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Experiences of internationally qualified registered nurses enrolled in a bridging program in Australia: A pilot study
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Experiences of internationally qualified registered nurses enrolled in a bridging program in Australia: A pilot study Christina Aggara,b,∗ , Lucy Shinnersb , Tamsin Thomasb , Lynette Stockhausenb a b
Southern Cross University, Gold Coast Campus, Southern Cross Drive, Bilinga, Qld 4225, Australia Department - School of Health and Human Sciences, Australia
a r t i c l e
i n f o
Article history: Received 3 July 2019 Received in revised form 4 September 2019 Accepted 7 September 2019 Available online xxx Keywords: Internationally qualified registered nurses
a b s t r a c t Background: The recruitment of internationally qualified registered nurses (IQNs) is one strategy to meet Australia’s healthcare needs. New Australian Standards require some IQNs to complete an approved bridging program run by an eligible higher education institution in Australia. Little is known about the experiences of the IQNs enrolled in these bridging programs or their intention to remain in the workforce. Aim: The aim of this pilot study was to investigate the experiences of IQNs enrolled in an approved bridging program and explore their intention to remain and seek employment in the Australian healthcare system. Methods: Students enrolled in the Graduate Certificate in Australian Nursing program for internationally qualified registered nurses at a regional Australian university were invited to participate. A longitudinal, mixed-methods, exploratory design was used. Participants completed the Six-dimension Scale of Nursing Performance (Schwirian, 1978) and the Casey-Fink Graduate Nurse Experience Survey (Casey et al., 2004) pre, and post-program, and also participated in post-program focus groups. Findings: The program met participant expectations, provided confidence in clinical practice and perceived competence, particularly in the leadership domain. However, the cultural differences and expectations in nursing and academia experienced by participants require further investigation and intervention. Over time, the participants experienced stress related to social and financial issues, with the greatest concern around gaining employment. All participants indicated their intention to remain and seek employment in the Australian healthcare system. Discussion: IQNs enrolled in approved bridging programs intend to remain in the workforce. Consideration of how to support IQNs experiencing social and financial stress, and achieve successful employment post program is warranted. Conclusion: A transition to professional practice program may support the integration of IQNs into the Australian healthcare workforce. © 2019 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Summary of Relevance Problem Little is known about the experiences of the IQNs enrolled in approved bridging programs or their intention to remain in the workforce. What is Already Known Acculturation impacts IQNs’ quality of life, their ability to adapt to the work environment overall satisfaction with work environments, and staff retention.
∗ Corresponding author at: Southern Cross University, Gold Coast Campus, Southern Cross Drive, Bilinga, Qld 4225, Australia. E-mail address: [email protected] (C. Aggar).
What this Paper Adds A transition to professional practice program may support the integration of IQNs into the Australian healthcare workforce.
1. Introduction Australia has an ageing population and increasing prevalence of complex chronic illness and multimorbidity (Australian Institute of Health & Welfare, 2016), and registered nurses (RNs) are integral to the capacity of the Australian healthcare system to meet these increasing population demands (Health Workforce Australia, 2014). However, the nursing workforce in Australia is also ageing (Department of Health, 2014), and the availability of experienced nurses is decreasing (Australian Nursing & Midwifery Accreditation Council, 2014). Consequently, there is a predicted
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shortage of RNs in the workforce, which is reflected worldwide (Health Workforce Australia, 2012; Department of Health, 2014). To address this shortage, Australian nurses are being encouraged to return to practice, and internationally qualified registered nurses (IQNs) are being encouraged to practise in Australia (Russell, 2013), for example through improved education and training opportunities (Health Workforce Australia, 2012; Negin, Rozea, Cloyd, & Martiniuk, 2013). As a result there has been a growing interest by IQNs to become registered in Australia, regardless of the strict registration and visa requirements (Department of Immigration & Border Protection, 2017). In 2014, new Australian Accreditation Standards for IQNs seeking Australian registration were developed with the aim of ensuring the quality of the education IQNs receive, and allowing attainment of a nationally recognised qualification (Australian Nursing & Midwifery Accreditation Council, 2014). The new Standards require IQNs to have successfully completed the equivalent of an Australian Bachelor Nursing degree at an accredited education institution, with specific curriculum requirements, including 800 h of workplace experience and successful completion of a medication management assessment. IQNs not meeting national standard requirements may complete an approved bridging program run by an eligible higher education institution in Australia. Little is known about the experiences of the IQNs enrolled in the new bridging programs or their intention to remain in the workforce. 1.1. Literature review There is increasing international and local recognition of the need to explore the experiences of IQNs and their intention to remain in the workforce (Brunero, Smith, & Bates, 2008; Chok, Mannix, Dickson, & Wilkes, 2018; Jenkins & Huntington, 2015; Ohr, Holm, & Brazil, 2016; Xu, 2012). International evidence suggests acculturation impacts IQNs’ quality of life, their ability to adapt to the work environment (Goh & Lopez, 2016), overall satisfaction with work environments, and staff retention (Adeniran et al., 2008; Ohr, Jeong, Parker, & McMillan, 2014). Socioeconomic factors negatively impact IQNs’ sense of competence and levels of stress (Chok et al., 2018; Stankiewicz & O’Connor, 2014). In order to develop confidence, IQNs require support in the clinical setting, as well as leadership development (Cummins, 2009), and the practice of English-language skills in a professional nursing context (Chok et al., 2018; Newton, Pront, & Giles, 2018; Philip, Woodward-Kron, Manias, & Noronha, 2019). The aim of this pilot study was to investigate the experiences of IQNs enrolled in the Graduate Certificate in Australian Nursing program and determine their intention to work in the Australian workforce. The program builds on prior knowledge, skills and nursing experience to develop a deeper understanding of nursing in the Australian healthcare context. The program consists of a four-week intensive theoretical component comprising on-campus lectures, tutorials, and high and low fidelity simulated learning, followed by an eight-week full-time facilitated professional experience placement in an acute care hospital. The research questions guiding this study included: • What are the students’ intention to remain in the Australian healthcare system? • What impact does the program have on students’ competence, confidence and program experience? 2. Method 2.1. Participants All IQNs (n = 9) enrolled in the Graduate Certificate in Australian Nursing program (hereafter ‘the program’), participated in
the study; participants were informed participation in the study was voluntary. 2.2. Ethics Ethical approval was granted by the Southern Cross University Human Research Ethics Committee (ECN-16-305) and methods conformed to the guidelines of the National Statement on Human Experimentation (NHMRC, 2007). Participants received an information sheet and informed consent was indicated by completing and returning the consent form. 2.3. Setting The study was conducted in an Australian regional university. 2.4. Design The program evaluation utilised a longitudinal mixed-methods design. Participants completed questionnaires during program orientation (Time 1; T1) and on completion of the program (Time 2; T2). 2.5. Measures 2.5.1. Demographics Demographic information collected at T1 included country of origin, nursing education, past work experience and current employment status. 2.5.2. Program evaluation 2.5.2.1. The Six-Dimension Scale of Nursing Performance (Schwirian, 1978). This psychometrically tested and widely used tool, assessed IQNs’ self-rated competence. Subscales include leadership, critical care, teaching and collaboration, planning/evaluation, interpersonal relations/communications, and professional development. The tool was adapted so participants were only asked how well they performed skills (no ‘frequency’ questions); ‘N/A’ option was added. Cronbach’s alpha range .86–.95 (Stephenson & Cosme, 2018), the validity has been established in various countries and languages (Szara, Ksykiewicz-Dorota, & Klukow, 2016). 2.5.2.2. The Casey-Fink Nurse Experience Survey (Casey, Fink, Krugman, & Propst, 2004). This psychometrically tested and widely used tool, assessed IQNs’ confidence and program experience. Subscales include stressors, transition challenges, and perceptions of important/beneficial aspects of the program. Cronbach’s alpha range .74–.89, the validity has been established in various countries and languages, and more recently via expert panel (Stephenson & Cosme, 2018). 2.5.3. Intention to remain in the Australian workforce Participant intention to remain in the Australian healthcare system was assessed with two questions: “What are your intentions upon completion of the Graduate Certificate in Australian Nursing program?” and “If you intend to seek employment in Australia as a registered nurse, are your intentions to work in [acute/aged care/community settings/other]?”. 2.5.4. Focus groups The small sample and exploratory nature of this pilot study indicated integration of quantitative and qualitative data to diminish potential weaknesses of a single approach and enhanced validity of findings (Polit & Beck, 2004). Thus, participants also completed focus groups at T2 that assessed the most enabling, and most challenging aspects of the program and how these could be improved.
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Table 1 Participant Demographics. Age (years) Gender (female) Country of origina India UK China Netherlands Philippines Highest education Bachelor’s degree Graduate diploma Master’s degree Doctoral degree Experience as an RN (years) Prior employment settingb Acute care Aged care General practice Rehabilitation a b
M = 34, SD = 9.6 9 (100%) 4 (44%) 2 (22%) 1 (11%) 1 (11%) 1 (11%)
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met expectations, increased confidence, and provided sufficient opportunities to learn and “practice quality nursing”. Participants stated the program provided them with a good understanding of the Australian health system, nursing in the Australian healthcare context and the Australian nursing standards. This program is very helpful for international nurses to be aware of the Australian health system and will greatly benefit future international nurses to work their way through its complexities.
4 (44%) 2 (22%) 2 (22%) 1 (11%) Range 1–13, M = 6.3, SD = 3.7 7 (78%) 3 (33%) 1 (11%) 1 (11%)
Same as country of undergraduate nursing degree for all participants. Do not sum to 100 as some participants worked in more than 1 prior setting.
Focus group questions included: What were the most enabling aspects of the program? What were the most challenging aspects of the program? What aspects of the program could be improved? Focus groups were conducted by a research assistant who had provided logistical support to participants over the course of the study (was known to participants) but who was not involved in any program assessments. 2.6. Analysis Quantitative data were analysed using SPSS 22 (IBM Corp., 2013). Paired-samples t-tests compared participant competence from T1 to T2 with alpha significance cut-off of 0.05. Qualitative data was subjected to thematic analysis and assessed for themes independently by three researchers who discussed their findings. Analysis relied on a pragmatic philosophical approach (Johnson & Onwuegbuzie, 2004) and was based on the methodology described by Braun and Clarke (2006). 3. Results All participants (n = 9) enrolled in the program were female, they had a mean age of 34 years (SD = 9.6), and an average of 6.3 years (SD = 3.7) experience as an RN, primarily in acute care settings (n = 7, 78%); Table 1. Participants’ work experience did not have an impact on results. 3.1. Focus groups Focus groups had a mean duration of 44 min (range 29–61). The following themes derived from the data propose that the program
In order to present comprehensive and integrated results of the study, selected representative comments from the focus groups are presented below with the quantitative results to which they relate. 3.2. Six Dimension Scale of Nursing Performance (Schwirian, 1978) The Six-Dimension Scale of Nursing Performance (Schwirian, 1978), assessed IQN competence. Performance in all domains increased from baseline (Table 2). Perceived clinical leadership ability increased significantly from T1 to T2 (p = .045). Participants reported Australia has comparatively more independence and decision-making capacity than they had previously experienced. They felt that ongoing support following the program would be helpful for integrating into the workforce. During my last week of placement there were newly qualified RNs. They were completing a graduate induction program. I’m not sure but I think they would be placed with an experienced member of staff for a time. Maybe this would be beneficial for international nurses. There was a near significant increase in critical care ability and in professional development capacity, which included the ability to demonstrate self-confidence, and knowledge of legal boundaries and ethics of nursing. One participant reported demonstrating selfconfidence was particularly difficult as: . . .questioning an instruction from a senior nurse is disrespectful. 3.3. Casey-Fink Nurse Experience Survey (Casey et al., 2004) The Casey-Fink Nurse Experience Survey (Casey et al., 2004) assessed participant program experiences including stressors, transition challenges, and perceptions of important/beneficial aspects of the program. 3.3.1. Stress Participant stress tended to increase over the course of the program. Stress related to work and finances increased from T1 (n = 0 experiencing stress) to T2 (n = 4). Similarly, stress related to job performance increased from T1 (n = 2) to T2 (n = 3). Participants had initial concerns about the workload of the program, reporting high study demands contributed to their financial stress as
Table 2 Six Dimension Scale of Nursing Performance (Schwirian, 1978).
Total Score Leadership Critical care Teaching and collaboration Planning and evaluation Interpersonal relations and communication Professional development
Time 1
Time 2
Paired-samples t-test
Mean (SD)
Mean (SD)
t
df
Sig.
3.34 (0.51) 3.24 (0.42) 3.11 (0.62) 3.25 (0.60) 3.33 (0.71) 3.56 (0.40) 3.37 (0.62)
3.67 (0.29) 3.71 (0.33) 3.47 (0.42) 3.50 (0.41) 3.62 (0.41) 3.85 (0.30) 3.79 (0.30)
1.89 2.37 2.04 1.22 1.13 1.59 1.95
8 8 8 8 8 8 8
.096 .045 .075 .256 .292 .150 .087
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Table 3 Importance and Benefits of Aspects of Professional Clinical Placement (Casey et al., 2004).
Peer support Belonging, team approach, helpful and friendly staff Patients and families Making a difference, positive feedback, patient satisfaction/interaction Ongoing learning Preceptors, unit role models, mentorship Professional nursing role Challenge, benefits, fast pace, critical thinking, empowerment Positive work environment Good ratios, available resources, up-to-date technology
Time 1Importance
Time 2Benefit
7 (78%)
8 (89%)
7 (78%)
4 (44%)
3 (33%)
7 (78%)
4 (44%)
6 (67%)
6 (67%)
9 (100%)
they did not get sufficient time to undertake paid employment. They also reported that towards the end of the program they were experiencing greater concerns about gaining employment. The number of participants experiencing stress related to social issues also increased over the course of the program, this included childcare (T1: n = 1, T2: n = 3), living situation (T1: n = 2, T2: n = 5), and personal relationships (T1: n = 0, T2: n = 2). Participants reported personal stress was related to long commutes, caring for small children, or living with extended family or in shared accommodation. Additionally, one participant reported stress due to visa problems.
Participants reported the most challenging aspect of the program was the workload, especially the combination of clinical placements and assignments.
3.3.2. Transition challenges Participants experienced an overall decrease in perceived work transition difficulties. Clinical workload was not identified as difficult throughout the program (n = 0). Role expectation challenges remained constant (n = 2) from T1 to T2, whereas a perceived lack of confidence decreased (T1: n = 6, T2: n = 3).
3.3.4. Intention to seek employment in Australia All participants (n = 9) intended to seek employment in Australia at the end of the program (T2). This did not change significantly from T1 (n = 8). At T2 all participants intended to apply for employment in a number of settings: acute hospital (n = 8), aged care facility (n = 3), community (n = 2), or other (n = 1) i.e. a university. Participants stated they had primarily completed the program to improve their employment prospects in Australia. They were interested in gaining exposure to the Australian healthcare setting, progressing their careers and pursuing further university qualifications in the Australian system.
3.3.3. Program benefits The Casey-Fink tool evaluated which aspects of the program participants anticipated would be important at T1, and which aspects they found beneficial upon reflection on the program at T2; Table 3. At T1, most participants anticipated peer support would be important during the program and at T2 reported it was beneficial. It is really good to meet other professionals and get the opportunity to network, seek advice and support one another. Most participants expected that opportunities for relationships with patients and their families during the program would be important, but after the program only half reported these were beneficial. Prior to program commencement three participants reported opportunities for ongoing learning and preceptorship would be important, at the end of the program the majority felt these aspects benefited them. Similarly, experiencing the professional nursing role was only rated as important by approximately half of the participants at T1, but was rated as beneficial by most participants after the program. The role of the nurse in Australia is so different than what I am used to. . .the [placement] allowed me to become familiar, more confident and practice quality nursing. A positive work environment was anticipated to be important by the majority of participants at T1, and as beneficial by all the participants at T2. [Placement] provided me with adequate awareness and orientation in the clinical setting, our duties, responsibilities and standards of care. Staff were supportive in our learning.
Too [many] tasks including theory study, exams, assignments, and placements in such a short time. Assignments are a new learning method; I never followed APA 6th style. Participants reported the program could be improved by preprogram learning resources, such as: . . ...on-line lectures, pre-reading lists, revision of disease processes and pathophysiology, as well as communication skills.
4. Discussion This pilot study explored the experiences of IQNs enrolled in a Graduate Certificate in Australian Nursing program in a regional university. The results of this study indicate that participants graduating from the bridging program intended to remain and seek residency and employment in the Australian healthcare setting, and that the program improved their competence and confidence, and provided an overall valuable experience. Participants found the study workload challenging, however they reported the clinical workload was manageable. Atack et al. (2012) also found that IQNs had difficulty in managing workload despite using time management strategies. They attributed this to either a lapse in study skills or exposure to a different educational system (Atack et al., 2012). Support with academic skills, such as referencing techniques and a hybrid course structure to improve computer skills, has been beneficial to IQNs (Ohr et al., 2014; Stubbs, 2017). Whilst academic skills support is available for international students, online delivery of pre-program resources and additional reading material may also prepare and support IQNs experience of a study program workload. Participants suggested that there was more autonomy, independence and leadership in nursing practice in Australia than they had experienced in their home country. Most of the participants enrolled in the program were from non-English speaking backgrounds, originating from China, Philippines and India. Jenkins and Huntington (2015) and Sherman and Eggenberger (2008),
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reported similar percentages of nationality cohorts in New Zealand and Canada, respectively. Takeno (2010) found that IQNs were impacted most by the difference in values and systems embedded in nursing in Australia. This may be because ideologies such as the interaction of nurses with individuals and groups differ in eastern and western countries (Obrey & Shillingford, 2011; Xu & He, 2012). Other cultural differences include role and expectations of the nurse, scope of practice, legal environment, accountability, professional autonomy, healthcare technology and the relationship between the nurse and physician (Chege & Garon, 2010; Xu & He, 2012; Isherwood & King, 2017; Montayre, Montayre, & Holroyd, 2018). In order to improve confidence, IQNs need academic and clinical assessment support, and time to develop leadership skills and ethical and legal accountability (Newton, Pront, & Giles, 2016). Research has demonstrated that IQNs require a comprehensive level of support during the transition to professional practice, including orientation and regular preceptorship (Adeniran et al., 2008; Ohr et al., 2016; Ohr et al., 2014). Montayre et al. (2018) suggest internationally qualified nurses require culturally targeted support, and further recommends an international transcultural nursing framework and standards. Stress experienced by participants was related to a full-time study load, concerns about future employment, finances, and social stress. International studies have reported IQNs being under considerable financial, professional and personal pressure (Bland & Woolbridge, 2011; Chok et al., 2018; Jose, 2011). Dywili and O’Brien (2013) found that economic and professional development factors dominate IQNs’ reasons to migrate, and some migrate under stressful circumstances such as political instability and/or leaving their families and friends. Jenkins and Huntington (2015) suggest more research is needed to understand the financial burden that IQNs undertake when making the decision to migrate. Whilst financial support from the university is minimal, short term accommodation support is available upon arrival. There may however, be a need for logistical support during the pre-arrival period to reduce IQN stress (Xu, 2012; Walker & Clendon, 2012). Studies have established acculturation impacts IQNs’ quality of life and ability to adapt to the work environment (Goh & Lopez, 2016). Culturally sensitive preceptor and mentorship teaching programs that develop communication skills (Higginbottom et al., 2011; Case, 2015), and address non-verbal behaviours, have been found to support the experience of IQNs during integration to the host country healthcare system (Philip, Manias, & Woodward-Kron, 2015; Pung and Goh, 2017). It has also been reported that such support impacts IQNs’ overall satisfaction with the work environment (Adeniran et al., 2008; Ohr et al., 2014). Participants reported a desire for ongoing support after completion of the bridging program. Post-program, IQNs are faced with the challenges of a complex healthcare system and the need for ongoing professional development (Dywili & O’Brien, 2013; Ohr et al., 2016; Stankiewicz & O’Connor, 2014; Xu, 2012). Therefore, to support the IQNs’ level of commitment to the workplace, there is a need to provide them with future workplace opportunities. A transformative adaptive model to support the integration of IQNs into the workforce could be achieved through a transition-to-practice program. In addition to orientation, such a program could include information about systems, professional stakeholders, the community, populations served and expected cultural practices (Ohr et al., 2014, 2016; Sherwood & Shaffer 2014; Stankiewicz & O’Connor, 2014; Zizzo & Xu, 2009).
5. Limitations This pilot study included a small sample (n = 9) of female only participants, a limitation to the quantitative findings. Whilst par-
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ticipants suggested that there was more autonomy, independence and leadership in nursing practice in Australia than they had experienced in their home country, further exploration of this finding comparing registered nurses from non-English and English speaking backgrounds and previous work experience is recommended. 6. Conclusion This pilot study examined the experiences of IQNs transitioning into the Australian nursing workforce through a postgraduate bridging program. Results indicate participants had an overall positive experience. The program met participant expectations, provided confidence in clinical practice and perceived competence, particularly in the leadership domain. However, the cultural differences and expectations in nursing and academia experienced by participants require further investigation and intervention. Over time, the participants experienced stress related to social and financial issues, with the greatest concern around gaining employment. Therefore, consideration of how to support IQNs experiencing social and financial stress, and achieve successful employment post-program is warranted. All participants indicated their intention to remain and seek employment in the Australian healthcare system. Ethical statement This manuscript includes research with human participants. Ethical approval was granted by the Southern Cross University Human Research Ethics Committee (ECN-16-305) on the 24th October, 2016, and methods conformed to the guidelines of the National Statement on Human Experimentation (NHMRC, 2007). Recommendations Pre-program preparation consisting of on-line resources and additional reading material. A transition to professional practice program may support the integration of IQNs into the Australian healthcare workforce. Declaration of Competing Interest The authors declare that they have no conflict of interest. Acknowledgements There has been no financial assistance for this program or evaluation. References Adeniran, R. K., Rich, V. L., Gonzalez, E., Peterson, C., Jost, S., & Gabriel, M. (2008). Transitioning internationally educated nurses for success: A model program. Online Journal of Issues in Nursing, 13(2). Atack, L., Cruz, E., Maher, J., & Murphy, S. (2012). Internationally educated nurses’ experiences with an integrated bridge program. Journal of Continuing Education in Nursing, 43(8), 370–378. Australian Institute of Health and Welfare. (2016). Australia’s health 2016 no. 15 Canberra Cat. No. AUS 199. AIHW. Australian Nursing and Midwifery Accreditation Council. (2014). Entry programs for internationally qualified registered nurses: Accreditation standards 2014. Canberra: ANMAC. Retrieved from. www.anmac.org.au/publications Bland, M., & Woolbridge, M. (2011). From India to New Zealand – A challenging but rewarding passage. Kai Tiaki: New Zealand Nursing, 17(10), 21–23. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. Brunero, S., Smith, J., & Bates, E. (2008). Expectations and experiences of recently recruited overseas qualified nurses in Australia. Contemporary Nurse, 28(1–2), 101–110. Case, D. L. (2015). Providing continuing education for international nurses. The Journal of Continuing Education in Nursing, 46(10), 428–430.
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Contents lists available at ScienceDirect
Collegian journal homepage: www.elsevier.com/locate/coll
Experiences of internationally qualified registered nurses enrolled in a bridging program in Australia: A pilot study Christina Aggara,b,∗ , Lucy Shinnersb , Tamsin Thomasb , Lynette Stockhausenb a b
Southern Cross University, Gold Coast Campus, Southern Cross Drive, Bilinga, Qld 4225, Australia Department - School of Health and Human Sciences, Australia
a r t i c l e
i n f o
Article history: Received 3 July 2019 Received in revised form 4 September 2019 Accepted 7 September 2019 Available online xxx Keywords: Internationally qualified registered nurses
a b s t r a c t Background: The recruitment of internationally qualified registered nurses (IQNs) is one strategy to meet Australia’s healthcare needs. New Australian Standards require some IQNs to complete an approved bridging program run by an eligible higher education institution in Australia. Little is known about the experiences of the IQNs enrolled in these bridging programs or their intention to remain in the workforce. Aim: The aim of this pilot study was to investigate the experiences of IQNs enrolled in an approved bridging program and explore their intention to remain and seek employment in the Australian healthcare system. Methods: Students enrolled in the Graduate Certificate in Australian Nursing program for internationally qualified registered nurses at a regional Australian university were invited to participate. A longitudinal, mixed-methods, exploratory design was used. Participants completed the Six-dimension Scale of Nursing Performance (Schwirian, 1978) and the Casey-Fink Graduate Nurse Experience Survey (Casey et al., 2004) pre, and post-program, and also participated in post-program focus groups. Findings: The program met participant expectations, provided confidence in clinical practice and perceived competence, particularly in the leadership domain. However, the cultural differences and expectations in nursing and academia experienced by participants require further investigation and intervention. Over time, the participants experienced stress related to social and financial issues, with the greatest concern around gaining employment. All participants indicated their intention to remain and seek employment in the Australian healthcare system. Discussion: IQNs enrolled in approved bridging programs intend to remain in the workforce. Consideration of how to support IQNs experiencing social and financial stress, and achieve successful employment post program is warranted. Conclusion: A transition to professional practice program may support the integration of IQNs into the Australian healthcare workforce. © 2019 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Summary of Relevance Problem Little is known about the experiences of the IQNs enrolled in approved bridging programs or their intention to remain in the workforce. What is Already Known Acculturation impacts IQNs’ quality of life, their ability to adapt to the work environment overall satisfaction with work environments, and staff retention.
∗ Corresponding author at: Southern Cross University, Gold Coast Campus, Southern Cross Drive, Bilinga, Qld 4225, Australia. E-mail address: [email protected] (C. Aggar).
What this Paper Adds A transition to professional practice program may support the integration of IQNs into the Australian healthcare workforce.
1. Introduction Australia has an ageing population and increasing prevalence of complex chronic illness and multimorbidity (Australian Institute of Health & Welfare, 2016), and registered nurses (RNs) are integral to the capacity of the Australian healthcare system to meet these increasing population demands (Health Workforce Australia, 2014). However, the nursing workforce in Australia is also ageing (Department of Health, 2014), and the availability of experienced nurses is decreasing (Australian Nursing & Midwifery Accreditation Council, 2014). Consequently, there is a predicted
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shortage of RNs in the workforce, which is reflected worldwide (Health Workforce Australia, 2012; Department of Health, 2014). To address this shortage, Australian nurses are being encouraged to return to practice, and internationally qualified registered nurses (IQNs) are being encouraged to practise in Australia (Russell, 2013), for example through improved education and training opportunities (Health Workforce Australia, 2012; Negin, Rozea, Cloyd, & Martiniuk, 2013). As a result there has been a growing interest by IQNs to become registered in Australia, regardless of the strict registration and visa requirements (Department of Immigration & Border Protection, 2017). In 2014, new Australian Accreditation Standards for IQNs seeking Australian registration were developed with the aim of ensuring the quality of the education IQNs receive, and allowing attainment of a nationally recognised qualification (Australian Nursing & Midwifery Accreditation Council, 2014). The new Standards require IQNs to have successfully completed the equivalent of an Australian Bachelor Nursing degree at an accredited education institution, with specific curriculum requirements, including 800 h of workplace experience and successful completion of a medication management assessment. IQNs not meeting national standard requirements may complete an approved bridging program run by an eligible higher education institution in Australia. Little is known about the experiences of the IQNs enrolled in the new bridging programs or their intention to remain in the workforce. 1.1. Literature review There is increasing international and local recognition of the need to explore the experiences of IQNs and their intention to remain in the workforce (Brunero, Smith, & Bates, 2008; Chok, Mannix, Dickson, & Wilkes, 2018; Jenkins & Huntington, 2015; Ohr, Holm, & Brazil, 2016; Xu, 2012). International evidence suggests acculturation impacts IQNs’ quality of life, their ability to adapt to the work environment (Goh & Lopez, 2016), overall satisfaction with work environments, and staff retention (Adeniran et al., 2008; Ohr, Jeong, Parker, & McMillan, 2014). Socioeconomic factors negatively impact IQNs’ sense of competence and levels of stress (Chok et al., 2018; Stankiewicz & O’Connor, 2014). In order to develop confidence, IQNs require support in the clinical setting, as well as leadership development (Cummins, 2009), and the practice of English-language skills in a professional nursing context (Chok et al., 2018; Newton, Pront, & Giles, 2018; Philip, Woodward-Kron, Manias, & Noronha, 2019). The aim of this pilot study was to investigate the experiences of IQNs enrolled in the Graduate Certificate in Australian Nursing program and determine their intention to work in the Australian workforce. The program builds on prior knowledge, skills and nursing experience to develop a deeper understanding of nursing in the Australian healthcare context. The program consists of a four-week intensive theoretical component comprising on-campus lectures, tutorials, and high and low fidelity simulated learning, followed by an eight-week full-time facilitated professional experience placement in an acute care hospital. The research questions guiding this study included: • What are the students’ intention to remain in the Australian healthcare system? • What impact does the program have on students’ competence, confidence and program experience? 2. Method 2.1. Participants All IQNs (n = 9) enrolled in the Graduate Certificate in Australian Nursing program (hereafter ‘the program’), participated in
the study; participants were informed participation in the study was voluntary. 2.2. Ethics Ethical approval was granted by the Southern Cross University Human Research Ethics Committee (ECN-16-305) and methods conformed to the guidelines of the National Statement on Human Experimentation (NHMRC, 2007). Participants received an information sheet and informed consent was indicated by completing and returning the consent form. 2.3. Setting The study was conducted in an Australian regional university. 2.4. Design The program evaluation utilised a longitudinal mixed-methods design. Participants completed questionnaires during program orientation (Time 1; T1) and on completion of the program (Time 2; T2). 2.5. Measures 2.5.1. Demographics Demographic information collected at T1 included country of origin, nursing education, past work experience and current employment status. 2.5.2. Program evaluation 2.5.2.1. The Six-Dimension Scale of Nursing Performance (Schwirian, 1978). This psychometrically tested and widely used tool, assessed IQNs’ self-rated competence. Subscales include leadership, critical care, teaching and collaboration, planning/evaluation, interpersonal relations/communications, and professional development. The tool was adapted so participants were only asked how well they performed skills (no ‘frequency’ questions); ‘N/A’ option was added. Cronbach’s alpha range .86–.95 (Stephenson & Cosme, 2018), the validity has been established in various countries and languages (Szara, Ksykiewicz-Dorota, & Klukow, 2016). 2.5.2.2. The Casey-Fink Nurse Experience Survey (Casey, Fink, Krugman, & Propst, 2004). This psychometrically tested and widely used tool, assessed IQNs’ confidence and program experience. Subscales include stressors, transition challenges, and perceptions of important/beneficial aspects of the program. Cronbach’s alpha range .74–.89, the validity has been established in various countries and languages, and more recently via expert panel (Stephenson & Cosme, 2018). 2.5.3. Intention to remain in the Australian workforce Participant intention to remain in the Australian healthcare system was assessed with two questions: “What are your intentions upon completion of the Graduate Certificate in Australian Nursing program?” and “If you intend to seek employment in Australia as a registered nurse, are your intentions to work in [acute/aged care/community settings/other]?”. 2.5.4. Focus groups The small sample and exploratory nature of this pilot study indicated integration of quantitative and qualitative data to diminish potential weaknesses of a single approach and enhanced validity of findings (Polit & Beck, 2004). Thus, participants also completed focus groups at T2 that assessed the most enabling, and most challenging aspects of the program and how these could be improved.
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Table 1 Participant Demographics. Age (years) Gender (female) Country of origina India UK China Netherlands Philippines Highest education Bachelor’s degree Graduate diploma Master’s degree Doctoral degree Experience as an RN (years) Prior employment settingb Acute care Aged care General practice Rehabilitation a b
M = 34, SD = 9.6 9 (100%) 4 (44%) 2 (22%) 1 (11%) 1 (11%) 1 (11%)
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met expectations, increased confidence, and provided sufficient opportunities to learn and “practice quality nursing”. Participants stated the program provided them with a good understanding of the Australian health system, nursing in the Australian healthcare context and the Australian nursing standards. This program is very helpful for international nurses to be aware of the Australian health system and will greatly benefit future international nurses to work their way through its complexities.
4 (44%) 2 (22%) 2 (22%) 1 (11%) Range 1–13, M = 6.3, SD = 3.7 7 (78%) 3 (33%) 1 (11%) 1 (11%)
Same as country of undergraduate nursing degree for all participants. Do not sum to 100 as some participants worked in more than 1 prior setting.
Focus group questions included: What were the most enabling aspects of the program? What were the most challenging aspects of the program? What aspects of the program could be improved? Focus groups were conducted by a research assistant who had provided logistical support to participants over the course of the study (was known to participants) but who was not involved in any program assessments. 2.6. Analysis Quantitative data were analysed using SPSS 22 (IBM Corp., 2013). Paired-samples t-tests compared participant competence from T1 to T2 with alpha significance cut-off of 0.05. Qualitative data was subjected to thematic analysis and assessed for themes independently by three researchers who discussed their findings. Analysis relied on a pragmatic philosophical approach (Johnson & Onwuegbuzie, 2004) and was based on the methodology described by Braun and Clarke (2006). 3. Results All participants (n = 9) enrolled in the program were female, they had a mean age of 34 years (SD = 9.6), and an average of 6.3 years (SD = 3.7) experience as an RN, primarily in acute care settings (n = 7, 78%); Table 1. Participants’ work experience did not have an impact on results. 3.1. Focus groups Focus groups had a mean duration of 44 min (range 29–61). The following themes derived from the data propose that the program
In order to present comprehensive and integrated results of the study, selected representative comments from the focus groups are presented below with the quantitative results to which they relate. 3.2. Six Dimension Scale of Nursing Performance (Schwirian, 1978) The Six-Dimension Scale of Nursing Performance (Schwirian, 1978), assessed IQN competence. Performance in all domains increased from baseline (Table 2). Perceived clinical leadership ability increased significantly from T1 to T2 (p = .045). Participants reported Australia has comparatively more independence and decision-making capacity than they had previously experienced. They felt that ongoing support following the program would be helpful for integrating into the workforce. During my last week of placement there were newly qualified RNs. They were completing a graduate induction program. I’m not sure but I think they would be placed with an experienced member of staff for a time. Maybe this would be beneficial for international nurses. There was a near significant increase in critical care ability and in professional development capacity, which included the ability to demonstrate self-confidence, and knowledge of legal boundaries and ethics of nursing. One participant reported demonstrating selfconfidence was particularly difficult as: . . .questioning an instruction from a senior nurse is disrespectful. 3.3. Casey-Fink Nurse Experience Survey (Casey et al., 2004) The Casey-Fink Nurse Experience Survey (Casey et al., 2004) assessed participant program experiences including stressors, transition challenges, and perceptions of important/beneficial aspects of the program. 3.3.1. Stress Participant stress tended to increase over the course of the program. Stress related to work and finances increased from T1 (n = 0 experiencing stress) to T2 (n = 4). Similarly, stress related to job performance increased from T1 (n = 2) to T2 (n = 3). Participants had initial concerns about the workload of the program, reporting high study demands contributed to their financial stress as
Table 2 Six Dimension Scale of Nursing Performance (Schwirian, 1978).
Total Score Leadership Critical care Teaching and collaboration Planning and evaluation Interpersonal relations and communication Professional development
Time 1
Time 2
Paired-samples t-test
Mean (SD)
Mean (SD)
t
df
Sig.
3.34 (0.51) 3.24 (0.42) 3.11 (0.62) 3.25 (0.60) 3.33 (0.71) 3.56 (0.40) 3.37 (0.62)
3.67 (0.29) 3.71 (0.33) 3.47 (0.42) 3.50 (0.41) 3.62 (0.41) 3.85 (0.30) 3.79 (0.30)
1.89 2.37 2.04 1.22 1.13 1.59 1.95
8 8 8 8 8 8 8
.096 .045 .075 .256 .292 .150 .087
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Table 3 Importance and Benefits of Aspects of Professional Clinical Placement (Casey et al., 2004).
Peer support Belonging, team approach, helpful and friendly staff Patients and families Making a difference, positive feedback, patient satisfaction/interaction Ongoing learning Preceptors, unit role models, mentorship Professional nursing role Challenge, benefits, fast pace, critical thinking, empowerment Positive work environment Good ratios, available resources, up-to-date technology
Time 1Importance
Time 2Benefit
7 (78%)
8 (89%)
7 (78%)
4 (44%)
3 (33%)
7 (78%)
4 (44%)
6 (67%)
6 (67%)
9 (100%)
they did not get sufficient time to undertake paid employment. They also reported that towards the end of the program they were experiencing greater concerns about gaining employment. The number of participants experiencing stress related to social issues also increased over the course of the program, this included childcare (T1: n = 1, T2: n = 3), living situation (T1: n = 2, T2: n = 5), and personal relationships (T1: n = 0, T2: n = 2). Participants reported personal stress was related to long commutes, caring for small children, or living with extended family or in shared accommodation. Additionally, one participant reported stress due to visa problems.
Participants reported the most challenging aspect of the program was the workload, especially the combination of clinical placements and assignments.
3.3.2. Transition challenges Participants experienced an overall decrease in perceived work transition difficulties. Clinical workload was not identified as difficult throughout the program (n = 0). Role expectation challenges remained constant (n = 2) from T1 to T2, whereas a perceived lack of confidence decreased (T1: n = 6, T2: n = 3).
3.3.4. Intention to seek employment in Australia All participants (n = 9) intended to seek employment in Australia at the end of the program (T2). This did not change significantly from T1 (n = 8). At T2 all participants intended to apply for employment in a number of settings: acute hospital (n = 8), aged care facility (n = 3), community (n = 2), or other (n = 1) i.e. a university. Participants stated they had primarily completed the program to improve their employment prospects in Australia. They were interested in gaining exposure to the Australian healthcare setting, progressing their careers and pursuing further university qualifications in the Australian system.
3.3.3. Program benefits The Casey-Fink tool evaluated which aspects of the program participants anticipated would be important at T1, and which aspects they found beneficial upon reflection on the program at T2; Table 3. At T1, most participants anticipated peer support would be important during the program and at T2 reported it was beneficial. It is really good to meet other professionals and get the opportunity to network, seek advice and support one another. Most participants expected that opportunities for relationships with patients and their families during the program would be important, but after the program only half reported these were beneficial. Prior to program commencement three participants reported opportunities for ongoing learning and preceptorship would be important, at the end of the program the majority felt these aspects benefited them. Similarly, experiencing the professional nursing role was only rated as important by approximately half of the participants at T1, but was rated as beneficial by most participants after the program. The role of the nurse in Australia is so different than what I am used to. . .the [placement] allowed me to become familiar, more confident and practice quality nursing. A positive work environment was anticipated to be important by the majority of participants at T1, and as beneficial by all the participants at T2. [Placement] provided me with adequate awareness and orientation in the clinical setting, our duties, responsibilities and standards of care. Staff were supportive in our learning.
Too [many] tasks including theory study, exams, assignments, and placements in such a short time. Assignments are a new learning method; I never followed APA 6th style. Participants reported the program could be improved by preprogram learning resources, such as: . . ...on-line lectures, pre-reading lists, revision of disease processes and pathophysiology, as well as communication skills.
4. Discussion This pilot study explored the experiences of IQNs enrolled in a Graduate Certificate in Australian Nursing program in a regional university. The results of this study indicate that participants graduating from the bridging program intended to remain and seek residency and employment in the Australian healthcare setting, and that the program improved their competence and confidence, and provided an overall valuable experience. Participants found the study workload challenging, however they reported the clinical workload was manageable. Atack et al. (2012) also found that IQNs had difficulty in managing workload despite using time management strategies. They attributed this to either a lapse in study skills or exposure to a different educational system (Atack et al., 2012). Support with academic skills, such as referencing techniques and a hybrid course structure to improve computer skills, has been beneficial to IQNs (Ohr et al., 2014; Stubbs, 2017). Whilst academic skills support is available for international students, online delivery of pre-program resources and additional reading material may also prepare and support IQNs experience of a study program workload. Participants suggested that there was more autonomy, independence and leadership in nursing practice in Australia than they had experienced in their home country. Most of the participants enrolled in the program were from non-English speaking backgrounds, originating from China, Philippines and India. Jenkins and Huntington (2015) and Sherman and Eggenberger (2008),
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reported similar percentages of nationality cohorts in New Zealand and Canada, respectively. Takeno (2010) found that IQNs were impacted most by the difference in values and systems embedded in nursing in Australia. This may be because ideologies such as the interaction of nurses with individuals and groups differ in eastern and western countries (Obrey & Shillingford, 2011; Xu & He, 2012). Other cultural differences include role and expectations of the nurse, scope of practice, legal environment, accountability, professional autonomy, healthcare technology and the relationship between the nurse and physician (Chege & Garon, 2010; Xu & He, 2012; Isherwood & King, 2017; Montayre, Montayre, & Holroyd, 2018). In order to improve confidence, IQNs need academic and clinical assessment support, and time to develop leadership skills and ethical and legal accountability (Newton, Pront, & Giles, 2016). Research has demonstrated that IQNs require a comprehensive level of support during the transition to professional practice, including orientation and regular preceptorship (Adeniran et al., 2008; Ohr et al., 2016; Ohr et al., 2014). Montayre et al. (2018) suggest internationally qualified nurses require culturally targeted support, and further recommends an international transcultural nursing framework and standards. Stress experienced by participants was related to a full-time study load, concerns about future employment, finances, and social stress. International studies have reported IQNs being under considerable financial, professional and personal pressure (Bland & Woolbridge, 2011; Chok et al., 2018; Jose, 2011). Dywili and O’Brien (2013) found that economic and professional development factors dominate IQNs’ reasons to migrate, and some migrate under stressful circumstances such as political instability and/or leaving their families and friends. Jenkins and Huntington (2015) suggest more research is needed to understand the financial burden that IQNs undertake when making the decision to migrate. Whilst financial support from the university is minimal, short term accommodation support is available upon arrival. There may however, be a need for logistical support during the pre-arrival period to reduce IQN stress (Xu, 2012; Walker & Clendon, 2012). Studies have established acculturation impacts IQNs’ quality of life and ability to adapt to the work environment (Goh & Lopez, 2016). Culturally sensitive preceptor and mentorship teaching programs that develop communication skills (Higginbottom et al., 2011; Case, 2015), and address non-verbal behaviours, have been found to support the experience of IQNs during integration to the host country healthcare system (Philip, Manias, & Woodward-Kron, 2015; Pung and Goh, 2017). It has also been reported that such support impacts IQNs’ overall satisfaction with the work environment (Adeniran et al., 2008; Ohr et al., 2014). Participants reported a desire for ongoing support after completion of the bridging program. Post-program, IQNs are faced with the challenges of a complex healthcare system and the need for ongoing professional development (Dywili & O’Brien, 2013; Ohr et al., 2016; Stankiewicz & O’Connor, 2014; Xu, 2012). Therefore, to support the IQNs’ level of commitment to the workplace, there is a need to provide them with future workplace opportunities. A transformative adaptive model to support the integration of IQNs into the workforce could be achieved through a transition-to-practice program. In addition to orientation, such a program could include information about systems, professional stakeholders, the community, populations served and expected cultural practices (Ohr et al., 2014, 2016; Sherwood & Shaffer 2014; Stankiewicz & O’Connor, 2014; Zizzo & Xu, 2009).
5. Limitations This pilot study included a small sample (n = 9) of female only participants, a limitation to the quantitative findings. Whilst par-
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ticipants suggested that there was more autonomy, independence and leadership in nursing practice in Australia than they had experienced in their home country, further exploration of this finding comparing registered nurses from non-English and English speaking backgrounds and previous work experience is recommended. 6. Conclusion This pilot study examined the experiences of IQNs transitioning into the Australian nursing workforce through a postgraduate bridging program. Results indicate participants had an overall positive experience. The program met participant expectations, provided confidence in clinical practice and perceived competence, particularly in the leadership domain. However, the cultural differences and expectations in nursing and academia experienced by participants require further investigation and intervention. Over time, the participants experienced stress related to social and financial issues, with the greatest concern around gaining employment. Therefore, consideration of how to support IQNs experiencing social and financial stress, and achieve successful employment post-program is warranted. All participants indicated their intention to remain and seek employment in the Australian healthcare system. Ethical statement This manuscript includes research with human participants. Ethical approval was granted by the Southern Cross University Human Research Ethics Committee (ECN-16-305) on the 24th October, 2016, and methods conformed to the guidelines of the National Statement on Human Experimentation (NHMRC, 2007). Recommendations Pre-program preparation consisting of on-line resources and additional reading material. A transition to professional practice program may support the integration of IQNs into the Australian healthcare workforce. Declaration of Competing Interest The authors declare that they have no conflict of interest. Acknowledgements There has been no financial assistance for this program or evaluation. References Adeniran, R. K., Rich, V. L., Gonzalez, E., Peterson, C., Jost, S., & Gabriel, M. (2008). Transitioning internationally educated nurses for success: A model program. Online Journal of Issues in Nursing, 13(2). Atack, L., Cruz, E., Maher, J., & Murphy, S. (2012). Internationally educated nurses’ experiences with an integrated bridge program. Journal of Continuing Education in Nursing, 43(8), 370–378. Australian Institute of Health and Welfare. (2016). Australia’s health 2016 no. 15 Canberra Cat. No. AUS 199. AIHW. Australian Nursing and Midwifery Accreditation Council. (2014). Entry programs for internationally qualified registered nurses: Accreditation standards 2014. Canberra: ANMAC. Retrieved from. www.anmac.org.au/publications Bland, M., & Woolbridge, M. (2011). From India to New Zealand – A challenging but rewarding passage. Kai Tiaki: New Zealand Nursing, 17(10), 21–23. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. Brunero, S., Smith, J., & Bates, E. (2008). Expectations and experiences of recently recruited overseas qualified nurses in Australia. Contemporary Nurse, 28(1–2), 101–110. Case, D. L. (2015). Providing continuing education for international nurses. The Journal of Continuing Education in Nursing, 46(10), 428–430.
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Please cite this article in press as: Aggar, C., et al. Experiences of internationally qualified registered nurses enrolled in a bridging program in Australia: A pilot study. Collegian (2019), https://doi.org/10.1016/j.colegn.2019.09.003