Introduction

[Type text]

University of Alberta

Career Advancement and Education Opportunities: Experiences and Perceptions of Internationally-Educated Nurses

by

Jordana Salma

A thesis submitted to the Faculty of Graduate Studies and Research

in partial fulfillment of the requirements for the degree of

Master of Nursing

Faculty of Nursing

©Jordana Salma

Fall 2009

Edmonton, Alberta

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Examining Committee

Kathy Hegadoren, Faculty of Nursing

Anne Sales, Faculty of Nursing

Linda Ogilvie, Faculty of Nursing

Kathryn Dong, Faculty of Medicine, University of Alberta

DEDICATION

This thesis is dedicated to the strong women in my life: My mother Linda and Grandmother Souhaila. This humble achievement and all others I owe to you….

ABSTRACT

The recruitment of internationally-educated nurses (IENs) is increasing in Canada, as a strategy to remedy nursing shortages. Effective recruitment and retention are needed, if this strategy is to be deemed a success. One of the criteria for successful retention is the availability and accessibility of career advancement and education opportunities. Little research exists on the opportunities for career advancement and education for IENs in Canada. This interpretive descriptive study was conducted to look at the perceptions of IENs regarding education and career advancement opportunities in Alberta, Canada. Eleven IENs were interviewed using semi-structured interviews. Eight themes were identified: motherhood as a priority, communication challenges, learning a new culture, the process of skill recognition, perceptions of opportunity, personal responsibility for success, personal definition of advancement, and need for mentorship.

ACKNOWLEDGEMENT

I would like to thank the following individuals who have supported me in this process and contributed to the preparation of this thesis:

Dr. Kathy Hegadoren I am deeply grateful for your guidance and support as my faculty advisor and thesis supervisor. Over the past three years you showed me that research can be fun, rewarding, and compassionate. Your enthusiasm and commitment has truly been an inspiration throughout my studies!

To the members of my thesis committee, Dr. Anne Sales, Dr. Linda Ogilvie, and Dr. Kathy Dong thank you for your support and guidance along this journey.

To my husband Abed thank you darling for always keeping a smile on my face and encouraging me to give my best.

I would like to thank all the participants in this study for sharing their stories with me. Your strength in the face of adversity and commitment to the nursing profession touched me deeply.

Finally, a special thanks to my father, aunt Nancy and Dwayne, my lovely sister Jinan, my bro Hamoudi, and my friends in Lebanon.

Alhamdoulillah (Thank you God) for this blessing!

TABLE OF CONTENTS

Chapter 1

1.0 Introduction p.1

1.1 Purpose of the Study p.3

1.2 Research Question p.5

1.3 Significance of the Study p.6

1.4 Definition of Terms p.9

Chapter 2

2.0 Literature Review p.11

2.0.1 Strangers in a Foreign Land p.11

2.0.2 Getting Ahead in a Land of Opportunity p.14

2.0.3 Fitting the Jigsaw Puzzle Together p.18

2.0.4 Tying it together: Opportunity, Satisfaction, and Retention p.25

Chapter 3

3.0 Methodology p.29

3.1 Research Methodology p.29

3.1.1 Sample p.30

3.2.1 Setting p.33

3.2 Data Collection p.34

3.3 Data Analysis p.39

3.4 Rigor p.41

3.5 Ethical Considerations p.46

Chapter 4

4.0 Findings p.49

4.0.1 Participant Demographics and Characteristics p.49

4.0.2 Motherhood as a Priority p.51

4.0.3 Communication Challenges p.57

4.0.4 Learning a New Culture p.58

4.0.5 The Process of Skill Recognition p.61

4.0.6 Perceptions of Opportunity p.64

4.0.7 The Emphasis on Personal Responsibility p.70

4.0.8 A Personal Definition of Advancement p.72

4.0.9 A Need for Mentorship p.74

4.0.10 Summary of Findings p.78

Chapter 5

5.0 Discussion p.80

5.0.1 The Case of the Immigrant Working Mother p.80

5.0.2 The Role of Communication and Culture p.84

5.0.3 Recognition as an Immigrant, a Minority, and a Woman p.87

5.0.4 Strategies for Success in the face of Adversity p.89

5.0.5 Mentorship as a Tool for Career Development p.91

5.0.6 Looking through the Lens of the Social-Identity Theory p.93

Chapter 6

6.0 Study Summary and Conclusions p.96

6.0.1 Study Strengths and Limitations p.96

6.0.2 Implications for Nursing Leaders and Relative Stakeholders p.98

6.0.3 Recommendations for Future Research p.99

6.0.4 Conclusion: An Eye to the Future p.100

References p.102

Appendices p.118

APPENDIX A: Participant Questionnaire

APPENDIX B: Recruitment Poster

APPENDIX C: Information Letter and Consent Form

Chapter 1

Introduction

The nursing shortage constitutes a global crisis in today’s world. Future predictions paint a bleak picture of increasing needs and a diminishing nursing workforce (Baumann, Blythe, Kolotylo, & Underwood, 2004a; Kingma, 2007). As a result of disproportionate supply and demand coupled with increasing liberation of the global labor market, nurse migration emerges as an important phenomenon of the 21st century. This phenomenon of nurse migration, though not a novelty, has increased significantly over the last decades (Buchan, Kingma, & Lorenzo, 2005). The migration of nurses occurs mainly from poor or developing nations to the wealthy or developed (Kline, 2003). However, nurse migration is not confined to this unilateral process, but is multidirectional to include migration from one developed or developing country to another (Kline). Countries that have been known to export their nurses, seeing them as a worthy commodity for the economy, are now themselves in danger of being depleted of their workforce. The Philippines, for example, reports that 59% of Philippine nurse turnover is due to overseas migration (Perrin, Hagopian, Sales, & Huang, 2007). Other countries are now just starting to see the exportation of nurses as a supplement to their economies. India and China are expected to be, in the near future, the two largest exporters of nurses for the global nursing market (Thomas, 2006). In contrast, countries such as those in Sub-Sahara Africa have pleaded with the international community to halt nursing recruitment processes, which deplete their healthcare systems (Buchan & Sochalski, 2004). While developed countries are increasingly motivated to address the ethical dimensions of nurse migration, they are weakened in this pursuit by the need to recruit internationally as a result of ongoing shortages (Kline).

The phenomenon of nurse migration has spurred a growing body of literature concerned with a diversity of issues. A few of the most scrutinized areas of study include the ethics of nurse migration, the transcultural and multicultural dimensions of nursing, the standards of global nursing education and practice, and the working conditions of migrating nurses. With increasing attention directed to these issues, one questions Canada’s position in respect to nursing shortages and nurse migration. Canada is suffering from a nursing shortage, which threatens to continue growing in the future. According to a 2002 study by the Canadian Nurses Association [CNA], Canada will experience a shortage of 78,000 registered nurses [RNs] by 2011 and 113,000 RNs by 2016 (CNA, 2002). A report by the International Council of Nurses states that Canada will need at least 10,000 nursing graduates each year through 2011 to meet future needs, but is currently graduating only half that number (Trossman, 2002). Canada is, also, both a source and a destination for nurse migration with a net loss of nurses (Little, 2007).

Solutions proposed to this ongoing nursing shortage in Canada are a highly debated topic. Two main strategies to increase the Canadian nursing workforce are being implemented by government and related stakeholders. The first of these strategies is to increase the domestic production of nurses in order to achieve a self-sustaining human resource pool (Little, 2007). The second strategy, increasingly suggested by policy makers and stakeholders, is the recruitment of internationally-educated nurses [IENs] (Baumann, Blythe, Kolotylo, & Underwood, 2004b; Little, 2007). As defined by the Canadian Institute for Health Research [CIHI], IENs are nurses who graduated from a nursing school outside Canada, whether or not they are Canadian citizens (CIHI, 2006a). Since the year 2000, the percentage of foreign graduates in the Canadian RN workforce has remained between 6 and 8 percent, although their overall numbers have gradually increased (CIHI, 2006a). The top seven countries of graduation for IENs currently working in Canada are the Philippines, the United Kingdom [UK], the United States of America [USA], India, Poland, Australia, and Hong Kong (CIHI, 2006a). Almost half of all current IENs are graduates from either the UK or the Philippines (CIHI, 2006a). Future trends point to India as a major supplier of IENs, since India has become the largest source for international applicants writing the Canadian Registered Nurse Exam [CRNE] (Little).

Purpose of the Study

The presence of IENs in Alberta is predicted to increase significantly in the future. In Alberta 4.4% of RNs, 1.8% of licensed practical nurses [LPNs], and 8.5% of Registered Psychiatric Nurses are IENs (CIHI, 2006b). The Alberta Government allocated 30 million dollars to implement a plan that would increase the recruitment of IENs to the province (Government of Alberta, 2007). During the last six months of 2007 the Canadian Association for Registered Nurses of Alberta [CARNA] witnessed a four-fold increase of IEN applicants to approximately 150-200 per month (Government of Alberta). Capital Health, now part of Alberta Health Services [AHS], offered 900 positions to nurses from the UK and the Philippines (The Calgary Herald, 2008). Capital Health had also developed a plan to recruit from New Zealand and Australia, with an aim of filling 400 nursing positions by December 2008 (Edmonton Journal, 2008). However, with the recent global economic downturn this plan has been put on hold. Since this study was first developed, significant changes have occurred in Alberta health-care. Alberta’s nine Regional Health Authorities, Alberta Alcohol and Drug Abuse Commission, Alberta Cancer Board and Alberta Mental Health Board have merged to form the largest healthcare provider in Canada, AHS. The mission of the AHS is to provide patient-centered care that is accessible to all Albertans but, most importantly, economically sustainable (Alberta Health and Wellness, 2008). The AHS has currently put into effect a hiring freeze which places the province at greater risk for nurse attrition (United Nurses of Alberta, 2009). If the AHS is truly committed to quality and accessibility in healthcare, then the nursing shortage must be put at the forefront of its concerns. Looking to the future, successful nurse recruitment and retention is crucial for the high standards of quality and accessibility outlined in the AHS mandate. In the short-term, it is not clear where the AHS is going with its policies to curtail the province’s health care budget. Yet, evidence continues to suggest that IENs will play an integral role in the future Canadian healthcare system. This fact warrants an in-depth analysis and understanding of the issues surrounding this portion of the nursing workforce.

This study sheds light on a specific area of concern to IENs. The study addressed the issue of career advancement and education opportunities in the IEN population working in urban Alberta hospitals. Evidence in the literature suggests IENs face many barriers with regards to career advancement and education opportunities (Hawthorne, 2001; Xu, 2007b). These barriers decrease nurses’ job satisfaction and, thus, conflict with the principles of fair and ethical nurse recruitment (Aiken et al., 2001; Lundh, 1999; Lu, While, & Barriball, 2004; Nolan, Nolan, & Grant, 1995; Price, 2002). Also, decreased satisfaction with career advancement and education opportunities is linked to high turnover, which impacts negatively the employer healthcare institutions (Andrews & Dziegielewski, 2005; Blegen, 1993; Irvine & Evans, 1995). This study used a non-categorical qualitative methodology to understand the experiences of IENs working in urban Alberta hospitals regarding career advancement and education opportunities. The overall aims of the study were two-fold: (a) to encourage ethical IEN employment by understanding their needs, and (b) to maintain successful IEN recruitment by understanding factors which increase retention.

Research Question

This study investigated IENs’ experiences and perceptions about education and career advancement opportunities in a sample of Canadian hospitals and long-term care institutions in Alberta. The study focused on IENs’ perceptions with regard to availability of advancement opportunities, barriers present if any, and potential strategies for career enhancement. Mentorship was looked at as a possible strategy for increasing IENs’ career advancement and education opportunities. Exploratory questions regarding IENs’ mentorship experiences were included in this study. Participants’ multi-layered identities as IENs, mothers, immigrants, and minorities surfaced during the interviews. This prompted further investigation of these identities as they relate to experiences with career and education advancement.

The research question: what are the experiences and perceptions of IENs working in urban Alberta with regard to career advancement and education opportunities?

Significance of the Study

Many argue that the global migration of nurses is a phenomenon of today, where a global market regulates the flow of labor (Cutcliffe & Yarbrough, 2007). The task ahead lies not with justifying or condemning the phenomenon. Rather, the task involves containing and modeling nurse migration to meet the ethical obligations towards the individual nurses who migrate and the global community (Buchan & Sochalski, 2004; Xu & Zhang, 2005). In Canada, as the population of IENs increases, it is essential that IENs are not forgotten within the healthcare system. It is crucial to ask and answer questions regarding working conditions, integration into the workforce, challenges, expectations, and experiences of IENs. This study brings greater understanding to a specific area of the diverse issues of concern in the Canadian IEN workforce.

The study highlights IENs’ experiences and perceptions with regard to career advancement and education opportunities. The CNA emphasizes the importance of providing opportunities for successful integration and professional development of IENs within the Canadian healthcare system (CNA, 2005). Two motivational factors influenced the decision to study IENs’ experiences about career advancement and education opportunities. First and foremost, Canada has an ethical obligation to provide recruited IENs with a practice setting that promotes job satisfaction and emphasizes equitable opportunities. Exploitation of IENs does not occur only at the initial phase of recruitment, but can continue on during employment through unequal opportunities for professional development or limited career choices (Adams & Kennedy, 2006). Alexis and Chambers (2003) identified five components for ideal recruitment and retention of IENs: (a) valuing nurses, (b) diversity and equality, (c) the environment, (d) induction programs, and (e) education and training. Educational opportunities include self-directed personal development plans, ongoing professional development, and English language courses (Alexis & Chambers). Ethical recruitment, therefore, is tied to ethical employment, where providing opportunities for professional development is paramount.

Second, successful retention of the IEN workforce is vital if IEN recruitment is to assist in resolving the nursing shortages in Canada. It is necessary that IENs are successfully integrated into the Canadian healthcare system, but integration is only the first step to effective retention. Research on IENs reveals that the ideal practice environment suitable for short and long-term retention is still an elusive objective. According to Buchan, Jobanputra, & Gough (2005) more than four out of ten IENs consider traveling elsewhere for employment. The challenges with initial integration have been largely discussed in the literature. However, retention of IENs during later periods of their employment has been less scrutinized. If retention of IENs is to be achieved, then it is important to identify those barriers to retention. One of the main barriers to retention identified in the literature is the absence or limitation of career advancement and education opportunities. The International Center for Nurse Migration issued a document in 2006 titled: “Positive Practice Environments: Key Considerations for the Development of a Framework to Support the Integration of International Nurses.” This document emphasizes opportunities for professional development as one of the key considerations in minimizing high turnover and increasing retention (Adams & Kennedy, 2006).

It is imperative to understand the experiences and perceptions of those IENs already employed in the Canadian healthcare system. This will allow stakeholders to ethically recruit and successfully retain the new waves of IENs expected to enter the Canadian practice environment. This study describes the experiences of IENs already working in urban Alberta hospitals in Canada with regard to career advancement and education opportunities. The study also reveals strategies perceived by IENs to enhance the opportunities for career advancement and education. As the study progressed, new areas of focus emerged related to the experiences of immigrant working mothers. These experiences were discussed within the context of working as an IEN in Alberta. The importance of this study is great, as the world stands witness to competitive global markets and increasing nursing shortages. The window for nurse migration opens wider as global shortages increase. If Canada is to benefit from the process of recruiting IENs, a nurturing environment is not only an ethical obligation but a strategic necessity for the future.

Definition of Terms

Internationally-educated nurses: Nurses who graduated from a nursing school outside Canada, whether or not they are Canadian citizens (CIHI, 2006a). Many IENs complete a Canadian refresher nursing program or courses to meet Canadian requirements for registration (Ogilvie, Leung, Gushuliak, McGuire, & Burgess-Pinto, 2007). Others might have taken additional certificates or degrees from Canadian institutions. For the purpose of this study, IENs are those nurses who have completed their basic nursing education abroad, whether or not they took additional schooling in Canada. Although IENs can be registered or practical nurses, this study focuses specifically on the experiences of registered nurses.

Career advancement: includes career information and guidance, support for development and implementation of career plans, opportunities to assume leadership roles, potential for recognition, and promotion opportunities.

Education opportunities: includes presence of financial, social, and/or organizational support for pursuing educational activities.

Mentorship: involves a long-term commitment by a senior or more experienced individual to providing guidance, emotional support, and professional expertise to a junior or less experienced individual (Yonge et al., 2007).

Chapter 2

Literature Review

The literature review was conducted using the following databases: Medline, CINAHL, Pub Med, Scopus, Eric, and Proquest dissertation and theses. Websites of relevant organizations were also searched such as the CNA, CARNA, CIHI, Alberta Government, and the International Center on Nurse Migration. The search terms used were: “foreign nurse”, “immigrant nurse”, “international nurse”, “internationally-educated nurse”, “foreign-educated nurse”, “minority nurse”, and “overseas nurse”. These terms were matched with general terms related to IENs’ experience such as experience, expectations, challenges, barriers, and integration. More specific matching terms were used, which constituted synonyms of the terms “career advancement” and “education opportunities”.

Strangers in a Foreign Land

IENs do not constitute a uniform population and therefore generalizations of their work experience in host countries must be made with extreme caution. Still, the literature on IENs reveals commonalities in experience that transcend the differing countries of origin and destination. Looking at the literature on IENs working across the developed world, there is an unmistakable emergence of common themes related to their work experience. Presented here are some of the themes found to be universally cited in the IEN literature.

One of the major themes is the presence of language barriers manifested through both verbal and nonverbal communication. In a phenomenological study on Australian IENs the experience of silencing, as a result of communication and language difficulties, emerged from the data analysis (Omeri & Atkins, 2002). These difficulties were echoed by IENs working in Iceland and the UK, where the intense fear of answering the telephone was reported as the hallmark experience (Magnusdottir, 2005; Matiti & Taylor, 2005). In IEN populations, language markers, in the form of lack of fluency or presence of an accent, form the basis for discrimination, devaluing, and social isolation (Xu, 2007b). Communication barriers, also, result from differing cultural interpretations of certain non-verbal cues. Korean nurses reported having to adopt non-verbal behaviors in the USA, such as smiling and maintaining eye contact, which in Korean culture were perceived as rude and untrustworthy (Myungsun & Jezewski, 2000). Learning the subtleties of communication such as understanding jokes and interpreting body language were challenging for IENs (Blythe, Baumann, Rheaume, & McIntosh, 2009).

Cultural differences with regard to nursing practice are, also, recognized by IENs as a significant difficulty. Filipino nurses recruited to work in the UK found the nursing role different in areas of task delegation, shift work, elderly care, and family involvement in patient care (Daniel, Chamberlain, & Gordon, 2001). Similar cultural differences were touched on by Filipino nurses working in Ireland, regarding family dynamics in western society and the role of family in patient care (Gonagle, Halloran, & O’Reilly, 2004). In a study on Indian nurses working in the US a feeling of cultural displacement was expressed, which transcended the healthcare milieu to include aspects of their personal and social lives (Dicicco-Bloom, 2004).

The lack of recognition of previous experience and the process of deskilling during employment are other sources of dissatisfaction and stress for IENs. Ethnic minority IENs working in the British National Healthcare System [NHS] reported living through a devaluation process. These nurses suffered from low self esteem as a result of experiencing a lack of trust and, subsequently, a lack of opportunity to demonstrate their skills (Alexis, Vydelingum, & Robbins, 2007; O’Brien, 2007). Similarly, IENs working in Australia described feeling undervalued when employers overlooked the experience they acquired from their home countries (Omeri & Atkins, 2001). This lack of trust and disregard for IENs’ professional skills persisted despite proof of their competence and, when acknowledged, was seldom followed with reward (Dicicco-Bloom, 2004; Larsen, 2007). Also, nurses’ autonomy level and decision-making role was described by IENs to be significantly different from their home countries. Some IENs, mostly from Asian countries, were satisfied with the increased levels of autonomy (Taylor, 2005). Other IENs, mostly those from South Africa, reported greater autonomy in their home countries (Taylor).

One final area of note when looking at the experiences of IENs is the social aspect of their lives outside the healthcare institution. Here it is crucial to understand the potential disconnect between IENs’ expectations and experiences of the host country. In the literature, IENs frequently reported such disconnect in the areas of financial gain, housing, career advancement opportunities, and interpersonal relationships with the host community (Dicicco-Bloom, 2004; Gonagle et al., 2004; Matiti & Taylor, 2005).

The different aspects of IENs’ work experience in host countries are interconnected and complex. When looking at a specific area such as career advancement and education opportunities, it is crucial to be aware of the socio-political context in which the healthcare institution exists. It is important to understand that multiple factors associated with other aspects of IENs’ work experiences influence the particular experience of career advancement and education opportunities.

Getting Ahead in a Land of Opportunity

IENs’ work experience in host countries has been the focus of numerous studies. Most of the studies were conducted in Australia, the UK, and the USA. These studies show limited opportunities for IENs with regard to career advancement and education opportunities in comparison to their domestic peers. In a metasynthesis of the lived experience of immigrant Asian nurses working in western countries, marginalization, discrimination, and exploitation emerged as the major themes (Xu, 2007b). This marginalization, discrimination, and exploitation manifested as unequal career opportunities for Asian nurses in comparison to their domestic peers. Asian nurses felt the need to work harder than other nurses to prove their competence and gain respect, which once attained did not guarantee equal status or wages (Xu, 2007b). Inequality in career advancement and education opportunities is also evident when comparing different groups of IENs. Hawthorne explored the barriers confronting IENs working in Australia. She reported that IENs, from non-English speaking countries, were significantly less likely to advance beyond their baseline registered nurse [RN] status to managerial or nurse supervisor positions in comparison to IENs from English-speaking countries (Hawthorne, 2001). Hawthorne, also, used logistic regression to observe the relationship between obtaining senior positions and a variety of background variables, such as number of qualifications and region of origin. Interestingly, coming from a non-Commonwealth Asian country was the only significant factor associated with working in less desirable positions and facing barriers to advancement (Hawthorne). Similar results were found in another Australian study. The study by Omeri & Atkins (2002) used a Heideggerian phenomenological approach to look at IENs’ lived experience in working in New South Wales. IENs reported lacking support and being discouraged from pursing education opportunities that would advance their careers. In fact, the literature reveals that limited numbers of IENs, especially those from ethnic or visible minorities, fill management or leadership positions (Omeri & Atkins). Similar findings were replicated in Britain. Alexis, Vydelingum, & Robbins conducted two studies looking at the experiences of minority ethnic IENs working in the NHS in Britain. Qualitative methodologies were used to extract the overarching themes of minority ethnic IENs’ experiences, as related through semi-structured interviews. The themes of discrimination and lack of equal opportunities for career advancement and education emerged with strength in both studies (Alexis, Vydelingum, & Robbins, 2006; Alexis et al., 2007). IENs perceived that, regardless of equal opportunity policies in the hospitals where they were employed, their white counterparts were first to receive the benefits from education or promotion opportunities. Another US study showed that IENs did not find the promised land of opportunity. The study looked at the experiences of immigrant nurses from India working in the US. The Indian nurses reported that, despite their positive personal attributes and professional abilities, they were unable to advance in their careers (Dicicco-Bloom, 2004).

Supporting IENs to create a positive work experience in the host country begins during the initial phases of recruitment. Studies have encouraged orientation programmes, which address the challenges IENs face in areas such as culture, language, nursing role, and organization policies. Xu (2007b) identifies the need for pre-arrival preparation and post-arrival training programs in the form of buddy mentoring programs, language training, and extended internship programs. Withers & Snowball (2003) reported the positive feedback obtained from IENs about their adaptation programme, which addressed cultural, language, and organizational issues pertaining to the new work environment. Educational programmes for domestic nurses, in the areas of cultural competency and mentoring, are also encouraged in the literature (Daniel et al., 2001). However, the effect of such programmes on the future career progression of IENs is still unknown. A study by Troy, Wyness, & McAuliffe (2007) revealed the frustration of Irish nursing directors when attempting to advance IENs into senior positions. The directors perceived that IENs were reluctant to assume higher levels of responsibility, due to cultural and language barriers. The study’s conclusion emphasizes the need for encouragement and support mechanisms to enhance IENs’ career progress, but does not clearly specify the nature of these mechanisms.

One possible mechanism of support is the mentorship process. Mentorship has been suggested in the literature as a strategy to support IENs in their work environment during the initial phases of adaptation and later phases of professional development (Chambers & Alexis, 2004; Henry, 2007). Mentorship, meaning to counsel, occurs when two individuals voluntarily develop a relationship, where the more experienced, older, or wiser of the two serves as a counselor, guide, and role model to the other (Stewart & Krueger, 1996). This mentorship process can occur formally, where individuals are paired through mentorship programmes, or informally, where individuals develop a relationship based on common interests, respect, and commitment (Yonge, Billay, Myrick, & Luhanga, 2007). Mentoring relationships benefit nurses in leadership development, career progression, career motivation, enhanced opportunities, and confidence building (Allen, Eby, & Poteet, 2004; McCloughen, O’Brien, & Jackson, 2006). Allen (1998), in interviewing 12 nursing leaders on leadership development, concluded in her study that one of the essential pre-requisites for leadership development was the presence of mentors, who could provide both opportunities and encouragement. There is a need to address the role mentorship plays in providing opportunities for career advancement and education in the IEN population. It is possible that such relationships occur informally, through networking, where the more experienced IENs mentor their peers from the same countries of origin.

The evidence in the literature supports the notion that IENs are disadvantaged with regard to career advancement and educational opportunities. The possible strategies to enhance career advancement and education opportunities are even more obscure in the literature. In Canada there are no studies that address the issue of career advancement and educational opportunities for IENs in the healthcare system. In fact, Canada has only a modest pool of literature regarding IENs compared to other developed nations. The presence of barriers to career advancement and education opportunities, and the potential strategies to increase such opportunities in Canada have yet to be explored.

Fitting the Jigsaw Puzzle Together

Self-identity theory states that an individual uses inter-group and outer-group comparisons to identify self with one group and differentiate self from other groups (Hogg & Terry, 2000). Self-categorization, an extension of self-identity theory, involves an individual seeing his or her identity as an embodiment of certain in-group prototypes, where self is not seen as unique but rather a replica of in-group characteristics and attributes (Hogg & Terry). This change in the identity of self, from individualistic to determined by in-group characteristics, forms the basis for understanding group phenomena and social processes such as othering. Othering is an exclusionary social process, where the targeted individual or population is seen as different from the expected norm or in-group majority (Canales, 2000; Johnson et al., 2004). Othering results in the individual or group experiencing alienation, marginalization, and, in extreme cases, racism (Canales; Johnson et al). In other words, othering is the starting point from where more harmful practices, such as marginalization and racism, emerge.

Marginalization is the process by which people are placed at the periphery of society as a result of their identities, associations, experiences, or environments (Hall, Stevens, & Meleis, 1994). In the process of marginalization, the exertion of power is not unilateral (Vasas, 2005). Hierarchal power is exerted by those at the center, the dominant majority, to maintain the boundaries at the periphery. In reaction, the marginalized exert horizontal power in opposition to their marginalization. Racism can be seen as an extreme example of marginalization, involving a marginalization process based on race. Racism includes any act by an individual, community, or organization where others are subordinated on the basis of race or ethnicity (Calliste, 1992). The processes of othering, marginalization, and racism have been associated in the literature with the limited opportunities experienced by IENs in the work environment of host countries.

IENs come from different backgrounds and bring to the host country unique world views, norms, and beliefs. It is also evident that the social and structural context of healthcare and the broader society differs from country to country. Significant speculations exist as to why IENs are limited in their ability to advance in their careers. In attempting to summarize the reasons for barriers to career advancement and educational opportunities, racism emerged as a root cause. Yet, few of the studies citing racism present an in-depth analysis of the issue. Conclusions are mostly limited to statements, by research participants or researchers, of racism present in the healthcare system. Further analysis of the individual, social, and structural contexts from which racism emerges is mostly absent.

In the literature on IENs, unequal opportunities have been linked to the presence of racism in the healthcare system. In many of the studies IENs voiced the opinion that racism was a major reason they were rejected when applying for higher positions or educational opportunities. IENs reached this conclusion from both overt and covert incidences linked to racist mentalities. In many cases, IENs witnessed less experienced or less educated peers advancing ahead in their careers. IENs were unable to explain this phenomenon, except that their peers were given preference due to race or country of origin. In a literature review on the experiences of African nurses in the British NHS, IENs reported racism in the workplace, which manifested in areas of promotion and access to educational opportunities (Lipuke, 2005). This racism was not equally directed to all IENs, but differed in severity and incidence based on race and country of origin (Lipuke). The finding that “not all IENs are treated the same” was echoed by Taylor. IENs who were from visible ethnic minorities and those for whom English was not a first language were more likely to report incidences of racism manifested through unequal opportunities (Taylor, 2005). Nurses in this category reported racism in the form of skill devaluing and dismissal of their previously gained experience in the homeland. The assumption being made by those in power was that IENs were incompetent or lacked professional attributes needed to succeed in the work environment. These assumptions persisted in many situations where IENs had proven their abilities and trustworthiness. Many IENs concluded that they would not attempt to advance in their careers, due to the stress involved and the futility of the effort (Larsen, 2007).

In Canada, few studies have addressed the issue of racism in relation to IENs. Hagey et al. (2001) conducted an exploratory study of nine immigrant nurses of color in Ontario who had filed grievances based on racism experienced in their practice setting. During the interviews, the theme of being a victim of racial discrimination emerged, where nurses experienced incidents of harassment and hostility from both their peers and their superiors. In some of these incidents nurses were hindered from promotion or denied access to education opportunities. It is interesting to note that these nurses saw the need for minority representation in higher levels of management as a crucial policy initiative to promote equity and diversity (Hagey et al.). The fact that these nurses were chosen for the study on the basis of their filing grievances gives room for the argument that this was simply an example of extreme cases. The same authors argue in another article that these seemingly unique events could be evidence of a wider social phenomenon of racism (Turrittin, Hagey, Guruge, Collins, & Mitchell, 2002). Calliste (1993) argues that racism in nursing has always existed, dating back to the 1940s when black nurses were not allowed to practice nursing in Canada. Calliste looked at the history of Caribbean nurses migrating to Canada. Discriminatory practices expanded from the immigration policy level to the institutional level, where nurses were faced with racism during the employment process. This racism continued during their careers as nurses in Canadian hospitals. It is well documented that nurses who spoke up about these acts of discrimination were faced with reprimands and unjust resolutions to the conflicts (Calliste; Hagey et al.).

Most institutions in developed nations have attempted to minimize the incidences of racism through policy statements at the government and institutional level, advocating for diversity and criminalizing racist activity. The research, however, shows that an acknowledgment of diversity and shunning of racism at the policy level are not interpreted into equal opportunities within the healthcare organization. Culley (2000) argues this point with reference to the British NHS explaining the failure of equal opportunity policies to have a positive impact for nurses. Canada boasts a respect for diversity and a celebration of multi-culturalism (Turritin et al., 2002). The question of how this is interpreted within the healthcare organization, with regard to IENs, is yet to be answered. Kirkham (2003) makes this point in a Canadian ethnographic study examining the social context of inter-group healthcare relations. Kirkham concludes that the commitment to multi-culturalism and equity at the legislative level is threatened by discourses that construct Canada as white, middle class, English-speaking, and Christian. Kirkham discusses how this discourse leads to the creation of criteria for belonging and acceptance, where not belonging leads to discrimination and marginalization.

Looking at the literature it is clear that the issue of unequal opportunities are more complex than racism. It is essential to look beyond the statement that unequal opportunities are a result of individual acts of racism and can be cured by purging the system of those with racist mentalities. IENs are minority groups in healthcare systems, many of whom are also ethnic minorities in the host society at large. From the moment IENs arrive on host soil, the process of marginalization might begin through various societal and institutional practices. Research has been conducted looking at the dire effects of marginalization on patients when practiced by healthcare providers. In Canada barriers to receiving adequate healthcare still face marginalized populations, such as immigrant and ethnic minority groups (Johnson et al., 2004). These barriers are interpreted by many healthcare professionals to be a result of marginalized populations’ differing cultural norms and values. Culturalism refers to the ease with which cultural explanations are taken up to explain differences or similarities between groups (Johnson et al.). In this process the underlying issues of racism, class, and gender, at the individual and institutional level, are overlooked (Johnson et al.). For example, marginalized patients can be seen as noncompliant with care due to differing cultural beliefs about treatment and health. Hence, non-compliance with care resulting from a language or financial barrier is, instead, interpreted to be a result of cultural differences.

Less research has been done to examine marginalization when the victims are groups of healthcare workers. Differences between IENs and their domestic peers are automatically traced to culturalism. Thus, IENs become “the other” in the healthcare system. A study on Ghanaian nurses and midwives, employed in Britain, revealed that these individuals experienced difficulties progressing into senior positions. This seemed on the surface to be a result of differing cultural attitudes and knowledge gaps. In reality, the Ghanaian healthcare workers found difficulty using the “appropriate” communication styles and were unable to demonstrate their qualifications (Henry, 2006). The term “appropriate” used to describe the required communication styles meant “appropriate as seen by the dominant culture”. Here the concept of “the other” surfaces, where promotion is given to those who fit in with the dominant culture, which is judged by the ability to express competence in the “appropriate” manner. The Royal College of Nursing [RCN] commissioned a report into the experiences of IENs working in the UK. One of the issues discussed in the focus groups was British managers and nurses’ perceptions that IENs were unmotivated to advance in their careers (Allan & Larsen, 2003). The reasons for this lack of motivation were not explained beyond the cultural mindset. The feelings of being discriminated against and labeled as the other were also strongly reported by IENs, where color not country of origin was deemed the strongest factor for discrimination (Allan & Larsen). The literature reveals that those belonging to minority groups rarely have the opportunity to assume managerial and leadership positions because they do not fit the expected organizational prototype (Hogg & Terry, 2000). In other words, these individuals do not have the characteristics of the in-group or the center, but rather belong to the periphery-the marginalized group.

These studies bring to light the more subtle effect of practices like othering, marginalization, and racism, where inequity is perpetuated by generalized assumptions. Unequal opportunities with regard to career advancement and education are acknowledged, but attributed to random incidences of racism or cultural differences of IENs. This assumption results in an eclipsing of the underlying factors possibly associated with this phenomenon of unequal opportunities. Stakeholders, policy makers, and management need to be aware of the possible effects of inequities, which are not necessarily addressed by policies of equality. IENs might lack the communication skills, the language ability, or the knowledge of the host countries socio-political make-up crucial for career advancement. Studies on IENs seem to glide over the issues without truly addressing what it is that creates so little space for IENs in the higher levels of the healthcare system hierarchy.

Tying it Together: Opportunity, Satisfaction, and Retention

A study by Buchan et al. (2006) in the UK surveyed 380 IENs from 30 different nationalities newly employed in London. The survey revealed that professional development was one of the major incentives to migrate from South Africa, Philippines, and Asia. On the other hand, nurses from the UK, Australia, and the US were more likely to migrate for personal reasons such as experiencing a different country. It is interesting to note that in the same study 43% of the nurses stated they were considering moving to another country. For example, 83% of the Filipino nurses were considering moving to the US and half of these had already been contacted by a recruitment agency in the US (Buchan et al.). Respondents in this study did not explain the reason for wanting to re-migrate, but the study brings to light the possibility of professional development as an incentive. In a Canadian study of 39 IENs from 23 different countries, motivating factors for migration to Canada were career advancement and financial benefits (Blythe, Baumann, Rheaume, & McIntosh, 2009). As previously stated, job satisfaction has been linked to the availability of career development and educational opportunities (Aiken et al., 2001; Lundh, 1999; Lu, While & Barriball, 2004; Nolen et al., 1995; Price, 2002). In turn, job satisfaction is highly related to nurse turnover, intent to quit, and retention (Andrews & Dziegielewski, 2005; Blegen, 1993; Irvine & Evans, 1995). Other studies assessed the direct relationships between career advancement and nurse turnover. A meta-analysis was done to look at the relationship among individual, organizational, and environmental factors as they relate to nurses’ intention to stay or quit their job in Taiwanese hospitals. Stress resulting from the shortage of advancement opportunities was found to be significantly related to turnover (Yin & Yang, 2002). Gibson, in an attempt to understand the reasons for nurse turnover in the intensive care setting, surveyed 45 nurses who had left their units. The main factor contributing to the decision to leave was the lack of career development, especially since promotion was tied to the completion of further specialty critical care education (Gibson, 1994). The study points to the importance of education opportunities as a pre-requisite for career advancement and the possible attrition of nurses resulting from the absence of such opportunities.

As the global competition for nursing recruitment increases, stakeholders and policy makers are beginning to pay attention to the need for successful retention strategies. The implementation of professional career ladders in an effort to guarantee career advancement and education opportunities is one of the suggested strategies (Gullate & Jirasakhiran, 2005). However, what impacts job satisfaction and what impacts the effect of job satisfaction on turnover are not constant or universal. Coomber & Barriball (2007) make this conclusion in a literature review regarding the impact of job satisfaction components on intent to leave and turnover for hospital-based nurses. Coomber & Barriball conclude that the variables which constitute job satisfaction and the impact of those variables on turnover vary with time, nurses’ professional level, and hospital environment. It is, therefore, important to realize gaps in the literature with regard to these variables and IENs. There is no research looking directly at the variables constituting job satisfaction for IENs working in Canada. Also, there is no research looking at the variables related to IENs turnover intent or retention rates within Canada. Still, the importance of career advancement and education opportunities in job satisfaction and retention cannot be ignored.

The proposed study was constructed to identify the experiences of Canadian IENs with regard to career advancement and education opportunities. There is an acknowledgement of the deeper questions that present themselves when such an issue is discussed. This study did not answer all these questions but makes a first step in that direction. The study brings insight into career advancement and education opportunities for IEN populations and the perceived strategies for enhancing such opportunities. This study can assist Canadian stakeholders to develop more targeted retention strategies for IENs working in Canada, while being consistent with the principles of ethical recruitment.

Chapter 3

Methodology

Research Methodology

This study was implemented using an interpretive descriptive methodology. Thorne (1991) states that well established research methods born from within other disciplines in the social sciences, such as sociology and anthropology, do not always assist in answering nursing questions. The purpose of such research methods is to answer the questions of their disciplines and, thus, is not always compatible with the practical purpose expected of nursing research. Thorne, Kirkham, & MacDonald-Emes (1997) reinforce the same argument and present a non-categorical interpretive descriptive approach as an alternative to research methodologies derived from other disciplines. Nurses function within the paradigm of two distinct beliefs: (a) shared realties exist in experiencing a given phenomenon, and (b) human experiences are individually constructed within a given context (Thorne et al.). The interpretive descriptive methodology serves the purpose of this nursing paradigm by extracting common patterns of experience, analyzing the practical implications of these patterns, and creating a basis for understanding the individual and contextual applicability of the findings. Hence, interpretive description, as explained by Thorne, Kirkham, & O’Flynn-Magee (2004), is a method used to investigate a clinical phenomenon important to nursing, by extracting themes that are based on subjective interpretations of experiences, with the goal of generating findings useful to nursing practice.

The goal of this study was to understand IENs’ experiences and perceptions in the areas of career advancement and education opportunities. It was ultimately a study of nurses by a nurse about an issue of interest to nursing. Therefore, a non-categorical approach in the form of interpretive descriptive methodology was both appealing and pragmatic. In a generic study of this form, the principles are not based on well established research methodologies and theoretical traditions, such as those found in ethnography or grounded theory. However, it is crucial to acknowledge that the research study is still inherently based on certain paradigms, beliefs, and assumptions (Caelli, Ray, & Mill, 2003). Not doing this means the researcher runs the risk of combining methods with conflicting underlying philosophical assumptions or using terminology without clearly defining their meaning (Caelli et al.). The philosophical underpinnings underlined by Thorne et al. (2004) and adopted for this interpretive descriptive methodology are as follows: (a) reality is subjectively constructed in a given context, (b) the researcher is inseparable from the object of research, and (c) theory needs to be extracted from the data and, thus, a priori theory is impossible.

Sample

Recruitment strategy. This research study targeted nurses who are a minority in the healthcare system and addressed emotion-laden issues. Therefore, the recruitment process strictly adhered to the principles of voluntary participation. The researcher avoided approaching nurse managers and other related stakeholders to recruit IENs, as in such cases the risk of involuntary participation increases. The power differential between authority figures and IENs might have resulted in IENs unwillingly participating in the research process, through a sense of obligation. Instead, recruitment posters were distributed within two hospital settings in Edmonton (see Appendix A). Potential participants were expected to contact the researcher directly. However, only one of the IENs participated in response to the recruitment posters. Nursing colleagues introduced my research to seven of the potential participants and gave me their contact numbers. The remaining three participants were recruited through other participants. There was no monetary incentive for participation in this research study except, when applicable, transportation costs and/or childcare costs.

Sampling Technique. In the beginning of this study I used convenience sampling. Convenience sampling refers to a sampling technique where participants are chosen based on their availability at the right place and time (Burns & Grove, 2007). Data analysis starts with the first data collected and can guide the sample selection process by identifying sources which increase the understanding of the issue at hand (Gibbs, 2007). As the study progressed, purposive sampling further helped to investigate areas pertaining to the research issue. Purposive sampling occurs when the researcher selects certain participants to gain insight into a new area of study or obtain in-depth knowledge of an experience (Burns & Grove, 2007). Purposive sampling was used at two points in this study. On recruitment of the first British IEN, it was apparent that major deviations in experience from Asian IENs were present. Therefore, a second IEN from Britain was interviewed to observe if such deviations were consistent. Also, an IEN working in long-term care expressed interest in the study. Once interviewed, some of the concepts extracted from the interviews prompted further investigation with other IENs working in long-term care.

Another technique that was helpful in this study was snowballing. Snowballing is a type of purposive sampling technique, where participants connect the researcher to other willing participants (Speziale & Carpenter, 2007). The snowballing technique proved to be useful where participants were a minority and were reluctant to critique the practice setting to a stranger for fear of reprisal. Participants, who identified other potential participants for the study, were asked to provide that potential participant with a copy of the information letter. If the potential participant was willing to partake in the study, he or she contacted me using the provided contact information. Three of the participants were recruited using this method.

Inclusion/exclusion criteria. The inclusion criteria were consistent with the CIHI definition of IENs. All IENs were registered nurses with at least two years of experience in Canadian healthcare organizations. Initially, inclusion criteria involved nurses working in Canadian hospitals. However, IENs from long-term care expressed interest in the study. Preliminary data collected from the first IEN interview in long-term care proved valuable in understanding IENs’ experiences with education and career advancement opportunities. Therefore, IENs working in long-term care were included in this study. Two IENs were working in long-term care at the time of the interview but had previously worked in a hospital setting. A third IEN was working in both long-term care and a hospital setting at the time of the interview. A minimum of two years experience was necessary to render IENs able to answer questions regarding retrospective experience. I acknowledge that nurses have different needs at different stages in their careers. In an exploratory study of this nature, regarding an issue not addressed previously in the Canadian context, my aim was to interview a diverse sample at different career stages. I was able to do this. Four of the participants were near retirement and had been in Canada for over fifteen years. The remaining participants had been nursing in Canada from three to fifteen years.

Sample size. Eleven participants were recruited for this study. The number of IENs recruited for the study depended on the number needed for data saturation. Data saturation is said to have occurred when data collection becomes repetitive and no new issues emerge (Gibbs, 2007; Morse, Barrett, Mayan, Olson, & Spiers, 2002). Ideally, comprehensive explanation of the research issue is achieved through following up with odd cases (Gibbs, 2007). For the purpose of this research project, data collection was stopped once the experience of the IENs was considered to be adequately described. Evidence of this was the repetition of certain categorical identifiers emerging from interview data with different participants. This allowed me to extract and focus on dominant themes, while acknowledging identified limitations.

Setting

Two hospitals in Edmonton were used for the initial participant recruitment. Since the IEN population is increasing in these hospitals, it was necessary to understand the experiences of the already established IEN workforce. Pragmatic reasons of time and cost constraint, also, influenced my choice of these two hospitals. IENs working in other Albertan hospitals expressed interest in participating in this study and were included, providing they met the inclusion criteria. IENs who participated in this study were recruited from three hospitals and two long-term care settings in Edmonton.

Data Collection

Data were collected over a span of four months. I used an interview guide with open-ended questions for this study. Data collected from interviews are subjective narrations of the experience as lived by the participant. Semi-structured interviews provide participants with the best opportunity to fully describe their experience (Speziale & Carpenter, 2007). It is best practice to conduct the interview at a time and place comfortable for the participant (Speziale & Carpenter, 2007). It was important to accommodate the participants with regards to interview location and timing. Most of the participants were working mothers. The shift scheduling of nursing meant that any free time was reserved for family commitments. During the recruitment process, many times, participants voiced the difficulty of finding availability in their schedule for an interview. I set a location and time for the interview meeting according to the comfort of the participant. A location that offered maximum privacy was chosen. Some participants chose to be interviewed at home. Others were interviewed in one of the nursing faculty interview rooms. Others had private offices available at their work setting. Child-care costs were offered to participants with young children. One of the participants on maternity leave brought her baby to the interview.

I offered the participant at the beginning of the meeting the consent form and answered any questions about the study. Once it was clear that the participant understood the study and was willing to proceed, the interview process began. At this phase, I acknowledged the importance of building a rapport with the participant through establishing mutual trust and respect (Speziale & Carpenter, 2007). I began the process of building trust and respect by giving a brief autobiography. I, also, explained the reasons for my interest in IENs as a research topic. One of the interviews was done via telephone as the participant was not in Alberta at the time. The information letter and consent were received by the participant via email. Although a telephone interview meant the loss of visual cues, auditory cues could still be detected through tone of voice and use of silence. Novik states that, via telephone, participants may feel more relaxed, thus, more willing to disclose sensitive information (2007). I audio-taped the interviews and took notes as needed. Note taking was used to document my thoughts and impressions during the interview. The main opening question for the semi-structured interview was as follows:

· Tell me what it is like to work as a nurse in Canada?

Issues of interest to this study, which were not addressed by the participant, were explored using the following guiding questions and probes:

· When you first started working in a Canadian hospital, what career and educational goals did you have? How, if at all, did these goals change over time?

1. Pre-arrival and post-arrival integration programs/ processes? Describe them? Describe relation to expectations and goals?

2. Expectations versus experiences over time.

3. Effect of external responsibilities(family, financials) on goal setting and pursuits

· What are your perceptions with regard to the availability of a supportive environment for your career and educational aspirations in the past, present, and future? (Presence of barriers/ Challenges)

1. Language/culture

2. Recognition of previous experience/skills

3. Differences in nursing practice; standards; expectations

4. Socio-political make-up of healthcare system and Canada

5. Minority status/ Discrimination

· Where do you see yourself career-wise in the next five years?

1. Educational pursuits

2. Promotions(charge nurse, management, teaching)

3. Specialty changes

· What are some of the strategies that could be implemented to help you reach your future career goals?

1. Education opportunities

2. Mentorship

3. Leadership training

· What do the terms “mentorship” and “mentor” mean to you? Could having a mentor play a role in your career? Would you consider mentoring junior IENs?

1. Have you had someone as a mentor? How did this relationship form? How did you benefit from this relationship?

2. What qualities are most important to you in a mentor?

3. Does a mentor need to have your cultural background/educated in the same country as you/share your IEN experience?

4. How can a mentor assist you in bettering your career advancement and education opportunities?

5. Would you be a good mentor? Why? Are there specific qualities you prefer in a junior you choose to mentor?

· What other experiences regarding working in Capital Health would you like to relate which would be helpful in understanding IEN’s experiences with career advancement and education opportunities of IENs?

After the first three interviews, categories not addressed by any of my questions began to surface. Hence, two main questions were added to the interview guide:

· From the perspective of a working mother, what challenges do you perceive with career and education advancement?

· What personal characteristics are important for IENs to succeed in the workplace?

Finally, at the end of the interview a questionnaire related to demographic, educational, and professional background was given to the participant to complete (appendix C). The data collected from this questionnaire assisted in better understanding the characteristics of the IEN sample population and the context from which their experiences emerged.

I transcribed each audio-taped interview using verbatim transcription. Transcriptions were checked for errors by listening to the interview for a second time. Being both the interviewer and transcriber decreases the risk of transcription errors such as mishearing of words and misinterpretation of jargon (Easton, L. K., McComish, F. J., & Greenberg, R., 2000). The literature discusses the increased risk of errors in cross-cultural or English as a second language transcription. In such cases, there is an increased occurrence of word omissions, inaccurate transcription of colloquial expressions, and misinterpretation of word meaning (MacLean, M. L., Meyer, M., & Estable, A., 2004). My nursing and multi-cultural background helped counter-effect this risk. I was comfortable conversing with individuals for whom English was a second language. Nursing jargon was, also, familiar. I still had to be wary of assuming I understood what a participant was saying. Being the interviewer made it possible to clarify meanings, through paraphrasing a participant’s words or asking for examples to further explain a concept.

Data Analysis

Interpretive descriptive methodology relies on constant comparative analysis processes, originating from grounded theory, to understand human phenomena (Thorne, 2000). Thematic data analysis depends on constant comparative analysis processes to develop an understanding of human experiences in a given context. Green et al. (2007) discuss four steps of thematic data analysis used in the analysis of interview-based qualitative studies: immersion, coding, categorizing, and generation of themes. Data analysis does not consist of a linear process but rather the researcher moves back and forth among the different steps of analysis (Green et al.).

The first step, immersion into the data, consists of reading and rereading the interview transcripts. During this step, I linked the data from the transcripts to the interview context, creating a clear picture of the data as a whole. Immersion began in early stages of data collection to detect gaps in the data and areas needing further investigation. Thorne et al. (1997) in their interpretive descriptive methodology recognize the importance of early immersion in the data and movement between the data and the field to gather more information. Through data immersion at an early stage, I was able to modify my questions to better investigate dominant concepts. Early data immersion revealed the need for interviews with IENs from particular backgrounds or age groups.

The second step was data coding. Codes are descriptive labels designated to segments of the transcript (Burns & Grove, 2007). I tried to understand what the participant was saying and summarize it with a code. These codes were fluid during the research process. They were refined or changed as clarity of the data increased. The third stage was the creation of categories. Codes are linked to form categories that summarize the different aspects of the issue, as related by the participants (Creswell, 1998). I used a practical method to extract the codes and identify categories. Interviews were printed out on colored paper. A different color was specified for each interview. Phrases and words pointing to particular codes were cut out and placed on poster sheets. These codes were organized into categories. The placement of codes and categories shifted as the data collection and analysis evolved. Categories were merged and codes transferred from one category to another. Here it was important that saturation of the data occurred, so that categories were not prematurely synthesized without an evident relationship between the codes. Also, I chose not to ignore codes from data that did not fit with the overall picture. Such codes were set within categories of their own to be further explained or analyzed at a later time. Some of the codes were not supported by sufficient data and, thus, were abandoned. It is important to avoid too detailed a coding, where the analyst fails to see the whole picture.”What is occurring here?” must be asked constantly so that the analyst is intellectually engaged with the data extraction and interprets themes in the context of the overall picture (Thorne et al., 2004). After I conducted the first three interviews and went through the process of data analysis, I presented the work to my supervisor. This allowed me to obtain feedback regarding the interview and data analysis process. My supervisor assisted in identifying missing questions, areas that needed further exploration, and flaws in the data analysis process. My supervisor, also, read through the last four interviews and offered feedback on the categories she identified as prominent through the interviews.

The fourth step was the identification of themes. A theme provides an interpretation of the categories generated in the previous stages of the analysis process. The researcher must have a solid knowledge base of the theory and the literature already available on the topic. Thus, the researcher simultaneously refers to the abstract theory and the concrete realities of the practice setting to emerge with the themes (Thorne et al., 1997). The final product of an interpretive descriptive inquiry is an intelligent conceptual description of the themes that characterize the phenomenon under study, while taking into account the individual variations from these themes (Thorne et al., 2004).

Rigor

To adhere to the principles of rigor the researcher needs to acknowledge the possibility for error and describe the detailed process used to minimize that possibility (Meyrick, 2006). According to the argument made by Meyrick, a pragmatic approach to rigor in qualitative research is to adhere to two principles, transparency and systematicity, where the method of achieving this can vary from researcher to researcher. This transparency and systematicity must be evident in all stages of qualitative research from discussing the method to data collection and analysis. Thorne et al. (1997) advocate for the use of techniques which increase the transparency of the research process. Verification is another term used to establish quality in qualitative research. Verification means being certain and, in qualitative research, it refers to the mechanisms used in the research process, which contribute to ensuring reliability and validity (Morse et al., 2002). Some crucial elements for ensuring verification and, consequently, rigor are methodological congruence, appropriate sample, collecting and analyzing data concurrently, and thinking theoretically (Morse, Barrett, Mayan, Olson, & Spiers, 2002). I followed this pragmatic definition of rigor throughout the research process. During the research process there was ongoing discussion with my supervisor regarding the emerging categories and themes. My supervisor read through the interviews and shared her thoughts on the dominant categories detected in the interviews. This process enhanced rigor by decreasing the risk of personal biases during the data collection and analysis phase.

Reflexivity is one of the methods to ensure rigor and was adopted in this study. The term refers to the researchers’ acknowledgement of their influence on the research process and outcome. (Finlay, 2002; Horsburgh, 2002). Walsh & Downe (2006), in conducting a meta-synthesis of qualitative studies, report criteria deemed essential for positive appraisal of qualitative research. Reflexivity was seen as crucial, where researchers needed to discuss their influences on the stages of the research process, their relationship to the participants, and the effects of the research on the researcher. In qualitative research the researcher is part of the research process from formulating a question to concluding a result. The researcher’s views, beliefs, and philosophical stance will, whether knowingly or not, influence the research process (Speziale & Carpenter, 2007). Reflexive research is characterized by a clear explanation of the researcher’s choices and motives, which allows the reader to decide if the research product was plausible (Koch, 1998). Subjectivity is unavoidable in research (Peshkin, 1988). The conscientious researcher must be willing to examine his or her subjectivity throughout the research process.

I am an IEN working in Capital Health, on an acute care unit. I am, in this respect, an insider in this research process. The literature discusses the perils inherent in “insider” research. My interest in IENs’ work experience began to form through informal discussions with other IENs. Thus, my position as an insider influenced the earliest stages of my research. I believe that a researcher is never completely distant or separate from the object of study. As an insider, I cannot separate the data collection and analysis process from my own experiences of working in Canada. Yet, the maximum possible effort was exerted into justly representing IENs’ experiences. In the literature, “insider” researchers have mistakenly interpreted phenomena based on an assumed understanding of the related issues (Asselin, 2003). In such cases, unclear emerging data is falsely interpreted or pre-maturely dismissed because the researcher assumes to know the interpretations of these findings. Participants, identifying the researcher as “one of them” might superficially address issues, assuming that the researcher understands the meaning they wish to convey (Kanuha, 2000). At many instances during the interviews, participants would say: “You know what I mean.” or “as you know Jordana.” Assuming I shared their experiences, IENs at times would fail to elaborate on their thoughts. In the beginning, as a novice interviewer, I was not aware of this process. After reading through the first few transcripts, I became aware that some experiences were described superficially. I began to respond to such comments with:” Can you give me examples” or “can you explain some more.” I was aware that assumptions can wrongly be made when studying one’s own group. I, frequently, during the research process, made a conscious effort to uproot my assumptions that could limit the development of knowledge. This was partially made possible by a second researcher going over the interviews. I, also, had to let go of my expectations regarding what themes would emerge from the data. During the literature review and in formulating my questions, I expected certain themes to be dominant in the study. This was the result of my own experiences and the experiences of IENs documented in the literature. I was not an immigrant to Canada and I was not a mother. This fact rendered me oblivious to a large part of participants’ experiences in Canada. For most participants, experiences with career and education advancement involved being immigrant working mothers. After struggling with the first three interviews, I was able to listen and let the interviews flow more freely. This meant that when a participant focused on an experience, I would investigate that experience in greater depth. I was able to modify the guiding questions for the interview to better represent the categories that were identified through these first few interviews.

My closeness to the research topic had certain merits. The advantages of being a nurse researching nurses have been cited in the literature. The nurse researcher is aware of the environment, familiar with the language, and more readily accepted by the participants (Borbasi, Jackson, & Wilkes, 2003). IENs acknowledged me as “one of them”, a person able to understand their experience. This “one of them” status differed from participant to participant, as IENs are not a homogenous population. O’Conner (2004) argues that the multilayered identities of the researcher and participants means the margins between insider and outsider are fluid and unstable. Cultural, religious, and racial differences affected my status as an insider or outsider. This was important, as I can be easily identified through my presentation as an Arab Muslim. This means some participants identified me as an outsider, along religious and cultural lines, rather than as an insider, based on our common IEN status. Another reason I was identified at times as an outsider is the fact that I am a master’s student and not an immigrant or mother.

When seen as an insider, I could not assume that this status would automatically result in a good rapport with the participants. I needed to actively build a positive researcher- participant relationship. I needed to encourage trust by presenting myself as someone motivated to learn about IENs’ experiences. Telling IENs about my background and the reason for my interest in IENs helped build trust and encourage openness. Most of the IENs were recruited through other participants or nursing colleagues. This helped in building rapport, as I was seen as a friend of a friend and not a complete stranger. Another problem, arising from my status as an IEN, was the challenge of maintaining the role of researcher (Bonner & Tolhurst, 2002). I was at times at risk of slipping into the role of colleague, advisor, advocate, or even friend. Through being aware of this risk and continuously monitoring my behavior, I was able to maintain a balance between my insider position and my researcher status.

Ethical Considerations

The Health Research Ethics Board of the University of Alberta approved the research project before I began recruitment. Ethical considerations such as justice, beneficence, and autonomy are crucial in satisfying the ethical component of a research project (Orb, Eisenhauer, & Wynaden, 2000). Autonomy in research is exercised through informed consent prior and during the research process. Informed consent includes four essential elements: competence of the participant to give consent, voluntary consent, disclosure of essential information to the participant, and comprehension of the information by the participant (Burns & Grove, 2007). Participants were asked to read and sign a consent form which included an information letter containing the necessary information for ethical consent (see Appendix B). A copy of the signed consent form was given to the participant. I informed the participants of the goals of the research project. I emphasized the right to withdraw at any phase of the research or interview process.

It was, also, important that participants were not exposed to any harm as a result of participating in the study. Confidentiality is the concealing of information provided by the participant from others, so that the public is unable to identify participants in the final research product (Speziale & Carpenter, 2007). Confidentiality was a priority here, especially since participants revealed sensitive issues related to career advancement and education opportunities. The fear of reprimand, if negative experiences were related, was a legitimate concern for participants. All transcripts were identified using numbers. A list of these numbers with the corresponding individual identification, were kept in a separate locked cabinet accessible to me and my supervisor, Kathy Hegadoren. Any report, presented or published as a result of this study, will not identify names or places of employment. The names of the hospitals where participants are employed are excluded from this final report. Data will be stored in a locked cabinet accessible only to the research team, I and my supervisor Kathy Hegadoren. The original transcripts will be kept by Kathy Hegadoren under lock and key for seven years following the interview, after which the transcripts will be destroyed. Also, the contact number was only accessible to me and a research coordinator who would answer the phone in my absence.

Justice refers to fairness and is essential when conducting ethical research. I was aware of the nature of the researcher-participant relationship. I acknowledged the power differentials present, which exist inherently in the nature of the research process. I am an IEN who is committed to advocating for other IENs working in Canada. In this process, I am not one of them. I was aware that as a master’s student I might be perceived in a different light than other IENs. I determined the question and directed the interview process. I was, also, responsible for interpreting the data and disseminating the findings. Hence, throughout the research process a power differential between me and the research participants was unavoidable.

Research must be relevant and make a useful contribution to be considered ethical (Flick, 2007). It is unethical to waste time and resources, and to burden participants for a research project that does not satisfy this component of ethical practice. This research study brings insight into an area often neglected within the healthcare system. Understanding the experience of IENs working in Canada is the first step in a series of necessary steps to improve the working conditions of our healthcare workforce. Another component of ethical research is quality assurance. Research that fails to meet the standards of good quality is not ethical research (Flick, 2007). The researcher must adhere to quality assurance and make this process explicit in the research process. In summary, conducting ethical research means being aware of the ethical obligations inherent in the entire process.

Chapter 4

Study Findings

Participant Demographics and Characteristics

Participants were IENs from a diverse mix of countries: Guyana, China, Iran, Philippines, India, Britain, and New Zealand. Two participants were between 20 and 30 years of age. Three participants were between 30 and 40 years of age. The remaining eight participants were above 45years of age. All except one of the participants were female and all except two of the participants were married. All married participants had children. Eight participants entered Canada as immigrants. One of the participants entered with a work visa and later applied for Canadian residency. Another participant came on a student visa and, also, applied for Canadian residency.

Participants had all worked in their home countries as RNs in the hospital setting. Some participants had, also, worked in community settings. Three participants had held management positions, and/or teaching positions in their home countries. Length of residency in Canada ranged from a minimum of four years to a maximum of twenty-one years. In Canada, participants’ work settings included long-term care, rehabilitation, intensive care, surgical specialty areas, internal medicine, mental health and geriatric specialty areas.

Participants did not experience dynamic career mobility in Canada. This was attributed to a variety of factors. Some participants liked their specialty areas. Others found their positions convenient with regards to location or shift scheduling. For some participants it was the desire to maintain the sense of belonging and security that developed in a job setting over time. Many participants working in Alberta during the health-care restructuring time, in the 1990s, attributed employment choices to the lack of jobs and the need for a steady income. This meant, for some, casual and part-time jobs in various specialty areas. For others, it meant remaining in one job over an extended period to maintain seniority.

All except two of the participants were working as RNs at the time of the interview. Only one participant, the male IEN, was employed in a manager role. None of the other participants had held a management position in Canada. One participant with a master’s degree was teaching in the clinical setting. Education qualifications differed among participants. Three participants had their master’s degrees. One of the participants obtained her master’s degree through an online university in New Zealand. The second and third participants studied in a Canadian university. Another participant had certificates in gerontology and mental health. The remaining participants did not have official degrees other than a Bachelor of Science in Nursing. Many, however, had completed courses and/ or workshops for continuing competencies over the span of their careers.

The IENs who participated in this study are diverse in terms of demographics, educational attainments, and career paths. This meant diversity in participants’ experiences regarding opportunities for career and education advancement in Canada. However, data analysis revealed commonalities of experience that transcended these differences. These commonalities in experie