subthemes: variations in education and clinical practice, country specific variations, and variations in culture. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 39 This chapter will be organized into a discussion of the three primary themes (Acknowledging the Complexities, Finding the “Right Fit”, and Navigating Differences) together with their subthemes. The chapter will conclude with a summary of the findings. Theme One: Acknowledging the Complexities The theme of Acknowledging the Complexities represented the dilemmas that Nurse Managers often face when deciding to hire IENs. While many expressed a desire to hire IENs, mentor, and support them, they also discussed various constraints that would prevent them from doing this. Nurse Managers have a complex responsibility to provide nurses with opportunities to be mentored and supported, but also a need to operate within the limits of the long-term care environment (ie. staffing, budgetary concerns, patient safety, etc.). This theme highlighted the every-day quandaries Nurse Managers confront in their decision-making process of hiring IENs. Sub-theme A: Giving Everyone a Chance In the sub-theme, giving everyone a chance, Nurse Managers would consider all nurses (Canadian educated or IENs) for possible employment as long as the nurses met certain employment requirements. The Nurse Managers often would compare IENs to newly graduated nurses relative to requiring similar levels of support and orientation to be able to work in the Canadian context. Many of the Nurse Managers expressed a desire to provide IENs with an opportunity for employment, however they were careful to weigh their options when interviewing potential candidates. Many of the Nurse Managers emphasized the importance of supporting nurses in their careers whether they were IENs or newly graduated nurses, and the comparison between these two levels of nurses emerged often in the interviews. One Nurse Manager expressed it as Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 40 follows: “I have faith in people. Especially… new grads, but also new immigrants… I mean they need a chance. They need opportunity. So, trying to support them that way” (1). This participant described how when newly graduated nurses or IENs who were not very confident and lacked experience were hired, they would be sent to a sister site where they had more support (in the form of a second RN on at the same time) before being brought back to the main location where they were required to be the clinical lead for the ward. “I’ll send them over there to get their feet wet, and to get some more experience, and then bring them back over here if they’re ready” (1). In this way, the Nurse Manager was able to provide IENs and newly graduated nurses with a chance to be mentored and supported by other experienced nurses in their new work environment. One Nurse Manager described how they were unsure of exactly what type of support IENs required, but stated that “if somebody came and asked [to be hired], I could probably consider it…” (3). Another Nurse Manager again comparing IENs to newly graduated Canadian nurses stated that they may “need to…learn some of our ways, our standards… [and] that requires maybe a little bit more support…. and… just like, you know some of our brand new grads that, that want to get going into their career” (4). But overall, this participant expressed that “there might be a bit of a difference [between IENs and Canadian nurses], but not too much” (4) and they needed to be provided with support for their nursing careers. The participant expressed this again in the following manner: “You also have to consider others who are just coming up and are very passionate about caring for the elderly and, you know supporting them in their career is important as well” (4). Similarly, another nurse manager who had experience working with IENs from Mexico and the Philippines expressed, “I will continue to hire any chance I get from those two locations” Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 41 (5). However, the participant did go on to compare these IENs to newly graduated Canadian nurses in the following passage: …they are ready to perform from, from day one. That being said, the learning curve for a new graduate is the same with, I don’t see any difference, new graduates whether they’re educated in North America or the Philippines, either way, they’re new graduates. And the license shows that they can probably practice safely, but, how to practice, they’re learning (5). Overall, most Nurse Managers expressed their willingness to support IENs in their careers by giving them a chance. One Nurse Manager relayed an experience where an IEN had been hired from acute care who had had conditions (frequent performance reviews in a non-acute care work environment) placed upon her from the regulatory body for Registered Nurses as it was believed that she could be more successful in a long-term care environment rather than in acute care. This Nurse Manager and a hiring partner examined the conditions and requirements, and “we thought that we could accommodate her so we did” (6). This participant described supporting IENs in the following manner: “I think that the basic thing is looking at, are they competent in their standards of practice, and if not then, …we need to look at what kind of plan can we put into place to support them” (6). Sub-theme B: Constraining Elements While Nurse Managers expressed the importance of giving IENs opportunities they need to get started in their Canadian nursing careers, they often felt that time or financial constraints of their department prevented them from providing the nurses with adequate support. Nurse Managers also expressed that they were often unaware of exactly what types of supports IENs Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 42 required. In addition, they often were unaware of the current nursing regulatory body requirements for IENs to become licensed as a RN in BC. Nurse Managers have many constraints that can hinder their ability to support IENs. One Nurse Manager mentioned that if they are busy in the facility, for example with a flu outbreak, or preparing for accreditation, it might prevent them from adequately supporting IENs, stating, What’s happening in the facility? I mean, if you’re over the top, then those sorts of things also can play a hindrance in that sort of thing, cause you really need to be, depending on what support they’re needing and that sort of thing, right? (4). The participant went on to explain in more detail: Because, I mean, not to say that I don’t think an international nurse couldn’t, but sometimes, you know, you also need to be able to give them the time and give them that support, and then there might be a better time than others to do that. Not saying that I would not consider, I certainly would. There might be times that are better within the facility, but right now in the fall, (chuckle) it just seems like everything is coming at us, right? It’s influenza season, it’s, you know it’s the start-up of after the summer when everyone’s kind of been on holidays, that sort of thing, where it seems like everything comes at you at once, and you’re kinda’ feeling a little bit overwhelmed and then you may consider, is this the best time to help support someone to do the best that they can do? (4) While time constraints may be one concern for Nurse Managers with regards to providing the right support for IENs, another concern was having the budget to provide support and mentoring for IENs. Nurse Managers felt conflicted with regards to the ideal of being able to Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 43 give everyone the opportunity and support they need, but being hindered by the financial aspects of their managerial role. One Nurse Manager expressed it this way: How can we fit them in, into our, into our budget? I mean it’s great if you can. It should be that way. It should be mentoring, we should be mentoring them. They should have a chance to succeed. But when you’re, you’ve got the other, as the administrator you’ve got the budget, you know (6). While many Nurse Managers often stated this predicament between wanting to provide adequate support to IENs, and also feeling constrained by their busy schedule, a lack of information as to what IENs actually need may further complicate the situation. Some Nurse Managers, when describing how they were unable to provide support to IENs, referred to outdated regulatory body guidelines that stated a requirement that IENs be supervised for a certain amount of provisional hours before practicing independently. One Manager referred to the following experience, “Somebody wanted to come here for 250 hours 1, and at that point it was supervised RN coverage…. I ended up declining because we were in absolute chaos here. And… it just wasn’t, the timing wasn’t right” (3). This same Nurse Manager described being uncertain as to the specific regulatory body requirements, and stated further clarification of the current guidelines for IENs would be most helpful. Similarly, another Nurse Manager stated that IENs often require supervised hours upon being hired: I think often the condition was that they be supervised, they couldn’t work on their own. That I think puts a bit of pressure on a, on an organization, where you may only have one 1 This “250 hours” refers to a former pre-registration requirement that IENs receive 250 unpaid supervised nursing work hours prior to gaining their nursing license in BC. This requirement was removed from the nursing regulatory body guidelines in 2013. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 44 or two nurses on, and so, if she can’t work alone for the first while, you know, those are the kind of things that I think would be problematic. Because we need someone now, we need someone that’s able to stay on the floor and be a leader all the time. Right, … then it’s sort of like an extra. And, well we have budgets (6). In summary, Theme One identified the importance of acknowledging the complexities involved in the hiring process for IENs. The opportunity to provide IENs with work, and being aware of some of the constraining elements led these Nurse Managers to consider other elements for hiring that can be found under Theme Two: Finding the “Right Fit”. Theme Two: Finding the “Right Fit” Finding the “Right Fit” for their workplace is one of the key goals of Nurse Managers when they are hiring RNs. The idea of fitness might look different depending on the individual Nurse Manager and his/her hiring practices. While each Nurse Manager’s hiring practices were found to be unique and while each also often had different ideas of who the ideal nurse is for their workplace, they all were looking for the “right fit”. How Nurse Managers determined the “right fit” will be explored in this section. Sub-theme A: Possessing the Right Attitude and Values The first indicator of the “right fit” was based upon the IEN “possessing the right attitude and values” that aligned with those of the Nurse Manager. The nurses’ attitude or expressed values often played a key role in the Nurse Manager's decision whether to hire a nurse or not and was something that they used in deciding whether to hire one nurse over another. In reference to the IEN’s attitude, Nurse Managers look for a positive attitude in the hiring process. One Nurse Manager conveyed this stating: “Sometimes in hiring…Often in hiring you look at things like Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 45 attitude, you would look at different types of things like that” (7). The participant went on to mention that attitude was one of the most important criteria with regards to being the right fit for the facility. “I’d say attitude would probably be my, I’d probably go on attitude. Or things like positive, so… just sort of their outlook, being optimistic” (7). Another Nurse Manager also expressed a similar sentiment regarding attitude stating: “Because, as long as you have the right attitude, and I mean, well you need a license, yes. But as long as you have the right attitude, the rest of it you can learn” (5). In addition to a positive attitude, Nurse Managers also found a nurse’s values to be a very important hiring criteria. Ensuring that IENs values aligned with those of the organization was also important. One Nurse Manager stated, I think that when you talk to somebody, um… you know if they’re gonna be a good fit. You know if they’re kind, …if they’re compassionate, just in the answers they give you. That is our values system here, and… if you’re looking for a paycheck, this isn’t the place to be. If you’re looking to work with seniors who really need your care, that’s what we’re looking for (3). The participant voiced later in the interview that “we want you here because you love our seniors” (3). Similarly, another Nurse Manager stated that they wanted nurses who value working with the elderly in residential care. This participant asserted, “A good fit for the facility is someone who has that kind and compassionate, and that drive to work with the elderly, I think that’s important” (4). This same Nurse Manager reiterated the importance of values again later in the interview: “We want to get an idea of are they a good fit for [facility]? Do they align with our values here at [facility]?. . . Are they kind, are they, … you know what I mean?” (4). Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 46 Kindness was a value that was mentioned by many of the Nurse Managers. Ensuring that these values come across in the interview process is important. One Nurse Manager stated, And that, that’s the other thing, also not just, well the kindness goes, but how do you treat people, you know, uh respect and dignity. You want to make sure that that comes across too when you’re, you’re, you’re looking at hiring them (6). The participant went on to emphasize the importance of kindness even over competence at specific skills. “Kindness is, goes a long ways. You can, you can teach tasks,… but if your heart isn’t in it, that, you can’t, you can’t teach kindness” (6). Similarly, another Nurse Manager stated, “You know if they’re kind, …if they’re compassionate, just in the answers they give you. That is our values system here, and… if you’re looking for a paycheck, this isn’t the place to be” (3). Some Nurse Managers spoke about the admiration they had for IENs as being hard workers and being determined to succeed in their struggle to overcome multiple barriers to obtain licensure as Registered Nurses in Canada (4). One Nurse Manager expressed preference for IENs because of their “exceptional work ethic” (5). Another Nurse Manager described IENs as being very resolute and hardworking, stating: And I would say people who come from, anyone who immigrates to Canada, I think they work very, very hard to meet the standards. And I think it’s a lot of hard work for them,… And it’s like I said previous, I have empathy for them for the fact that they have to prove themselves twice. Sometimes I am not sure if some of us who are born in Canada would do that twice (7). Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 47 Sub-theme B: Possessing the Right Experience Having the “right experience” was also key to being the “right fit” in the hiring process. Many of the Nurse Managers expressed how they preferred to hire nurses with background experience in long-term care nursing. These Nurse Managers also preferred to hire nurses with years of experience working as a RN, and many stated that Canadian nursing experience was also an important factor. Other Nurse Managers spoke about the importance of experience too, but were not explicit about what kind of experience they were looking for. One Nurse Manager referring to what type of nurse the organization was looking for stated, “…we only have one RN here, uh, 24 hours… they have to have experience and they have to be team leaders” (1). Another stated, “it’s important to me that they have the skills, … they are a good fit, … they have experience in some degree, and um… meet our criteria” (3). This Nurse Manager again emphasized the importance of experience in the following statement: If… somebody was coming to me as an international nurse with no experience compared to others that had experience, I’m going to take them [the one with experience]. And it doesn’t matter if that person is Canadian or internationally trained (3). Life experience and maturity were also considerations that some Nurse Managers thought were important for an IEN to possess. One Nursing Manager stated, “obviously you want to look at what’s their work experience, … but even… any interview that you do with people… who have life experience as well, that also, the maturity comes into play, right” (4). Similarly, another Nurse Manager stated: “It depends on where they come from, and also what their training was… also, age difference…. If they’re younger and inexperienced that’s also very different whereas if they’re older with experience, that’s … different” (7). Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 48 The “right fit” often meant having long-term care experience or experience working with older persons. One Nurse Manager preferred to hire nurses with experience specific to the longterm care setting. This was conveyed in the following: “So, if uh someone was let’s say uh working in neonatal unit for twenty years you know, and has no understanding of uh seniors care or seniors needs, …. that person uh would not be suitable candidate to work in our setting” (2). Another Nurse Manager expressed a preference for nurses to have experience working in longterm care by the following: “I look for people sometimes who have experience because um, residential is its own entity, right, it’s its own specialty… different than others. So, you… tend to look at those who may have some experience” (4). As well, some Nurse Managers preferred to hire IENs who had previous Canadian work experience. One Nurse Manager after stating that Canadian work experience was required, mentioned that a Canadian job reference can provide helpful information about a potential hire. For example, this Nurse Manager stated that if an IEN had a Canadian job reference this assisted her to determine, “were they punctual? Were they dependable? . . . How were they with people? Even if it was Tim Hortons, I think you can still get… a really good reference out of that” (1). Similarly, another Nurse Manager preferred IENs with Canadian work experience prior to hiring them, stating: It’s very important…that they have some time to be able to work here, and I know that’s difficult. And, and, I think that’s where it becomes a little more difficult for the first employer to have them come to your site…. it’s preferable that they come with experience (6). Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 49 This Nurse Manager also spoke about having had some previous negative experiences with an IEN who had conditions placed on her from the nursing regulatory body, whom at the end of the probation period, was not hired. The Nurse Manager also stated that since that negative experience, as a hiring manager, there has been an effort to be more intentional in setting the criteria for hiring of IENs. The participant continued, “It was difficult to have that first, to have them be your first experience. You just tended to, to shy, just shy away a bit, you know” (6). Conversely, another Nurse Manager stated that nursing experience, irrespective of what country the IEN was from, was just as valuable. This participant did not see Canadian work experience as a hiring requirement for IENs, stating: I think that nursing experience period…, if you’ve got experience working in a foreign country, … and you’ve never worked in Canada before, that experience in that foreign country is gonna come forth… and be brought into your Canadian workplace (3). While this Nurse Manager did not require Canadian nursing experience for hiring IENs, there was an expectation that they would have gone through an IEN bridging program and have Canadian references from the program. Sub-theme C: Possessing Adequate Communication Skills All nurse managers stressed how important it was to hire IENs with good English language skills. Speaking English well was mentioned as being key to ensure clear communication between health care professionals. Nurse Managers also emphasized the importance of residents being able to understand and be understood by their nurses. One Nurse Manager mentioned that the first thing assessed when interviewing IENs was language fluency Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 50 and their ability to be understood. Language was described as being “really important” as well as a “key factor” in the hiring process (4). Similarly, another Nurse Manager described language as being a “huge barrier” for IENs (1). This participant stated that “the verbal, the non-verbal, … and being able to communicate on the phone to the doctor is so important” (1). Language fluency was described in terms of being key to the prevention of medication errors and in communicating care requirements to other health professionals. One Nurse Manager stated: I do watch for their comfort with the English language. Um, and I don’t mean that to be bad, but everything we have is in English. It just, it just is. So you do run the risk of medication errors or something, if they don’t understand English (5). Similarly, another acknowledged the subjective nature of assessing language abilities and stated that she looked at “communication and accent, especially over the phone… that could be uh potential for error…. But then again, it’s so subjective” (2). A third Nurse Manager also conveyed the importance of clear communication and stated: Making sure that…there’s no language barrier is really important right, because if they can’t be understood, or written and verbal, right?. . . it’s important not only that they can be understood when they’re speaking, but also in their writing, because they do a lot of progress notes, they do a lot of connections with the doctors in writing up um, doctors’ orders or whatever that might be. So that’s a really important component of that (4). Similarly, one Nurse Manager framed the importance of clear communication in terms of “protect[ing] our residents” and ensuring that residents of the care home could understand and be understood by their nurse (3). This participant stated: Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 51 The one thing that I might pay more attention to is their command of the English language. And that is… simply because our older residents, need to be able to explain and be understood, and they need to hear and understand those that are caring for them (3). This Nurse Manager acknowledged that IENs are assessed for their language skills before they can get licensed, but ultimately stated, “If our residents can’t understand or can’t get their point across…, I have to look out for our residents. So that is the only thing that would stop me if that person was equally comparable to a Canadian um educated nurse” (3). While some Nurse Managers saw language and clarity of speech to be one of the most important factors in assessing IENs, one felt that it was not a significant concern as long as the nurse had the right values and skills. This participant acknowledged the importance of language for IENs, but did not think that it was automatically a barrier, especially if the nurse was a caring individual. The participant stated: You can have people where, where English is their second language, … but it’s not a barrier when your other qualities are… qualities of … kindness, respect, dignity, and,… you know, being able to, to meet their [resident] needs and… to problem solve. People overlook, you don’t notice that there’s an accent or that they can’t because… they treat people with… respect and dignity, and so you can work with that, I think (6). Sub-theme D: Determining Long-term Intentions Nurse Managers expressed their willingness to hire IENs who met their hiring criteria. However, they did not want to put in the effort to support IENs and train them only to have them leave long-term care for an acute care setting. Thus, in addition to having clear communication Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 52 skills, the right experience and positive values, some Nurse Managers sought to determine IENs long-term intentions before they are willing to hire them. The long-term care setting was described by one Nurse Manager as being perceived as “a foot in the door” to the nursing workforce for newly graduated Canadian nurses and IENs (1). Thus, when potential hires were interviewed: I always like to ask … what their future goals are, because are we a stepping stone? Are we just a way in so that they can have a reference so they can get back to acute care? Or do they want to spend time in residential care and get to know the residents (1). The participant stated that if an IEN or a newly graduated nurse who had good availability and was interested in long-term care, they would be mentored and supported as it was likely that that nurse would be “more reliable and invested in [our facility]” (1). Likewise, another Nurse Manager described long-term care as a “stepping stone” for IENs. This participant asked: Are they here as a stepping stone? And we can ask them straight up too, ‘Is your ambition to get into acute care?’ And if they say yes, I don’t want to hire somebody, train them, and have them hired at [local hospital] a month later (3). These sentiments were repeated later in the interview: “In order for the international nurses to get into acute care, Canadian experience is required and a lot of them I believe come as a stepping stone in residential” (3). This Nurse Manager was hesitant to invest the time in IENs whose long-term goal was to move to acute care, stating: Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 53 I look at… do they have a love for residential care, or are they… using it because they can’t find anything else right now, and they’re desperate for a job. Right? And that, with RNs, you’re not going to find too often… but if we think that they’re going to be leaving in a few months… like we have declined people who, you can see in their history and will tell you quite honestly they did Peds in their country where they came from, and that is where they’d like to get to. Well, you know, their hearts not in it. I need people whose heart is in residential, who love the elderly. That’s what I’m looking for (3). A third Nurse Manager corroborated the above findings by describing long-term care as “their shoe in the door to get to somewhere else” (4). This participant also did not want to train and support IENs whose long-term intentions were to move to a hospital setting, stating: If a nurse is coming in and … long-term care is not their passion…, then I might think about it some more… if they’re telling me that… ‘well, I ultimately want to go into pediatrics,’ or whatever… that’s probably not someone that I’m gonna really want to put all the effort into as much as I would if someone was like, ‘I have a passion for the elderly. I really want to work with them (4). Sub-theme E: Gaining an Innate Feeling Nurse Managers expressed the subtheme of gaining an “innate feeling” in different ways, but mentioned that fitness to practice can often be determined by a subjective feel for an individual during the interview process. Some described this feeling as innate, others called it intuition, but most of them felt that having a positive feeling about a nurse was important to the hiring process. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 54 One Nurse Manager described this as having a “good feel” about an individual. This participant stated, “But you get a good sense or a feel. In an interview you, you just, to me it’s an innate feeling, it’s something that’s a little intuitive, you know” (7). When asked to expand on what that feeling was the participant explained: I think the more people you meet, the more you talk with. It’s always um a feeling like a warm and friendly. If you have that feeling or sense. Or if it’s kinda matter of fact… a warm smile, look in the eyes, those kind of things. That all makes a difference (7). Likewise, a second Nurse Manager also described how “you just kinda get a feel for people” (1). This “feel” was related to how caring an individual was perceived to be. This participant stated, It all depends in the person and the feel you get. A lot of times it has to be how caring they are or how task-oriented they are. I mean we don’t need task-, we need taskoriented nurses here, but we don’t need ICU nurses. We need someone that’s going to stop, slow down, hold someone’s hand or have a conversation, get them tea. Right. So it’s just getting a feel for the person (1). This innate feeling was described by another Nurse Manager as a “gut perspective”. This participant stated that there was no “set data or criteria” that was looked for during an interview, but instead their “gut perspective” (3) guided hiring decisions. The term “good feeling” was also used in the participant’s description of why some individuals were selected over others. When asked to further explain this “gut perspective”, the participant stated: “So to say what is my, what does that mean, it’s just what, what you get. That feeling you get, ‘Yes this is gonna work’ or ‘uh-uh’. And if it’s not going to, we will cut the interview short” (3). Similarly, another Nurse Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 55 Manager stated: “we’ll have um a good, almost a sixth sense of who, you know, who someone is when we interview. We have a really good feeling about, and usually we’re right” (4). This participant described it as having a “really good sense of who people are when you interview them” (4). One other Nurse Manager described how hiring was often based on an “innate feeling”. However, this participant did caution that the feeling was not inerrant, stating, “It’s an innate feeling too, you know, do they connect with you? And yet that can go sideways too because sometimes they can come across very well in an interview” (6). Theme Two identified some of the various elements that Nurse Managers utilize to determine if an IEN is the right fit for their workplace such as a positive attitude and values, nursing experience, clear communication, a desire to work with older persons, and giving the Nurse Manager a “positive feeling”. The next theme, Navigating differences, will examine the various differences that Nurse Managers believe exist between IENs and Canadian Nurses. Theme Three: Navigating Differences Nurse Managers all discussed the importance of Navigating Differences that are often present when hiring IENs. Some felt that there were significant differences between the education of Canadian nurses and IENs whereas others saw the differences evidenced through variations in clinical practice. Some Nurse Managers saw these differences as being country specific, whereas others were unsure. Differences were also discussed as they related to cultural beliefs and practices and how this impacted nursing practice. Sub-theme A: Variations in Education and Clinical Practice Most Nurse Managers found that there were differences between Canadian educated nurses and IENs. However, some Nurse Managers thought that variations in education and Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 56 clinical practice between IENs and Canadian educated Nurses were negligible as it related to their readiness to practice in the Canadian long-term care setting. One Nurse Manager stated: Nurses in Canada already have a foot forward for the fact that they already know the culture, they already know, there’s a lot of things that they know. The comparison for the two, if the two were on par, I don’t think there would be any difference. If that makes sense. If they’re both well educated in the area that they serving. So if they’re both well educated in geriatric clientele, and they’re both nurses, they both passed their competencies, I would say that, depending on, maybe what might add a little flare is personality. Maybe what would add some flare is, their, uh maybe years of experience. There is lots of things, but I would say there would be no difference between the two (7). Similarly, another Nurse Manager described the difference between IENs and Canadian Nurses as generally being one of accent. “I wouldn’t say that there was any difference in their ability to do the work, the tasks…the only reason you knew that they were an international nurse was usually due to their accent” (3). This Nurse Manager was hesitant to make any broad generalizations about IENs and Canadian nurses because, “they’re all people and they all have some better skills and some lesser skills. ” This participant continued: I don’t really have a difference in their skills compared to Canadian nurses. You have some Canadian nurses that function at a higher level and those at a lower level. I think that would be comparable to any international nurse (3). This Nurse Manager had worked with both IENs and Canadian nurses who had demonstrated excellence in clinical practice and therefore the participant emphasized that there was no overarching differences between the two groups of nurses. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 57 One Nurse Manager was an IEN and had been in Canada for 20 years. This participant had been through and understood the “very extensive process” of becoming licensed in Canada, and thus felt that IENs entering the nursing profession in Canada were a good fit for the workplace, because the professional licensing body had already screened them and assessed their skills. This participant stated: “so for me …when I hire the nurses, I look at the applicants… and whether they have been internationally or not or Canadian educated, it really does not influence my decision” (2). While these Nurse Managers expressed that the differences between IENs and Canadian educated nurses did not make a difference with regards to readiness to practice, others were quick to point out what they saw as the differences in education and clinical practice between IENs and Canadian educated nurses. One Nurse Manager discussed experiences with nurses from the Philippines and described how some IENs had never practiced in the clinical setting, but went straight from their schooling into a Masters in Nursing and then were teaching other nurses. This demonstrated “a difference in the system there” (1). In continuing the discussion of the IENs from the Philippines, this participant stated that “the ones that have worked in the proper settings like in hospital settings” were competent, but the others that went straight into teaching would be a challenge to support in their practice” (1). Later the participant stated that some IENs were better prepared in their nursing education than Canadian newly graduated nurses as they had more hospital-based training programs in some other countries. “Our grads… I don’t think they have as good experience as hospital programs… I think they [IENs] have more hospital front-line experience” (1). For this Nurse Manager, in order to assess the differences and competencies of IENs, “you have to ask those specific clinical skills and what they’re used to and kind of how they would make some decisions to see if they’d be appropriate” (1). Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 58 Similarly, another Nurse Manager mentioned that even though “they’re [IENs] well trained…. there are areas where they might need some extra training clinically” (6). Another Nurse Manager, although not specifying as to the differences, stated: “So when you think of an internationally educated nurse, you think, ok, so their standards of practice might be a little different than from our country obviously” (4). The participant stated that as long as nurses had been through the IEN upgrading programs and completed all of their prerequisites, there would be no problem hiring them. This participant continued, I think… their background might be a little different, but I do think that they are prepared to learn … what they need to learn from … their change in practice from where they were to in Canada. I mean obviously, we have the advantage of being here in Canada already and, and learning those things from the very start, whereas they have to learn them probably afterwards (4). Another Nurse Manager thought that one of the primary differences between Canadian educated nurses and IENs was reliance on and familiarity with technology, stating, “What I hear, often, from international educated nurses … ‘oh, I hate computer’. And then my answer is always, ‘yes, I know’. We did not go into nursing because we love computers” (2). While this was recognized as a difference, it was not viewed as being significant to the hiring process. While many Nurse Managers thought that IENs might require extra training to be “on par” or equal with Canadian educated nurses, one Nurse Manager felt the opposite. This participant discussed how some IENs who were underemployed as LPNs had worked in that facility and described these IENs as “a gift to [the] community or the place” because of their underutilized skills. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 59 So we have licensed practical nurses who are hired…who have further education elsewhere, it really is a benefit to the workplace. And the benefit is that you have other expertise…. It’s much better. They’re better quality. So they’re able to assess better, they’re able to, umm, I think even the leadership portion, taking uh responsibility (7). This participant went on to describe these nurses as a “gift” for Nurse Managers because of their expertise and training beyond the role that they were in. Sub-theme B: Country Specific Variations Almost all Nurse Managers had various perceptions of the differences of IENs based on their country of origin and past experiences they had with nurses from those countries. When Nurse Managers would make these generalizations, they would often preface their statement by phrases indicating that they were not trying to be insensitive or judgmental in their remarks, but were simply relating their experiences. Generalizations of nurses based on country of origin were often as simple as, “I had a number of nurses from… India, and … I think they were well prepared” (6), or “Filipino nurses are very caring” (1). One Nurse Manager in making comparisons about IENs indicated that there was a difference in the consistency of practice based on country of origin. This participant stated favorable things about British and Irish nurses, “I know if I have a nurse coming from Britain or Ireland they’re going to be awesome nurses”. However, this participant still had some reservations about nurses from the Philippines. Filipino nurses were described as “caring”, but still, the participant stated that, “you just have to weigh everything out” (1). Some Nurse Managers made statements indicating that they were not trying to be judgmental before voicing generalizations about IENs that were country specific. After voicing Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 60 hesitations to hiring some IENs based on skills or language barriers, one Nurse Manager stated, “you hate to be judgmental, but…” prior to making positive statements about British and Irish nurses (see quote from previous paragraph) (1). Another Nurse Manager made similar statements before praising Filipino nurses, “I feel that… some of our best nurses are Filipino, and I’m not being racist or judgmental, but I do feel that…. it’s experience that tells me that” (3). This participant again expressed positive experiences of Filipino nurses later in the interview, “I see them… all the Filipino nurses I’ve worked with over the years and … lovely people, lovely. Not to say that other cultures aren’t. I’m not trying to be racist… just trying to… give you what I’ve seen” (3). In describing some challenges between their multicultural staff group of African, Indonesian, and Indian nurses, another Nurse Manager clarified stating, “but again, you know, it’s not everyone, so, I can’t say, I can’t generalize, because that’s not fair” (6). One Nurse Manager made very positive statements with regards to nurses educated in Mexico and the Philippines. This participant stated that these nurses were often preferable over North American nurses because, “they show less negative attitudes, in general, which is a very broad statement” (5). This participant continued on describing nurses educated in the Philippines, “you probably don’t need these kind of statements, but there’s no sense of entitlement. They will come and do whatever needs to be done. Period. And I can’t always say that of people born and raised in North America” (5). Some Nurse Managers appeared to indicate a difference in readiness to practice based on whether nurses were from high, middle or low income countries. As mentioned previously, one Nurse Manager had very positive things to say about nurses from Britain and Ireland, but voiced reservations about nurses from the Philippines and China (1). Another Nurse Manager when asked whether there was a difference between IEN preparedness depending on country of origin, Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 61 stated “yes, and it depends on what the expectations were in the country they came from” (7). When asked to explain further, this participant hinted at differences, but indicated that they were culture related, stating, “so, someone from Australia, or someone from South Vietnam. That kind of thing. Do you know what I mean? Like it’s completely different countries, it’s completely different exposure” (7). Another Nurse Manager described possible differences based on country of origin in the following: We might perceive that… what this country does and what that country does… I mean even what they do in the states for instance is different than some of the practices we do here… I expect that, you know maybe some of the countries that are … third world, … you know they’ve, they’ve got to challenge themselves to bring themselves to even get their license here… (4). Sub-theme C: Variations in Culture The final subtheme under Navigating differences comes from perceived variations in culture by some of the Nurse Managers. Some of these cultural variations were seen to be related to interpersonal communication or different ways of doing things. One Nurse Manager conveyed that challenges that originated with regards to cultural differences were often as result of “how different the culture is where they’ve come from to the new culture they’ve moved in to” (7). Another Nurse Manager described cultural differences as they related to specific types of nursing such as palliative care, stating, I had a nurse… struggling to understand the end of life care and symptom management because … when she was receiving education, uh … it was not part of the culture she was coming from…. Those are actually… things based sometimes on beliefs. So with Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 62 additional support and education, she was able to get to the level that needs expected her to perform (2). Other Nurse Managers saw variations in culture as being more impactful on communication and interpersonal skills rather than the practical skills of nursing. One Nurse Manager stated, The [nurse] was from Mexico, and they were working with an Anglo-Saxon group of residents who tended to be reserved. This [nurse] tended to be very outgoing… and I had residents take offense to her friendliness …So it, it wasn’t a clinical issue, it was a cultural issue (5). Likewise, another Nurse Manager in relating a challenge that was experienced with an IEN previously stated: It appeared that she had the appropriate training, right, but … it seemed to be more the relational, the uh interaction with staff that seemed to be um a bigger issue… it’s a different culture, … the other staff were also of a different culture… it just didn’t seem to work out (6). This participant also discussed how there were often misunderstandings related to “the way they speak sometimes… their tone and their understanding of … how that person might feel”. This was seen as a difference between IENs culture and the “Caucasian culture… even Canada” (6). Another Nurse Manager stated that there was some friction between staff at times that stemmed from cultural differences, but did not see it as much of a problem, stating, “Not Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 63 everybody gets along, not everybody. And it doesn’t matter where they come from. And it’s more about personalities and connection, and understanding each other and being able to work together” (7). This participant felt that as long as staff were prepared prior to introducing a new hire, and then supported afterward, there were really no significant issues due to a multicultural staff. This Nurse Manager preferred having a multicultural staff because of the different ethnicities represented in the residential care population. In relation to resident ethnic diversity, this Nurse Manager stated, “if your staff can reflect that [the different ethnicities of residents] there’s always someone who can connect to each client that comes in” (7). Theme Three examined several areas where Nurse Mangers perceive differences between IENs and Canadian educated nurses. These differences were described as they related to variations in education or in clinical practice and were often described as being country specific or related to cultural differences. Chapter Summary The purpose of this study was to explore how the perceptions and experiences of Nurse Managers in long-term care with regards to IENs influenced their hiring practice decisions. The findings in this chapter revealed that in this small sample of Nurse Managers, their perceptions and experiences varied widely making it difficult to make broad generalizations. However, the data revealed that Nurse Managers, in general, expressed a willingness to support and mentor IENs, but that they, at times, did not hire them as a result of various perceived constraints or challenges. Nurse Managers stated that language proficiency and interpersonal communication were important prerequisites for potential IEN hires. They also preferred IENs to have experience Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 64 working in both a setting with older persons and in the Canadian context. They desired new hires to be passionate about working with residents in long-term care and have long range career plans to remain working in long-term care. It emerged from the data that Nurse Managers had varying expectations of IENs readiness to practice in the Canadian context based on their perceptions of differences in their education, and clinical practice experiences in their home countries as compared to Canada. Many Nurse Managers made broad generalizations (although often their generalizations were qualified) about IENs based on their countries of origin and this appeared to influence their willingness to hire IENs in some cases. Some also viewed IENs as either an asset or a challenge in the workplace based on cultural differences. Chapter Five will revisit these findings, specifically the three themes, and they will be compared with current literature on this topic. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 65 CHAPTER FIVE: DISCUSSION This chapter provides a discussion of the themes that were presented in Chapter Four. The findings were compared to the existing literature on the topic. While the previous chapter provided description of the findings, this chapter moves beyond mere description and interprets and situates the findings in the broader context of the literature that aligns with the topic of IENs and their interactions with Nurse Managers. It will also discuss findings with regards to Nurse Manager’s lack of understanding of the process IENs undergo to become licensed in accordance to the current British Columbia licensing requirements for IENs (CRNBC, 2017). Comparison with Existing Literature Theme One: Acknowledging the Complexities In this first theme, Nurse Managers expressed their desires to hire, mentor, and support IENs in their careers, but then described several factors that constrained their abilities to hire them. Sub-theme A: Giving everyone a chance revealed how Nurse Managers often compared the nursing skills and abilities of IENs to newly graduated Canadian nurses. Similarly, Sherman and Eggenberger’s (2008) study described how Nurse Managers compared IENs to “smart new graduates”. They found that IENs required an extended orientation primarily to familiarize them with differences in practice from their home country to the host country, varying cultural practices, and the importance of speaking English in the clinical setting (p. 540). This direct comparison was not often seen overtly in the nursing literature reviewed, but emerged through suggestions to have orientation and mentoring programs in place for IENs that were similar to those provided for newly graduated nurses (Blythe et al., 2006; Sherman & Eggenberger, 2008). In addition, Sherman and Eggenberger (2008) also found that Nurse Leaders felt a responsibility Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 66 to assist and support IENs with their transitions to the workplace, but generally acknowledged that most leaders would not place emphasis on the transition process due to lack of interest or lack of time. These findings were similar to Nurse Managers in this study who expressed their desires to support and mentor nurses, but weighed their options as they thought they were unable to provide the required levels of support. In the second sub-theme, B: Constraining elements, Nurse Managers described factors that prevented them from hiring and supporting IENs in their workplace. Insufficient time to mentor IENs and adequate finances were two specific elements that were frequently mentioned. This finding was supported by other nursing studies that also found employers often will not hire IENs due to lack of financial or human resources to provide adequate education and mentoring for IENs (Baumann & Blythe, 2009; Covell et al., 2014; Jeans et al., 2005). Baumann et al. (2013; 2017) found that the main barriers for employers hiring IENs and implementing current recommendations to ensure effective integration were lack of funding, time involved, licensing issues, and a lack of resources. Thus, employers often preferred to hire Canadian educated nurses as they required less orientation time and mentoring support than IENs (Baumann & Blythe, 2009). A unique finding that emerged from this study was that it appeared that Nurse Managers were often unaware of the Registered Nursing licensing process and current registration guidelines for IENs in the province of BC. Two Nursing Managers, while acknowledging that they were unaware of current registration guidelines from the nursing regulatory body, described outdated information such as stating the “250 supervised hours” requirement for registration, was seen as a barrier for them to hiring IENs. This former registration requirement (which was an unpaid pre-registration requirement) was removed from the 2013 regulatory body guidelines, Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 67 and thus was no longer an issue for Nurse Managers (Hawkins, 2013). This lack of knowledge among Nurse Managers about outdated registration criteria could negatively impact IENs opportunity to be hired by them particularly based on a perceived constraint that was no longer current procedure. It became apparent that some Nurse Managers found it challenging to keep up-to-date of changing requirements for Canadian RN licensure, which in turn, influenced their hiring practice decision-making regarding IENs. Theme Two: Finding the “Right Fit” This second theme examined the criteria Nurse Managers use to find the “right fit” when they hired RNs. In sub-theme A: Possessing the right attitude and values, Nurse Managers mentioned qualities they looked for during the interview process such as possessing a positive attitude, demonstrating kindness, or expressing an exceptional work ethic. These specified qualities were not explicitly stated in the literature review about IENs, however, in critically reviewing some of the business literature in hiring employees, “hiring competencies” are used by Managers to ascertain whether to hire a potential employee. BC Public Service (2017) hiring principles shifts the focus of interviews from experience, education, and training to focus more on behaviours that relate to job requirements. The emphasis in hiring guidelines and recommendations has focused increasingly on “emotional intelligence” in recent years rather than technical or professional competence (BC Public Service, 2017; Brennan, 2016; Rudman, Hart-Hester, Richey, & Jackson, 2016). This focus on attitude, values, or personality characteristics rather than education and experience is supported by one nursing study that focused on the hiring preferences of Nurse Managers as it related to diploma prepared or bachelor prepared (BSN) nurses. Weinberg, Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 68 Cooney-Miner, Perloff, and Bourgoin (2011) conducted a study interviewing 27 Nurse Managers on their perspectives of the differences between BSN and other nursing graduates and how these perceptions informed their hiring decisions. They found that the majority of Nurse Managers in their study found personality, attitude and values such as compassion and caring to be more influential on their hiring decision than a nurse’s years of education or experience. Having set criteria for hiring someone with a specific set of expressed values seemed like a sensible way to hire potential employees. However, as attitude and values have various ways of being displayed dependent on cultural differences in expression, IENs could potentially be at a disadvantage if the Nurse Manager interviewing them was unfamiliar with their manner of cultural expression (either the subtleties of language or cultural communication) and interpreted this as lacking the values they were looking for in the interview process. As a result, a Nurse Manager may choose not to hire a highly skilled IEN and instead hire a Canadian Nurse if she perceived the Canadian Nurse’s attitude and values aligning more closely with her own. Conversely, some Nurse Managers expressed that they preferred to hire IENs as they had a stronger work ethic. In addition, they also found that IENs were less likely to require disciplinary action as compared with Canadian educated RNs. This however, may also represent an underlying concern for job security which prevents IENs from openly voicing other opinions. They suggested that IENs were grateful to have secured employment whereas Canadian nurses did not always display that type of outward gratitude. This finding might suggest that these Nurse Managers often did not recognize the additional difficulties IENs face. Specifically, a “power” imbalance existed between the “employer” and “employee”. For example, many of the IENs had for the most part, generally invested a significant amount of time and money to secure Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 69 gainful employment in the Canadian context, and so were often limited in their options for mobility. As a result, the IENs may be grateful simply to be employed. In the second sub-theme, B: Possessing the right experience, Nurse Managers expressed their preference to hire nurses with more years of experience, and specifically having Canadian work experience. As a result, such an emphasis that they possess specifically Canadian experience, resulted in devaluing the IENs previous nursing experience in another country and therefore placed them at a disadvantage during their initial search for employment. This finding is supported by Gogia and Slade (2011) and Hawkins and Rodney (2015) who also stated that the expectation from Canadian employers that potential IEN employees have “Canadian work experience” resulted in devaluing foreign education and experience. By requiring Canadian work experience, IENs past experience goes largely unacknowledged and is viewed as unimportant (Babenko-Mould & Elliot, 2015). Beyond a familiarity for the work environment, it was unclear what competencies were expected to be produced from possessing Canadian work experience. Prendergast (2014) in her dissertation on the “ideal type” of Canadian nurse viewed the emphasis of employers on “Canadian work experience” as a means to “streamline highly qualified newcomers with foreign credentials into low paid and low status jobs” (p. 45). In contrast, Nurse Managers in this study thought that any Canadian experience (even outside of the field of nursing) was valuable in that it provided a Canadian job reference. The challenge IENs faced to obtain “Canadian experience”, prior to being hired, often resulted in IENs getting hired in what was perceived to be the least desirable nursing positions, such as staff positions in Long-term care or acute care (Blythe, et al., 2009; Covell et al., 2015; Covell et al., 2017; Tuttas, 2015). Even when an IENs skills and experience were comparable with their Canadian counterparts, they generally ended up working in hard to fill menial nursing Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 70 positions that Canadian nurses refused to take or found undesirable (Covell, et al., 2015; Prendergast, 2014; Tuttas, 2015). By working in these types of positions, IENs tended to fill the unmet needs of the Canadian health care system. This finding is supported by Neiterman and Bourgeault (2015) who described how IENs were expected to work in these less lucrative or rewarding positions and were often “overtly or covertly blocked from career advancement and mobility” (p. 630). As described in Chapter Four, one Nurse Manager mentioned that even though she did not necessarily require a Canadian job reference from an IEN, she expected that he or she would have completed a Canadian nursing upgrading program for IENs. Such an upgrading program would introduce them to the Canadian nursing context, and ensure that their skills were at the level expected of Canadian nurses. As a result, the IEN would have a Canadian reference from the upgrading program. While most IENs participate in a bridging program to address any identified gaps from the nursing regulatory body Competency Assessment, some nurses who do well on the assessment are not required to take a further upgrading program (Hawkins, 2013). These nurses without an additional upgrading program may potentially have more difficulty obtaining employment, as they then have no Canadian nursing references. Thus, while doing well on the regulatory body competency assessment may be seen as positive, as the IEN does not have to incur additional expenses for paying for additional courses, this success could actually place them at a disadvantage, if they must have Canadian references and work experiences prior to being hired. Covell, et al. (2017) supported this finding, as they identified that participation in a bridging program was one of the most significant predictors to finding initial employment for IENs. Conversely, while Nurse Managers in this study emphasized the importance of the “right experience”, Covell et al. (2017) found that IENs professional nursing experience was not Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 71 a significant predictor for securing employment. The best predictors for securing employment for IENs was utilizing social networks to connect them to employers and participation in a bridging program. This demonstrates the importance of having programs in place to connect IENs to a social network, which can assist them in obtaining information about the job search process and connect them with potential employers. The emphasis placed on clear communication that emerged in sub-theme C: Possessing adequate communication skills was a very common finding found throughout the nursing literature on this topic. Many studies found that a lack of language proficiency can prevent IENs from finding employment, and it was often linked to their overall ability to competently perform as a nurse (Blythe et al., 2009; Jeans et al., 2005; Lum, Dowedoff, & Englander, 2016). In addition, language barriers, such as various cultural expressions and colloquialisms, tended to contribute to poor outcomes for IENs when interviewing for promotions in the UK (Tuttas, 2015), and could hinder their ability to foster positive working relationships with their colleagues (Pung & Goh, 2017). English language proficiency requirements for nursing licensure in Canada have steadily increased over the years making it increasingly difficult for IENs to obtain licensure. Studies by Hawkins and Rodney (2015) and Lum, Dowedoff, and Englander (2016) provided support for the importance of IENs demonstrating a high level of English proficiency to obtain their Canadian nursing license, however, even with language proficiency they found it could still be challenging for them to find employment. This finding appeared to suggest that Nurse Managers perhaps pay more attention to their own perceptions of language fluency than to language comprehension exams or their scores. Sub-theme D: Determining long-term intentions is something unique to this study and specific to the long-term care setting. Nurse Managers spoke about being concerned about Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 72 losing new hires to acute care settings. This may be related to the difficulty that IENs confront with regards to obtaining “Canadian work experience”. IENs may desire to work in an acute care setting especially if they come from a hospital nursing background, but begin working in long-term care for the sake of obtaining Canadian work experience. The long-term care setting was often viewed as requiring less skill as a nurse, being less appealing work, and being a difficult area to staff (Covell et al., 2016; Pendleton, 2016; Pung & Goh, 2017; Tuttas, 2015). Another concern noted by Hawkins (2013) is that IENs from the Philippines are often unfamiliar with the long-term care environment, and thus they seek to leave it for working in an acute care setting that better aligns with their nursing education and work experience. Thus, the requirement of Canadian Experience for IENs, in the end, can create more turnover and challenges for Nurse Managers in long-term care, as these nurses are being hired into positions that are outside of their field of expertise or desired nursing area. One attribute that Nurse Managers in this study spoke about using in order to find the “right fit” of employee for their workplace was captured in sub-theme E: Gaining an innate feeling. The description by Nurse Managers of this “gut feeling” of employing someone, was not found in the nursing literature on hiring IENs. In addition, very little was found in the nursing literature that explicitly discussed the hiring process and criteria for nurses. McMillan, Parker and Sport (2014) in their discussion of the use of an e-portfolio tool to streamline the preinterview process for Nurse Managers noted that historically, selection of nurse hires has lacked a structured process and has failed to focus on behavioural characteristics, personality, judgment, and values. However, they did not offer any potential guidelines for hiring beyond the implementation of an online screening tool to save time in the pre-interview phase of assessing job applicants. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 73 One study from the business literature by Rudman et al. (2016) made reference to the “gut feeling” that some employers have about new employees. They stated that when Managers rely on the “gut feeling” for hiring, they were more likely to have a poor outcome with that employee as opposed to when they followed a systematic hiring process. Using hiring methods outside of a formal process more often led to bringing on individuals that were a poor fit for the role and the organization. Similarly, BC Public Service (2017) also encourages hiring managers to strive as much as possible to follow the formal process in order to remain objective and avoid injecting their own personal bias into the hiring decision-making process. Nurse Managers who relied on garnering a “good feeling” about a potential hire, may have inadvertently injected their own personal or cultural bias into the hiring process. A Nurse Manager may “feel” more comfortable with an individual who thinks and expresses themselves according to the Nurse Managers own cultural background and experiences. Thus, if a Canadian Nurse Manager was confronted with a Canadian nurse with a shared cultural understanding versus an IEN with foreign or “other” ways of knowing or expressing themselves, that Nurse Manager, it appeared in this study, may choose the Canadian nurse over the IEN based on their own underlying cultural biases. There were no research studies found to support this finding in the nursing literature. Theme Three: Navigating the Differences In the final theme, Nurse Managers discussed the importance of navigating the varying practice differences that were present when hiring IENs. Variations in practice between IENs and Canadian Nurses can take many forms, for example, in India, physicians tend to direct patient care and are present on the units at all times, thus nurses rarely conduct assessments on Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 74 their own (Sherman & Eggenberger, 2008). Under sub-theme A: Variations in education and clinical practice, Nurse Managers described the perceived differences between nursing education and practice of IENs in comparison with Canadian educated nurses. Some studies described differences in a nursing scope of practice, roles, and expectations of care, which were often dependent on an IENs country of origin. In a study by Sherman and Eggenberger (2008), they discussed differences in nursing practice such as in levels of autonomy and the relationship and roles between nurses and physicians. As well, Babenko-Mould and Elliot (2015) and Lum, Dowedoff, and Englander (2016) described differences in roles and practice and conflicting practice norms from IEN home countries and Canada. Because of the vast array of differences that are culture and country specific, it appeared that Nurse Managers must recognize that all IENs require a more individualized approach because of the variation in their strengths and needs which is often related to their country of origin. This finding was also supported by Covell et al. (2016) as they suggested the importance of country specific research that could help to better support IENs dependant on where they had originated from. As IENs are not a homogenous group, Covell et al., (2017) suggests that an individualized Case management approach be taken in assessing their education and skills and then tailoring assistance to meet the individual’s needs. The recognition and description of the practice and educational differences of IENs by Nurse Managers was not a new finding and was supported by other authors in the nursing literature on IENs (Blythe et al., 2006; Blythe et al., 2009; Njie-Mokonya, 2014). For example, such differences in practice and education levels, whether perceived or not, can often be viewed as a barrier to IENs being hired. Many employers often perceived IENs practice and experiences to be below the minimum requirements when compared to Canadian standards. As a result, Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 75 Nurse Managers may hesitate to hire IENs due to the additional requirements for an extended orientation period and/or long-term mentorship (Babenko-Mould & Elliot, 2015; Covell et al., 2014; Newton et al., 2012; Pendelton, 2016; Primeau et al., 2014; Tuttas, 2015). Most employers tended to see IENs as an “unfavourable addition” to the workplace due to differing skills and competencies, but failed to see the benefits IENs bring to the Canadian healthcare environment such as enhanced linguistic and culturally sensitive nursing care provision (Baumann et al., 2017; Covell et al., 2016). Both Njie-Mokonya (2014) and Covell et al. (2016) emphasized the importance of having Nurse Managers highlight the unique contributions of IENs and how their skills contribute to providing culturally competent care rather than focusing on the potential differences that can be barriers to successful workplace integration. In addition, for the Nursing Managers in this study, it appeared that they lacked understanding and awareness that delving into IENs educational background was not required if the IENs had already been assessed by nursing regulatory body as meeting the Canadian standards of practice. The National Nursing Assessment Service (NNAS) already assesses the differences in education, and upon finding deficiencies will require IENs to upgrade any areas of education that are lacking. As a result, the additional screening by Nurse Managers seemed unnecessary. While to some degree Nurse Managers must do this with all nurses (Canadian or internationally educated), the literature revealed that IENs tended to face much more scrutiny than their counterparts when it came to their educational and practice backgrounds. While some Nursing Managers have expressed doubt in the nursing registration process, it was interesting that the one Nurse Manager, who was an IEN, expressed much more faith and trust in the registration process. It appeared that Nurse Managers who have more knowledge and awareness Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 76 of the licensing process and bridging programs may be more likely to be favorable towards IENs than those without that same familiarity. One other issue that was brought up by one Nurse Manager in this study was that IENs are often underemployed in the Canadian context. Some Nurse Managers preferred hiring underemployed nurses as they were more skilled than their similarly licensed colleagues (for example a physician working as a RN or a RN working as a LPN). The deskilling of IENs was a common theme in the literature regarding IENs. Gogia and Slade (2011) described how the devaluation of foreign education and work experience by Canadian licensing bodies and employers hindered IENs ability to work to their full capacity as nurses in the Canadian context. Similarly, in their respective studies, Baumann and Blythe (2015), Hawkins and Rodney (2015), Salami (2016), Salami and Nelson, (2014), and Singh and Sochan (2010) all described this pattern of downward occupational mobility for nurses as a result of the fragmentation between Immigration requirements and nursing regulatory bodies. Nurse Managers, in addition to describing variations in education and practice, also discussed country specific variations (sub-theme B). Nurse Managers made broad generalizations of IENs related to their country of origin based on the manager’s experiences of nurses from those countries. In Likupe’s (2015) study, Nurse Managers were interviewed about their perspective regarding black African nurses and those nurse’s experiences of racism and discrimination in the British National Health Service. Nurse Managers voiced many negative stereotypes of overseas nurses that led to an increase in scrutiny and a lack of promotion for many of these nurses. These stereotypes, for example, African nurses are slow, confrontational, and lack motivation or Asian nurses are hardworking, loyal, and do not question authority Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 77 resulted in the presence of ethnic hierarchies on nursing wards. The “racialization” 2 of IENs fostered a culture of divisiveness as the Nurse Managers’ approach to these nurses and comments about them based on stereotypes spread to other unit nurses. Nurse Managers in Likupe’s (2015) study failed to create an environment conducive to equitable treatment by condemning acts of microaggression, racism, and workplace harassment. Moyce et al. (2016) and Pendleton (2016) had similar findings in their literature reviews. While Nurse Managers in this study were cautious in their country specific generalizations and mentioned many favorable stereotypes, for example, Filipino nurses are very caring and hardworking, overall, these types of generalizations are nonetheless unhelpful as stereotyping can often be a precursor to structural racism. 3 Likupe’s (2015) study found that black African nurses were denied promotion because Nurse Managers assumed they lacked motivation to advance further. Nurse Managers must be careful in stereotyping IENs based on their country of origin and instead assess each IEN as a unique individual with learning needs and goals the same as any Canadian-educated nurse. One final area where Nurse Managers in this study navigated differences was captured in sub-theme C: Variations in culture. In addition to language difficulties, cultural differences were another potential barrier for IENs in the workplace that could impact hiring practices. This finding was a common theme found in other studies in the nursing literature. Sherman and Eggenberger (2008) found that cultural differences between a multicultural staff group were 2 “Racialization is defined as the process of assigning race categories to persons or contexts in a culturally constructed set of classifications. Racialization also connotes over application of these categories, which might obscure other factors operative in a care encounter or epidemiologic interpretation” (Hall & Fields, 2013, p. 166). 3 Structural Racism is defined as “A system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity. Structural racism is not something that a few people or institutions choose to practice. Instead it has been a feature of the social, economic and political systems in which we all exist” (The Aspen Institute Roundtable on Community Change, 2016). Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 78 often a source of conflict or friction among staff. Misunderstandings related to differences in culture, non-verbal communication, and methods of care delivery often created friction between IENs and other staff (Blythe et al., 2006; Blythe et al., 2009; Jeans et al., 2005; Lum, Dowedoff, & Englander, 2016; Newton, Pillay and Higginbottom, 2012; Pung & Goh, 2017; Sherman & Eggenberger, 2008). Moyce, Lash, and de Leon Siantz (2016) and Likupe (2015) found that host country nurses often perceived IENs as “slow” or “less motivated” which led to difficulties for IENs in finding employment and decreased their opportunities for promotion even once they secured work. Similarly, Newton, Pillay, and Higginbottom (2012) found IENs often thought that differences in race and culture can lead to them being ignored by management, colleagues and patients. As well, Allan (2010) found that Nurse Managers often did not consider the impact that cultural differences had on learning and thus were insensitive to the different learning styles and needs evidenced by some IENs. Chapter Summary This chapter examined the findings of chapter four in more depth and discussed some of the various implications of the findings in comparison to the nursing literature on the topic of IENs. Theme One: Acknowledging the Complexities was explored in the context of other studies that compared IENs to newly graduated Canadian nurses in the amount of time required to orientate, mentor, and support them. It also discussed how Nurse Managers were often unaware of current nursing regulatory body registration guidelines for IENs and as a result may perceive the constraints on their abilities to support IENs as more than they were in reality. Theme Two: Finding the “Right Fit” was explored by examining how some of the hiring criteria that Nurse Managers utilized in the hiring process could hinder a IENs ability to find employment. These hiring criteria that Nurse Managers utilized in their selection of IENs were explored and Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 79 compared to other nursing research. In Theme Three: Navigating Differences, the various differences that Nurse Managers perceived regarding the differences between IENs and Canadian educated nurses were compared to nursing literature describing various differences or stereotypes of foreign nurses, and then discussed as they related to their potential to influence a Nurse Managers hiring practice decisions. Chapter Six will describe conclusions, implications and recommendations based upon an understanding of the research findings. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 80 CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS The purpose of this study was to explore the perceptions and experiences that influence the hiring practice decisions of Nurse Managers in long-term care settings who employ IENs who have Canadian RN licensure. Chapter Six will present a summary of the study, final conclusions drawn from findings from the perspectives of the participants, as well as implications and recommendations for nursing education, nursing management, and nursing research. Summary of the Study Seven Nurse Managers from long-term care settings in British Columbia were interviewed with regards to their perceptions and experiences of IENs and how this impacted their hiring practices. Three primary themes emerged from the data: Theme One: Acknowledging the Complexities, Theme Two: Finding the “Right Fit”, and Theme Three: Navigating the Differences. Theme One had two sub-themes: A: Giving everyone a chance, and B: Constraining elements. Theme Two consisted of five sub-themes: A: Possessing the right attitude and values, B: Possessing the right experience, C: Possessing adequate communication skills, D: Determining long-term intentions, and E: Gaining an innate feeling. The Third Theme had three sub-themes: A: Variations in education and clinical practice, B: Country specific variations, and C: Variations in culture. Conclusions The following conclusions were gleaned from this study: 1. Nurse Managers took many elements into consideration when assessing whether to hire IENs. The primary considerations for Nurse Managers in long-term care settings Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 81 were hiring IENs with a positive attitude and similar values that aligned with the organization’s value system of being kind, caring and compassionate, and possessing clear communication skills. They also thought it was important to hire IENs with experience working as an RN, with preference for IENs who had a background working in a long-term setting. As well, combining this background with previous Canadian nursing experience was also an important factor when they made their hiring decisions. Lastly, Nurse Managers were more likely to hire IENs who expressed long-range goals of working in long-term care. 2. Nurse Managers often compared IENs with the newly graduated Canadian Nurses. While many of them were willing to provide the opportunity to hire IEN, the perception of insufficient time and financial resources in their budgets to provide adequate support and mentorship could become a barrier in hiring them. 3. Factors that influenced preferences to hire Canadian educated nurse over IENs included perceived educational differences, concerns about accent and communication, and the difficulty of navigating various cultural differences. Conversely, of those Nurse Managers who preferred to hire IENs over Canadian educated nurses, they generally hired them, not because they were perceived to be better qualified, but rather expected them to be more hardworking than Canadian nurses. In addition, some Nurse Managers preferred to hire IENs if they were overqualified for the position they were seeking. For example, an IEN who was an RN in their home country, may be hired to work as an LPN in Canada, as they were viewed as being better prepared than Canadian educated nurses with the same designation. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 82 4. Nurse Managers generally perceived IENs as being “ready to practice”. They generally perceived IENs to be “at par” or equal in terms of educational level with newly graduated Canadian nurses even if they had several years of prior nursing experience from their home country. Thus, IENs nursing education and previous years of nursing experience from their home countries could go unacknowledged by Nurse Managers in these situations. 5. Nurse Managers often perceived IENs as a homogenous group with similar experiences and competencies especially with relation to country-specific generalizations. Their tendency to evaluate individual IENs in reference to their past experiences with IENs or compare them to IENs from the same country of origin could potentially place IENs at a disadvantage for being hired if they are not assessed as unique individuals, but rather through the past experiences of Nurse Managers. 6. A Nurse Manager’s lack of current knowledge about the RN licensing procedure and registration guidelines for hiring IENs could become a barrier. 7. Nurse Managers did not report using established hiring guidelines when hiring IENs or Canadian Nurses. 8. One final criteria that some Nurse Managers used in assessing whether to hire IENs was their overall “gut feeling” as to whether the IEN was right for the position they were being hired for. Implications and Recommendations The following recommendations are directed at the areas of nursing most relevant to this study: nursing education, nursing management, and nursing research. These recommendations are derived from the study’s findings, but are also supported by current nursing research. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 83 Implications for Nursing Education It is important that Nurse Educators who work with IENs in the various bridging programs in Canada are fully aware of the expectations of employers and Nurse Managers in practice. With this increased understanding, these Nurse Educators would be better equipped to prepare IENs for job interviews and the hiring process. A key factor in better equipping IENs is to increase collaboration between Nurse Educators and other stakeholders who are involved in assisting IENs to find employment and integrate into the workforce. Also, while IENs must meet certain language competency requirements in order to become licensed, there should be a continued focus to enhance conversational English to better equip IENs to interact with Nurse Managers in the hiring process, with colleagues in the workplace, and with healthcare clients. Nurse Educators must tailor language courses and workshops specifically for IENs depending on their level of language competency in order to better equip IENs with English as a Second language with cultural communication skills and profession specific language competencies (Lum, Dowedoff, & Englander, 2016). These recommendations would enhance IENs abilities to communicate confidently in the practice environment, and better equip them to find employment upon graduation from bridging programs. Implications for Nursing Management Nurse Managers can benefit from this study as it will allow them to reflect on their own practice with regards to hiring decision making. Nurse Managers must engage in a reflexive process and analyze their perceptions and experiences with IENs to examine whether their own cultural biases may impact their hiring practice decision making. It would be helpful to know Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 84 what kinds of human resources support Nursing Managers receive when hiring IENs and also whether cultural safety training is offered or required for Nurse Managers which could assist with the hiring process of IENs. In addition, it appears that more communication is required between nursing regulatory bodies and the practice areas, so that Nurse Managers are apprised of the changes in RN licensure requirements for IENs. With more familiarity of the licensure process, this will enable the Nurse Managers to make appropriate and informed hiring decisions regarding IENs. It is also important that Nurse Managers not view IENs as a homogenous group from a specific country, rather to not use stereotypes and generalizations in their assessments of IENs seeking employment. An individualized case-management approach to tailor education and assistance, as suggested by Covell et al. (2017), would be a more practical and effective method to support IENs in their efforts to gain employment. Recommendations for Nursing Research One of the limitations of this study was its small sample size, and the single setting of long-term care. If the study had a larger sample size, it may have increased the variability of the data and provided even more evidence to support the study findings. As well, garnering the perspectives of Nurse Managers from other settings, for example, in acute care, could have provided a broader range of information about their hiring practices of IENs. As there are no formalized criteria that Nurse Managers can use for hiring IENs, or Canadian nurses, this is one area that requires further research. Exploring hiring criteria that Nurse Managers might employ when hiring IENs and Canadian educated nurses may provide more structure to support their final hiring decisions. Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs As stated in the literature review in Chapter Two, there has been an increase in multifaceted collaborative research interventions from Ontario, that focus on engaging stakeholders to assist IENs to find employment and integrate into the nursing workforce (Baumann & Blythe, 2015; Baumann et al., 2017). Research projects such as these recent initiatives in Ontario, are an excellent step forward for providing employment opportunities for IENs in Canada. This research will uncover the continuing challenges IENs face in finding employment, and integrating them into the workforce. This may be achieved through the utilization of job coaching, participating in mock interviews, and building social networks. Chapter Summary This chapter provided a summary of the study and the six conclusions derived from the findings. Some implications for nursing education were discussed in relation to bridging programs, and enhancing IENs communication skills, and preparing them for the interview process. Implications for Nurse Managers were discussed, specifically as related to enhancing reflection over hiring practice decisions, assessing potential bias, and better informing themselves with regards to the regulatory bodies’ registration requirements for IENs. Finally, recommendations for future nursing research areas, specifically in the development of hiring criteria for Nurse Managers when hiring IENs and Canadian RNs was suggested. 85 Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 86 References Armstrong, P. & Armstrong, H. (2008). About Canada: Health care. Blackwood, NS: Fernwood. Allan, H. (2010). Mentoring overseas nurses: Barriers to effective and non-discriminatory mentoring practices. Nursing Ethics, 17(5), 603-613. doi: 10.1177/0969733010368747. Babenko-Mould, Y. & Elliott, J. (2015). 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Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 94 Appendix A: Table Outlining the Literature Search Strategy Date Database searched Key words used “Internationally educated nurse*” OR “foreign nurse*” OR “migrant nurse*” Initial search conducted using CINAHL with OR “overseas trained nurses” OR Nov. “internationally recruited nurse*” OR assistance of academic 2015 librarian to formulate search “immigrant nurse*” strategy AND hiring OR experiences OR perspectives “Internationally educated nurse*” OR “foreign nurse*” OR “migrant nurse*” Biomedical Reference OR “overseas trained nurses” OR Dec. Collection and Medline and “internationally recruited nurse*” OR 2015 Social sciences citation “immigrant nurse*” index AND hiring OR experiences OR perspectives Result 304 results; 27 chosen for further review; 7 selected Biomed:89 results; 12 chosen for further review; 0 selected Medline: 102 results; 9 chosen for further review; 3 selected Social Sciences citation index: 103 results; 0 selected Canadian Health and Jan. Human Resources network Internationally Educated Nurses 2016 (CHHRN) 31 results; 5 selected Repeat search conducted of all above searches to find “Internationally educated nurse*” OR any recent additions to the “foreign nurse*” OR “migrant nurse*” OR “overseas trained nurses” OR Mar. literature 15, “internationally recruited nurse*” OR “immigrant nurse*” 2017 CINAHL, Biomedical AND Reference Collection, Medline and Social sciences hiring OR experiences OR perspectives citation index CINAHL: 321 results; 11 selected Biomed: 99 results; 0 selected Medline: 116 results; 4 selected Social Sciences: 122; 0 selected Mar. 15, CHHRN 2017 38 results; 5 selected Internationally Educated Nurses Running Head: NURSE MANAGER PERSPECTIVES ABOUT IENs 95 “Internationally educated nurse*” OR Repeat search conducted of “foreign nurse*” OR “migrant nurse*” OR “overseas trained nurses” OR June CINAHL, Biomedical “internationally recruited nurse*” OR 23, Reference Collection, 2017 Medline and Social sciences “immigrant nurse*” citation index AND hiring OR experiences OR perspectives CINAHL: 338 results, 12 selected, Biomed: 104 results; 0 selected Medline: 120 results; 4 selected Social Sciences: 127; 0 selected June 23, CHHRN 2017 39 results, 5 selected Internationally Educated Nurses 96 Appendix B: Review Matrix of Selected Articles Author/Title/Journal Year Purpose/ Research Focus Identifying barriers to effective and nondiscriminatory mentoring of overseas-trained nurses working in the UK. Research Method Ethnographic Interpretive Study Sample Relevant Finding/Results Allan, H. (2010). Mentoring overseas nurses: Barriers to effective and non-discriminatory mentoring practices. Nursing Ethics, 17(5), 603-613. 2010 93 IENs & 37 Managers and Mentors of IENs from 6 research sites were interviewed Discusses nurse manager’s lack of awareness of the unique learning needs of IENs. Managers demonstrated a lack of cultural awareness and perceived British nursing education and techniques to be superior to those of other countries. Identifies need for better training for mentors and managers of IENs to allow them to better support IENs. Babenko-Mould, Y. & Elliott, J. (2015). Internationally educated nursing students’ experiences of integration in the hospital setting. Journal of Nursing Education and Practice, 5(9), 100-109. 2015 Explore internationally educated nursing students’ experiences of integration in the acute care hospital setting Qualitative StudyHermeneutic phenomenolo gy 9 international ly educated nursing students involved in a bridging educational program were interviewed Discusses lack of support and discrimination by nurse managers from IEN point of view. Provides suggestions to increase education for nursing staff and administrators so that they better understand the strengths and challenges experienced by IENs and can better address racism and discrimination in the workplace. Baumann, A. & Blythe, J. (2009). Integrating internationally educated health care professionals into the Ontario workforce (pp.166). Hamilton, ON: Nursing Health Services Research Unit, McMaster University. 2009 Provide background information to support development of best practice guidelines to support integration of internationally educated health professionals into the workplace. Discussion Paper based on Literature review and interviews with stakeholders from government, education and health care organizations N/A IENs face challenges due to uniformed employers, bias in hiring practices, and their potential need for extended orientation. Many employers are more likely to hire Canadian educated nurses as they require less orientation and support. Baumann, A. & Blythe, J. (2015). Internationally educated nurse and English as a second language nurse integration project 20122015. Hamilton, ON: Nursing Health Services Research Unit. 2015 Project designed to ensure RNs and RPNs educated in Canada or abroad are fully integrated into the workforce in Ontario Multifaceted collaborative research intervention involving multiple employers and stakeholders designed to assist IENs to find employment IENs and ESL Canadian nursing graduates from Ontario IENs through participation in the various initiatives of the project (online webinars, workshops, job coaching/mock interviews, learning plans, networking programs etc.) were able to obtain employment over the course of the project. Evaluation by the NURSE MANAGER PERCEPTIONS OF IENS 97 and integrate into the nursing workforce IENs of the initiatives was overall very positive as they attributed success in securing employment to project participation. Baumann, A., Blythe, J., IdrissWheeler, D., Fung, M., & Grabham, A. (2013). A framework for integrating internationally educated nurses into the healthcare workforce (pp.1-80). Hamilton, ON: Nursing Health Services Research Unit. 2013 To create, implement, and evaluate a webbased practice guide to support employers to hire and integrate IENs into their workplace Knowledge Translation Project Report N/A Developed products (quick reference flipbook, employer workshops, and website) to provide employers and stakeholders with successful strategies to recruit, retain and integrate IENs into their workforce. Practice examples are used to facilitate IEN mentorship and orientation Baumann, A., Ross, D., IdrissWheeler, D., & Crea-Arsenio, M. (2017). Strategic practices for hiring integrating and retaining internationally educated nurses: Employment manual (pp. 1-84). Hamilton, ON: McMaster University Nursing Health Services Research Unit. 2017 Knowledge Translation Project Report 9 healthcare organization s Employer manual “to provide nursing and human resources healthcare leaders with evidence-informed strategic practices to facilitate the hiring, integration and retention of internationally educated nurses (IENs).” Case studies of organizations successfully integrating IENs are provided Blythe, J., Baumann, A., Rheaume, A., & McIntosh, K. (2006). Internationally educated nurses in Ontario: Maximizing the brain gain. Hamilton, ON: Nursing Health Services Research Unit. Retrieved December 17, 2015, from http://nhsru.com/publications/inter nationally-educated-nurses-inontario-maximizing-thebrain-gain/ 2006 To increase employer awareness of the value that internationally educated nurses bring to the workplace and the importance of a diverse workforce to care for Canada’s ethnically diverse patient population. To describe and analyze issues relevant to nurse migration to Ontario an investigate the experiences of IENs, including barriers and facilitators to integration in the Ontario health care system Qualitative Study 32 participants representing education, employers, government, the regulatory body, nurse associations and community support groups involved in interviews and focus groups Employers have varying perceptions of IENs but they agree that it is difficult to compare their skills and experience relative to Canadian nurses. Employers need to create orientation and mentoring programs for IENs comparable to those for new graduates Blythe, J., Baumann, A., Rheaume, A., & McIntosh, K. (2009). Nurse migration to Canada: Pathways and pitfalls of workplace integration. Journal of Transcultural Nursing, 20(2), 202-210. 2009 Explores factors that contribute to the success and failure of IENs to reestablish professional careers in Ontario Qualitative study IENs and 29 participants from institutions meeting IEN needs (ie. Educators, employers and IENs identified communication as the greatest barrier to workplace integration. Unfamiliarity with the Canadian health care NURSE MANAGER PERCEPTIONS OF IENS Canadian Health Human Resources Network. (2013). Internationally educated health care professionals. Ottawa, ON: Author. 2013 Covell, C.L., Neiterman, E., & Bourgeault, I.L.(2014). A scoping review of the literature on internationally educated nurses in Canada: Mapping a research agenda. CJNR, 46(3), 26-45. 2014 Covell, C.L., Neiterman, E., & Bourgeault, I.L. (2016). Scoping review about the professional integration of internationally educated health professionals. Human Resources for Health, (14), 38, 1-12. Covell, C.L., Primeau, M., Kilpatrick, K., & St-Pierre, I. (2017). Internationally educated nurses in Canada: Predictors of workforce integration. Human Resources for Health, 15(26), 1-16. 98 Educators, managers, professional bodies, support groups, etc.) system is another barrier to obtaining employment and integrating into the workplace. An adequate orientation is crucial to success in a job. N/A Identify the “employers perspective” as being an area that needs more research Health Canada report of recruitment, credential recognition, and integration of Internationally Educated Health Care Professionals Identify key themes in Canadian literature on the integration of IENs, identify research gaps and make recommendations for future research Discussion Paper Literature Review 157 papers (academic and grey literature) from the period of 2000-2013 Employers fail to hire IENs for 2 reasons: 1) they believe IENs lack nursing knowledge, expertise or language skills necessary for safe practice; 2) They lack the financial or human resources required to provide the education and mentoring required by IENs to successfully integrate into a workplace. Identifies research gap and need for an exploration of hiring practices from an employer’s perspective. 2016 To synthesize literature about the professional integration process for IEHP Literature Review 407 published sources (academic studies and grey literature) 2017 To describe the demographic and human capital profile of IENs in Canada and identify predictors of IENs’ workforce integration Crosssectional descriptive, correlational survey design 2280 IENs from all of Canada’s provincial jurisdictions Employers view IEHPs as both beneficial (enhancing cultural competency and sensitivity in care provision) and unfavorable (uncertain if IEHPs have the appropriate knowledge and skills). Employers play a critical role in IEHP professional integration, but gap identified with regards to employer hiring decisions Employers reported that IENs must have the required knowledge, competencies, experience and language skills for safe practice in order to be hired. The most significant factors that determine whether an IEN secures a job are NURSE MANAGER PERCEPTIONS OF IENS 99 Hawkins, M. & Rodney, P. (2015). A precarious journey: Nurses from the Philippines seeking RN licensure and employment in Canada. CJNR, 47(4), 97-112. 2015 To examine the structures and processes that pose challenges for IENs from the Philippines as they seek Canadian RN licensure Ethnographic Qualitative research design 47 IENs from the Philippines who had sought or were seeking Canadian RN licensure Hoxby, H., Fortier, V., Brown, N., Yardy, G., & Blythe, J. (2010). Internationally educated nurses: Building capacity for clinical/nurse managers. Nursing Leadership, 23(Spec No 2010), 132-133. 2010 Project designed to provide nurse managers with tools to increase knowledge about hiring and retainment of IENs Demonstratio n project 33 nurse managers completed a questionnair e to assess knowledge and 17 participated in focus groups to evaluate what information was needed for tools and workshops Jeans, M.E., Hadley, F., Green, J., & Da Prat, C. (2005). Navigating to become a nurse in Canada: Assessment of international nurse applicants- Final Report. Ottawa, ON: Canadian Nurses Association. 2005 To understand the experiences and challenges related to employing and integrating IENs Qualitative Study 19 employers completed surveys, and 23 participants (managers, recruiters and educators) participated in focus groups 1) Participation in a bridging program and 2) having a social network that assists them to find employment. Even after obtaining Canadian RN licensure, employers are reluctant to hire IENs unless they have Canadian RN education or work experience. IENs in BC would benefit from support programs similar to those available in Ontario (ie. CARE). IENs would also benefit from transition programs similar to those offered to Canadian educated nurses. In order to better integrate IENs into the workplace, clinical educators, mentors and all nurses need to be involved in interventions to assist IENs. More collaborative networks are needed to facilitate knowledge exchange between nurse managers, educators, and others that assist IENs with their integration into the Canadian health care system Hiring of IENs is strongly influenced by language and communication ability. Employers were critical of the process surrounding IEN licensure and registration; they felt that IENs from nonEnglish/French speaking countries should be required to participate in a bridging program. Employers felt that nurses from non-English or French speaking countries were less competent than their Canadian counterparts. Employers lacked funds to adequately orientate IENs. NURSE MANAGER PERCEPTIONS OF IENS 100 Likupe, G. (2015). Experiences of African nurses and the perception of their managers in the NHS. Journal of Nursing Management 23(2), 231-241. 2015 Experiences of racism, discrimination, and equal opportunity among black African nurses and their managers’ perspectives on these issues Qualitative Research Study 30 Black IENs from Africa and 10 Nurse Managers Lum, L., Dowedoff, P., & Englander, K. (2016). Internationally educated nurses’ reflections on nursing communication in Canada. International Nursing Review, 63(3), 344-351. 2016 IEN perceptions of Nursing communication skill requirements in Canada Qualitative Grounded Theory Study 22 IENs in a bridging program in Ontario Moyce, S., Lash, R., & de Leon Siantz, M. (2016). Migration experiences of foreign educated nurses: A systematic review of the literature. Journal of Transcultural Nursing, 27(2), 181-188. 2016 Migration experiences of foreign educated nurses Literature Review 44 research studies either primary research studies or secondary data analysis Newton, S., Pillay, J., & Higginbottom, G. (2012). The migration and transitioning experiences of internationally educated nurses: a global perspective. Journal of Nursing Management,20, 534-550. 2012 The migration and transitioning experiences of IENs Literature Review 21 research studies (qualitative and quantitative) Nurse Managers voiced many stereotypes of Black African Nurses and made comparisons between them and IENs from other countries. Managers saw these nurses as less motivated than their peers and thus showed preferences to other nurses (usually white) with less seniority for promotions and mentoring. They also supervised these nurses more than any other group and encouraged other nurses to do the same. Nurse Managers need to be more aware and acknowledge racism and actively work to create an environment conducive to equitable treatment. More attention needs to be directed towards providing quality information to IENs about Nurse Manager expectations. A lack of language proficiency can be a serious impediment to an IENs chances of finding employment in Canada. Foreign educated nurses (FENs) are often perceived as being “slow” which leads to difficulties finding employment and decreased opportunities for promotion. FENs often experiences racial discrimination from supervisors and are often mistrusted from host country nurses. They often face increased supervision and scrutiny from peers and managers. Nurse managers often do not recognize or value the skills and experiences of IENs and as a result are often passed over for career advancement opportunities. IENs feel ignored by managers and feel they are passed over for promotion even when NURSE MANAGER PERCEPTIONS OF IENS 101 Njie-Mokonya, N. (2014). Exploring the integration experiences of Internationally Educated Nurses (IENs) within the Canadian health care system (Unpublished Masters of Science in Nursing Thesis). University of Ottawa, ON, Canada 2014 To explore the integration experiences of IENs into Canadian work settings Qualitative descriptive phenomenolo gy 11 IENs in Ontario Pendleton, J. (2016). The experience of black and minority ethnic nurses working in the UK. British Journal of Nursing 26 (1), 37-42. 2016 The experiences of black and minority ethnic nurses in the UK in order to explain why inequalities exist in the NHS Literature Review 10 primary qualitative research studies from the UK Prendergast, N. (2014). Multiculturalism policies: Identifying the dialectic of the “ideal type” within the practices of Canadian nursing (Unpublished Doctoral Dissertation). University of Toronto, ON, Canada. 2014 The “ideal type” of nurse in Canada- why IENs of colour occupy menial nursing positions and primarily white nurses rise to positions of leadership Doctoral DissertationQualitative study 10 IENs of colour in Ontario their qualifications are equal to or superior than their counterparts. Supportive nurse managers are key to easing the transition of IENs and creating positive work environments. Nurse Managers often do not fully value or recognize IENs clinical expertise and contributions to nursing. Support networks are a crucial part of integrating IENs into the Canadian health-care workforce Nurse Managers viewed the employment of black and minority ethnic nurses as a necessity rather than an opportunity. This led to lack of respect for these nurses from their colleagues. These nurses often end up working in care home settings at the lowest level of entry into the NHS as their skills from overseas are not recognized. Promotions, coaching and support is often given to white colleagues with less experience and seniority. Racism comes from Nurse managers, but also from other minority ethnicities. An ethnic hierarchy exists with black nurses at the bottom. Employers require more cultural sensitivity training. Nurse managers often choose white nurses to mentor and groom for leadership positions and fail to do the same for IENs of colour. Also IENs with education and experience that is equal to or superior to their white Canadian counterparts are still passed over for leadership positions which are given to less experienced and less qualified white nurses. NURSE MANAGER PERCEPTIONS OF IENS 102 Primeau, M., Champagne, F., & Lavoie-Tremblay, M. (2014). Foreign-trained nurses’ experiences and socioprofessional integration best practices. The Health Care Manager, 33(3), 245-253. 2014 The retention or integration of IENs Literature Review 54 peerreviewed journals, reports, and PhD and master’s thesis Decision makers and nurse managers lack information on how to more effectively integrate IENs into the workforce. Even after receiving their nursing credentials, IENs nursing education and experience is not recognized or valued which limits employment opportunities. Pung, L. & Goh, Y. (2017). Challenges faced by international nurses when migrating: An integrative literature review. International Nursing Review, 64(1), 146-165. 2017 Challenges faced by IENs in their host countries following migration Literature Review 24 primary research studies (qualitative, quantitative, and mixed methods) Ramji, Z. & Etowa, J. (2014). Current perspectives on integration of internationally educated nurses into the healthcare workforce. Humanities and Social Sciences Review, 03(03), 225-233. 2014 Workplace integration for IENs within healthcare Literature Review Grey literature, reports and documents IENs often feel mistrusted by their Nursing Managers and feel that they must prove themselves before their skills are recognized. They are also more closely scrutinized than their co-workers especially when communication barriers are present. Both IENs and their employers must be responsible for integration of IENs into the workforce. Significant need for changes in attitudes, beliefs and behaviours of employer organizations and non- IENs in order to provide a better experience for all involved in the integration process of IENs Salma, J., Hegadoren, K.M., & Ogilvie, L. (2012). Career advancement and educational opportunities: Experiences and perceptions of internationally educated nurses. Nursing Leadership, 25(3), 56-69. 2012 Perceptions of IENs regarding career advancement and educational opportunities in Alberta Qualitative Research Study 11 IENs in Alberta Connections and networking are essential if IENs hope to advance in the workplace. However, IENs still note that their white Canadian peers are more likely to be groomed for leadership positions and promoted to leadership or management roles. IENs noted that who you know is more important than skills, education, and experience when it comes to career advancement and promotion. NURSE MANAGER PERCEPTIONS OF IENS 103 Sherman, R.O. & Eggenberger, T. (2008). Transitioning internationally recruited nurses into clinical settings. The Journal of Continuing Education in Nursing, 39(12), 535-544. 2008 Assessing the transitioning experiences and needs from the perspective of both IENs and nurse managers of IENs Qualitative study 21 IENs and 10 nurse managers that supervise IENs Nurse managers felt that IENs needed a longer orientation period specific to the needs of IENs. They felt that education for managers on how to better coach and support IENs would be beneficial. They were very positive about their experiences with IENs and felt that IENs were hard working, eager to learn and presented less disciplinary issues. Tuttas, C. (2015). Perceived racial and ethnic prejudice and discrimination experiences of minority migrant nurses: A literature Review. Journal of Transcultural Nursing, 26 (5), 514520. 2015 Experiences of perceived prejudice and discrimination as described by minority migrant nurses (MMNs) Literature Review 20 research studies Xiao, L.D., Willis, E., & Jeffers, L. (2014). Factors affecting the integration of immigrant nurses into the nursing workforce: A double hermeneutic study. International Journal of Nursing Studies, 51, 640-653. 2014 Nurse perceptions of factors that inhibit or aid workplace integration Qualitative study 24 IENs and 20 senior nurses in Australia MMNs often face racial and ethnic prejudice and discrimination from managers and colleagues which hinders integration into the nursing workforce. Their skills are devalued, they feel untrusted by managers and they are often passed over for promotions. Language barriers including colloquialisms and cultural expressions contribute to poor outcomes for MMNs in interviews for jobs or promotions. Senior nurses found that they were able aid integration of IENs by hosting seminars where IENs shared their stories with host nurses. This facilitated better interpersonal relationships between staff on wards and shows the importance of cultural competency education for both IENs and host nurses. NURSE MANAGER PERCEPTIONS OF IENS 104 Appendix C: Recruitment Letter of Introduction for Potential Study Participants Letter of Introduction Research Title: Nurse Manager Perspectives about Internationally Educated Nurses (IENs) and Hiring Practices in Long-term Care Hello, My name is Katrina Haynes and I am a Masters of Science in Nursing student at Trinity Western University. I am the Principal Investigator for a research study, and I am interested in exploring the perceptions and experiences that influence the hiring practice decisions of Nursing Managers who employ Internationally Educated Nurses (IENs) who have Canadian RN licensure in long-term care setting. I am looking for nurse managers who would like to be part of this study. If you volunteer in this study, you will be asked to share your experiences in a one-onone interview with the Principal Investigator. The interviews will be approximately 45 minutes in length and will take place at a mutually agreed upon time and place. The interviews will be audio recorded and field notes will be written. All information collected is confidential and each person’s identity will be kept anonymous. This research may benefit Nurse Managers of the long-term care settings who hire IENs, which may inform them about the potential barriers IENs may face as they are seeking employment. In addition the findings may be of benefit to educators, immigrant serving organizations, nursing unions and others that work with IENs to help make them employable. If you are interested in participating, you can contact me by email at or by telephone. NURSE MANAGER PERCEPTIONS OF IENS 105 Appendix D: Demographic Table of Study Participants Participants Years Years in Years as Educational Background Sex as Long-term Nurse Nurse Care Manager 01 25 20 15 Diploma RN, BSN F 02 32 16 12 Diploma RN F 03 36. 5 20 6 Diploma RN F 04 24 24 6 BN F 05 25 13 17 BSN, Masters of Public M Management 06 38 35 18 LPN, RN, BSN F 07 36 30 12 LPN, Masters in Healthcare F Leadership NURSE MANAGER PERCEPTIONS OF IENS 106 Appendix E: Demographic Information / Interview Guide Demographic Information 1. How many years have you been working as a Nurse? 2. What is your educational background? 3. How many years have you worked in Long-term Care? 4. How many years have you worked as a Nurse Manager in charge of hiring? Interview Guide 1. Tell me about your experiences of working with Internationally Educated Nurses (IENs)? Prompt: Can you think of any specific experiences you have had, positive or negative? Tell me about a positive experience. Tell me about a negative experience. 2. What are your perceptions about Internationally Educated Nurses (IENs) readiness to practice in the clinical area? Prompt: If the participant provides an example- Tell me a bit more about that experience. Can you give me a bit more detail about that? What would be an indicator an IEN is ready to practice? What would be an indicator that an IEN is NOT ready to practice? 3. Tell me how you would compare the Internationally Educated Nurses (IENs) performance and readiness to practice in comparison with nurses educated in Canada? Prompt: Tell me how you perceive an IENs readiness to practice depending upon the country where the IEN came from? 4. What is the decision-making process that you go through when you hire IENs? NURSE MANAGER PERCEPTIONS OF IENS Prompt: Tell me about a favorable or positive experience hiring an IEN. Tell me about an experience of hiring an IEN that may have been challenging. 5. When you hire IENs, tell me about the various elements or criteria that you consider that assist you with making the decision to hire an IEN? Prompt: for example, country of origin, education level, years of experience, language ability/fluency. 6. When you have a Canadian Nurse and an IEN with similar credentials – tell me about your experiences with hiring these nurses. Prompt: What influences you to hire one nurse over the other? What kind of references do you require? 7. Is there anything else that you would like to share with me regarding either hiring Internationally Educated Nurses (IENs) or anything else about your experiences working with IENs? 107 NURSE MANAGER PERCEPTIONS OF IENS 108 Appendix F: Research Ethics Board Consent Form Nurse Manager Perspectives about Internationally Educated Nurses (IENs) and Hiring Practices in Long Term Care Principal Investigator: Katrina Haynes, Graduate student, Masters of Science in Nursing, Trinity Western University. Supervisor: Dr. Barbara Astle, Associate Professor, School of Nursing, Trinity Western University. This research is part of a Capstone Project submitted in partial fulfillment of the requirements for the degree of Masters of Science in Nursing at Trinity Western University. Purpose: The purpose of the study is to explore the perceptions and experiences that influence the hiring practice decisions of Nurse Managers who employ Internationally Educated Nurses (IENs) who have Canadian RN licensure in long term care settings. You are being asked to participate because of your experience as a nurse manager that participates in the hiring process at your place of work. Research Questions: 1. What perceptions do Nurse Managers have about Internationally Educated Nurses (IENs) performance and readiness to practice as a nurse? 2. How does a Nurse Manager perceive Internationally Educated Nurses (IENs) performance and readiness to practice in comparison to nurses educated in Canada? 3. How do Nurse Managers perceptions and experiences of Internationally Educated Nurses (IENs) influence hiring practice decisions? 4. What elements do Nurse Managers take in consideration when deciding to hire Internationally Educated Nurses (IENs)? Procedures: If you agree to participate, you will be interviewed for 30-60 minutes by the Principal Investigator at a mutually agreed upon time and location. The interview will be audiorecorded. After the interview there will be a short debriefing session. You will receive a copy of the consent form to take home. A summary of the research findings will be made available to the participants by contacting the Principal Investigator. Potential Risks and Discomforts: No risks or discomforts are anticipated. If you feel at any point you need to withdraw from the study, please know you can do so with no negative consequences. NURSE MANAGER PERCEPTIONS OF IENS 109 Potential Benefits to Participants and/or to Society: Nurses often benefit from the reflexive activity of talking with another nurse about their professional practice decisions. This may help you in your future hiring practices with IENs who are seeking employment. There is no direct benefit, physical or monetary from participation in this study. Confidentiality: Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission or as required by law. Research materials will be identified by a participant number and kept in a secure digital file stored on a password-protected computer. A key code (linking participant names to participant numbers) will be stored in a separate secured electronic file, apart from the data. All hard copy documents will be stored in a locked filing cabinet. Research participants will not be identified by names in any reports of the completed projects. Data recordings and transcripts will be kept for five years after the project is completed in a password protected electronic file. After this time period, they will be destroyed. Hardcopies will be shredded after the completion of the project. Remuneration: A $5. 00 coffee card will be provided as a “thank you” for participating in the study, and you will receive it after the interview is completed. If you withdraw from the study at a later stage, you may keep the coffee card. Contact for information about the study: If you have any questions or desire further information with respect to this study you may contact Katrina Haynes (Principal Investigator). Contact for concerns about the rights of research subjects: If you have any concerns about your treatment or rights as a research participant, you may contact Ms. Sue Funk in the Office of Research, Trinity Western University. Consent: Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time without any negative outcomes to you, related to your work or this study. If you decide to withdraw from the study at any time, please let the Principal Investigator know of your decision not to continue and your answers and information will be removed from the study and destroyed. Any written material will be shredded and the recorded data collected will be destroyed. No information that you have given will be included in the study. Signatures: Your signature below indicates that you have had your questions about the study answered to your satisfaction and have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study and that your responses may be put in anonymous form and kept for further use after the completion of this study. NURSE MANAGER PERCEPTIONS OF IENS __________________________ Research Participant Signature __________________________ Printed Name of the Research Participant 110 ___________________________ Date NURSE MANAGER PERCEPTIONS OF IENS 111 Appendix G: Debriefing Script Nurse Manager Perspectives about Internationally Educated Nurses (IENs) and Hiring Practices in Long-term Care Principal Investigator: Katrina Haynes, Thesis, Masters of Nursing Student, School of Nursing, Graduate Program, Trinity Western University. This research is part of a Thesis Capstone Project for the Master of Science in Nursing Degree. Thank you so much for your participation in this study. Is there anything you would like to say about what it was like to participate in this interview? What do you think you gained from this experience? Your participation is very important to this study to help us understand how perceptions and experiences influence the hiring practice decisions of nurse managers who employ Internationally Educated Nurses (IENs) who are Registered Nurses (RNs) in long-term care settings. Do you have any questions? Thank you again for your time. I would like to present you with a small token of my appreciation for your participation. NURSE MANAGER PERCEPTIONS OF IENS 112 Appendix H: Code Book 1. Providing Opportunity a. Giving everyone a chance b. Providing them with workplace support c. Assessing nurses as individuals (Valuing other aspects over educational background) d. Needing Nurses (and not having the luxury of selecting them based on more detailed criteria) 2. “The Right Fit” (Reasons to Hire) a. Possessing Desired Criteria i. Possessing confidence ii. Possessing relevant experience iii. Possessing critical thinking skills iv. Possessing language skills and clear communication v. Possessing adequate nursing knowledge for LTC clients vi. Possessing knowledge of the healthcare environment (system and tech) vii. Possessing leadership abilities to manage other staff viii. Possessing the right attitude and values ix. Possessing self-motivation/determination x. Possessing commitment to life-long learning xi. Possessing a willingness to be flexible in their work schedule xii. Possessing Canadian work experience (can be outside nursing)/references xiii. Possessing nursing regulatory body licensure NURSE MANAGER PERCEPTIONS OF IENS b. Receiving that “feeling” for the individual c. Acquiring diversity in the workplace i. Possessing a second language ii. Possessing another religious background iii. Possessing generational differences d. Possessing qualifications above what is required for the position (underemployment) 3. “Not the right fit” (Reasons not to hire) a. Unable to provide workplace support (ex. Don’t have the time, funding, or manpower required) b. Seeing Long-Term Care as a stepping stone i. Determining long-term intentions ii. Unsure of level of commitment c. Lacking communication skills i. Lacking adequate language skills ii. Lacking cultural awareness in communication d. Lacking relevant experience e. Variation in educational level and practice i. Variation in clinical skill level ii. Lacking critical thinking skills iii. Variation in abilities – country specific iv. Variation in cultural practices/beliefs f. Lacking leadership ability 113 NURSE MANAGER PERCEPTIONS OF IENS i. Demonstrating nervousness ii. Lacking confidence 114 NURSE MANAGER PERCEPTIONS OF IENS Appendix I: TWU Research Ethics Board Approval 115