Globalization meets the healthcare workforce: Training, recruitment, and integration for health professionals

Background:

Since the liberalization of immigration in 1965, foreign educated nurses (FENs) have been increasingly recruited to meet the U.S. nursing shortage; 6% of new U.S. nurses in 2000 were immigrants whereas 15% were immigrants in 2004. FENs are part of a critical source of labor for urban, safety net hospitals with a largely underserved, multiracial patient base. It has been widely established that racial/ethnic differences between providers and patients affects quality of care, access to care, and health care service provision.  The potential barriers to effective interactions between immigrant nurses and their patients can be daunting, ranging from cultural differences – both medical and ethnic to linguistic, religious and social class differences. While the presence of immigrant nurses in urban safety net health facilities could have significant effects on the quality of care and health disparities, there is little research on the work experiences of such nurses in urban settings. This paper aims to examine the challenges of interaction and incorporation for one such group of nurses from India working in the U.S., particularly in urban inner-city hospitals. 

Methods:

This project is part of a larger qualitative study that examined the gendered immigration and settlement of Indian nurses, which included 18 months of ethnography among a community of Indian nurses and their families in an urban area of the United States and 6 months of ethnography in the sending community in Kerala, India. The data for this paper is primarily based on twenty-five in-depth interviews with Indian nurses, and direct observational data from a nursing home.

Results:

This study found that Indian nurses face a number of challenges to incorporation in their U.S. urban work settings including 1) racialization at work; 2) distrust of foreigners; 3) gendered and racialized expectations of emotional labor in nursing; and 4) the impact of Indian work experiences, shaped by unique ethnic and professional cultures. The new professional expectations in the United States along with difficult work environments, including rejection by patients, the distrust of co-providers and under-appreciation of administration, increase the level of tension for the nurses and may have implications for the quality of care that they are perceived as providing and consequently for health disparities.

Implications:

With the ongoing nursing shortage and the continuing recruitment of foreign nurses, it is important to recognize that such nurses come with their unique, culturally based professional outlooks and work experiences.  For these nurses to be better positioned to serve their patients, particularly in urban, underserved hospitals, they need to be integrated into the community through appropriate orientation programs.  Community members, co providers and administrators also need to be better informed about the backgrounds and credentials of international recruits. The findings from this study can contribute to the development of assistance programs to orient FEN care providers to their new work contexts in the U.S., develop new information to optimize provider-patient interaction, improve care and inform health disparities, immigration and labor force policy discussions about the continuing trend of recruiting FENs.