Abstract
Chinese-educated nurses are increasingly important to the international labor market. This study aimed to examine how Chinese migrant nurses adapt and evolve professionally while pursuing nursing careers in Australia, using a qualitative descriptive approach. A total of 17 Chinese-educated nurses were recruited by purposive and snowball sampling in Australia during 2017. Data were collected by individual semi-structured interviews and analyzed using thematic analysis. Three central themes and eight subthemes were generated. Perceived differences in nursing involved: work options and flexibility, professional autonomy and independence, and freedom of expressing professional opinions. Elements comprising challenges to adaptation included communication barriers, nursing workload and responsibilities, and collegial relationships. Participants’ professional transition journeys were accompanied by two key areas of self-evolution: Embracing the authentic self and embracing individual differences. Our findings have important implications for migrant-host nursing workforce integration in Australia and internationally.
Transnational nurse migration is a growing global phenomenon driven by a multitude of socioeconomic, professional, and personal factors. 1 Recent decades have witnessed a progressive influx of Asian qualified nurses to western countries through skilled migration programs. 2 Understanding professional adaptation of this cultural group is important to both migrant-host workforce integration and promotion of culturally competent nursing in the host country. While overseas-qualified nurses as a broad cultural group have been extensively studied, limited data are available on the professional adaptation experiences of Chinese migrant nurses, particularly in Australia.
Professional Adaptation of Migrant Nurses Overseas
Ongoing demand for foreign-trained nurses in Western countries is attributed to multiple factors. According to the World Health Organization, 3 the global health care system is increasingly challenged by an aging population and the rising burden of chronic diseases. For high-income countries such as the United States of America (USA) and Australia, overseas nurse recruitment is an efficient way to expand domestic workforce and improve a nation’s health care capacity. 2 It also introduces diversity to the workforce, which may benefit the nation’s multicultural community. 2 In Australia, the 2019 National Health Workforce Survey indicated that overseas-trained nurses constituted approximately 19.5% of the nursing workforce. 4 This figure had increased by 4.6% since 2009. 5
China is a major donor country of nurses, after the Philippines and India, to the Western labor market.2,6 China, with its large nursing labor pool, is seen as a viable source to relieve nursing shortages in the Western world. 7 Moreover, in countries such as Australia, skilled Chinese nurses are particularly beneficial to the Chinese immigrant population, a fast-growing ethnic group. 8 Chinese nurses are capable of bridging linguistic barriers and cultural gaps when providing care to Chinese immigrants, especially the elderly and non-English-speaking community members. Migration can also bring benefits at an individual level. Nursing is a relatively underdeveloped profession in China, with lower professional standing, poorer work conditions, and lack of social recognition. 9 Migrating to high-income countries allows Chinese nurses to practice nursing in a better work environment and with improved socioeconomic and professional status.2,6
Many studies have examined the lived experiences of Asian migrant nurses working in Western countries such as the USA,10-12 Italy, 13 Australia,14-17 and the United Kingdom (UK).18,19 Multiple barriers to professional adaptation among these nurses have been identified, including communication difficulties, cultural clashes, perceived discrimination, and variations in nursing practice.15,16 While previous studies have provided diverse and comprehensive views of Asian migrant nurses’ professional lives in the Western world, their findings are highly context specific. Asian migrant nurses are a heterogenous group of individuals from culturally and ethnically distinct backgrounds, whose acculturation processes in their host environments may vary markedly depending on the countries of origin and destination.
Relatively limited research has examined Chinese migrant nurses’ professional lives in Australia.6,7,20-22 The most recent work was based on data collected more than a decade ago.6,20-22 Considering the unprecedented level of nurse migration from China to Australia over the past decade, 4 robust up-to-date data are required to inform present and future workforce management strategies. Moreover, studies to date have addressed to only a limited degree how Chinese migrant nurses evolved professionally while adapting to their professional roles and practice overseas.6,7,20-22 Particularly, internal transformation that occurs as an essential element of professional adaptation remains insufficiently explored. Further, prior research has examined Chinese migrant nurses’ professional lives through different theoretical lenses, including the concepts of difference 22 and ambivalence. 20 While these theoretical frameworks have allowed unique concept-specific insights into this phenomenon, they may not fully unravel the multifaceted nature of lived experiences of this professional group.
Purpose
The aim of this study was to illuminate how Chinese migrant nurses adapt and evolve professionally while pursuing nursing careers overseas, with Australia chosen as the destination country, through qualitative descriptive analysis. Findings of the research provide valuable insights into the transition journeys of Chinese qualified nurses in overseas professional settings. These data may inform locally tailored workplace strategies to facilitate professional integration of this cultural group and enhance their clinical competence in Australia and internationally.
Methods
Study Design
This article presents work that is a subset of a larger research project in which the identity construction of Chinese migrant nurses in Australia was studied. The overall investigation focused on the process by which Chinese migrant nurses seek to reestablish themselves personally and professionally in a foreign environment. Gidden’s theories of structuration 23 and identity 24 and Connelly and Clandinin’s 25 narrative inquiry methodology were employed as theoretical and methodological underpinnings of the overall investigation. These qualitative approaches were chosen to unravel the dynamic complex interplay between participants’ self-definition and sociocultural contexts into story forms and to capture rich data from these stories. The present study aimed to analyze a subset of the data from the larger research, specifically pertaining to Chinese migrant nurses’ professional transition and adaptation, using a qualitative descriptive approach. The use of Gidden’s theoretical framework was suspended to undertake this descriptive analysis; Methodologically speaking, this was to keep the descriptive analysis close to the participants’ own framing of their migratory and transition experiences. 26
Prior to conducting this secondary analysis, the researchers rigorously assessed the original dataset for comprehensiveness of the data to address the secondary research question. 27 It was determined that the original dataset contained all the necessary data to effectively explore how Chinese migrant nurses adapt and evolve professionally while pursuing nursing careers in Australia at all angles. Additionally, the principal investigator for the primary research was also the one for this secondary analysis. This allows the original context of research where data were collected to be preserved in this secondary investigation.
Ethical Consideration
Ethical approval for this study was obtained from the Monash University Research Ethics Committee (Approval number 0985). Written informed consent was obtained from each participant prior to data collection. Participants were informed of their right to decline participation and withdraw from the study before data analysis. They were also informed that further analyses of the interview data may be undertaken for research purposes aligned with the original ones. All research data were de-identified, and each participant was assigned a pseudonym. Confidentiality was maintained throughout the research process.
Participants and Data Collection
Purposive and snowball sampling was used as the method of recruitment in the broader study. Eligible participants were Australian registered nurses of Chinese ethnicity who received their initial nursing qualification in mainland China and had between 1 and 10 years of work experience in Australia. Two migrant nurses known by the principal investigator were initially approached and were asked to suggest potential participants. Enrolled participants were encouraged to recommend other eligible nurses. Potential participants were contacted by email, message, or WeChat. A sample of 17 Chinese immigrant nurses with diverse demographic and professional characteristics were recruited during 2017 as detailed in Table 1.
Participant Profile (N = 17).
All participants were invited to attend an individual interview either face-to-face or online with the principal investigator at times and locations of their choice. The principal investigator (interviewer) was an English-Mandarin bilingual qualitative researcher in Australia with a nursing background in mainland China. The interviews were conducted either in English (n = 16), or in Mandarin (n = 1), according to participants’ preferences. Interviews were semi-structured, including a short list of guiding questions, such as “Can you tell me about your experiences of. . .?” Typical questions intended for this secondary analysis included the following: “Tell me about your journey of migrating to Australia to work as a nurse?”, “How did you adapt to the new job roles and working environment after migration?”, “How do you perceive nursing as a profession and has it been changed?” and “How do you see yourself as a migrant nurse and has it been changed?” These guiding questions were supplemented by follow-up and probing questions, such as “Can you give me an example of that?” and “What happened next?”. All interviews were audio-recorded except for one which was recorded by handwritten notes as per the participant’s request. The interviewer took descriptive field notes documenting the settings and participants’ body language during and immediately following each interview. The duration of interviews ranged from 39 to 123 minutes (most interviews lasted 50–90 min).
Data Analysis and Rigor
All audio data were transcribed verbatim and combined with field notes. The interview held in Mandarin was translated into English by the principal investigator and cross-checked by a Mandarin-English bilingual researcher not involved in the research project. All transcripts were verified for accuracy by the research team.
Secondary data analysis was jointly performed by two members of the research team, including the principal investigator, using Braun and Clarke’s 28 thematic analysis approach. Interview transcripts were read and reread alongside the field notes, and patterns of meaning within the data were identified and inductively coded. These initial codes were collated and categorized into potential themes. Researchers then reviewed the preliminary themes against each individual code and the entire dataset with modifications made where necessary. Themes were validated by the researchers through their reflective and thoughtful engagement in the data while acknowledging that no single true meaning exists within data. Data saturation for this secondary analysis, whereby no new aspects emerged, was reached at 17 participants.
Several strategies were employed to ensure rigor in this research. To establish dependability of the research findings, an audit trail detailing all steps involved in the broader study and this secondary investigation was maintained. Moreover, peer-debriefing meetings were regularly held to review, discuss, and explore various aspects of the research design and data analysis process. All participants were provided with a report of preliminary research findings and encouraged to participate in member checking. These data were agreed upon by participants as credible and reflective of their true accounts. Furthermore, detailed descriptions of participants’ demographic and professional characteristics were included in this article to enhance transferability of the findings.
Results
Three central themes and eight subthemes were generated to summarize how Chinese migrant nurses adapted and evolved professionally while pursuing nursing careers in Australia.
Perceived Differences in Nursing
Participants reported that a key aspect of adjustment after migrating to Australia to work as registered nurses involved adapting to differences in their professional roles. For most participants, this involved adaptations and shifts in their perceptions of nursing practice. The differences were professionally fulfilling and resulted in expansion of their practices and skills. Three aspects that participants consistently commented on are as follows: (1) diverse employment options and greater work flexibility, (2) higher degree of professional autonomy and independence, and (3) greater freedom to express professional opinions.
Diverse employment options and work flexibility
Participants revealed that the diverse employment options available to nurses in Australia were a major difference to their work experience in China. For example, as reported by Josie and Felicia, nurses could hold multiple concurrent jobs at different health care sectors. They could also undertake advanced practice roles (such as nurse educator, nurse coordinator, and nurse manager) that provided more professional scope of practice as a clinical registered nurse. For some participants, the increased career exploration opportunities in Australia helped alleviate feelings of boredom and stagnation at work that they previously experienced in China due to limited career choices. “[In China], once you are settled in a field of nursing, you do it forever. . .it’s hard to change,” Lara explained. Sophie described her previous work experience in China as being “monotonous” and “repetitive.”
For some participants, casual employment allowed greater work flexibility and helped with maintaining their work–life balance. Jazz stated: “Being an agency nurse, you have the freedom to choose shifts and avoid ones that you don’t like.” Lydia avoided night shifts owing to family duties, and she was delighted she could work this way: “I feel lucky here as I wouldn’t be working in such way if I were still in China.”
Professional autonomy and independence
Nurses’ authority to make independent judgment and autonomous decisions about patient care was highlighted as another key difference in nursing practice between Australia and China, as narrated by participants. For most participants, enhanced professional autonomy, reflected in the more active role nurses played in various aspects of patient care, contributed to their perceived meaningfulness at work. Ysabel and Ella reported that being able to apply critical thinking to some aspects of patient care, such as medication administration and wound care, gave them a sense of fulfilment at work. As Ysabel stated: “You just feel you are more important.” Conversely, nurses in China tend to assume a more passive role in patient management. Madison shared that she used to passively report any problems regarding her patients to doctors without actively thinking about the solutions while working in China. Ella described her clinical practice in China as “simply following doctors’ orders.”
Freedom to express professional views
Participants reported that they had more freedom to express opinions in the workplace culture in Australia. This contrasted with their previous nursing experience in China where “maintaining harmony” and “avoiding disagreement” were emphasized at work. For some participants, being able to freely express professional opinions allowed them to have a more equal, comfortable, and relaxed relationship with managers and senior colleagues. Madison’s narrative exemplified this: “I can respectfully disagree with my nursing manager in patient management as long as I can prove that my proposed approach is the best. I would not dare to challenge my boss in China.” Similarly, Ashley stated: “We (junior and senior nurses) can openly discuss any work-related issues without taking the arguments personally. This is very different in China where I must be cautious when saying anything or they won’t be happy.” Some participants believed that authentic self-expression at work promoted a sense of fairness and equality in the workplace culture. Ella and Hannah described the work culture in Australia as being “more transparent” and “fairer” compared with that in China.
Adaptation Challenges
Participants encountered multiple challenges while adapting to their nursing roles and workplace culture. These challenges induced an array of negative emotions in participants but also represent areas of growth or change which shaped their professional adaptation journeys. These challenges included the following: (1) communication barriers, (2) expansion of responsibilities and workload, and (3) difficulties in maintaining social connections with colleagues.
Communication barriers
Participants experienced various levels of frustration in adapting to communication in native languages at work. Evie and Lauren revealed that colloquial language used by nurses and patients were particularly difficult to understand and learn. As Lauren stated: “Sometimes I can’t understand what they (colleagues) are saying. . .. What I have learnt from textbooks are very different to what have been used in the real world.” Evie added that some Australian accents and slang used by patients “sound like a different language” to her. The inability to communicate effectively with colleagues and patients caused considerable anxiety for some participants. Jazz reported that she always found it stressful to communicate complex information: “What if they (nurses) think I can’t talk properly?” Ella attributed her lack of confidence in patient management to predominantly communication issues: “The way I spoke often make patients think that I am not as competent as other nurses.”
Expansion of responsibilities and workload
Another area of adaptation challenge highlighted in participants’ narratives was the intense workload and responsibilities associated with their nursing roles and practice. Erica, Madison, Sophie, and Ysabel believed that, in addition to providing patient care, the connecting and coordinating roles and practice of registered nurses in Australia contributed to a significant portion of the workload which they found difficult to adapt to. As Sophie stated:
I am responsible for liaising with doctors, physios [physiotherapists], ambulance workers, and client families. In the middle of these, I must find time to administer medications for clients. . .. I normally carry a phone at work, and the phone never stops ringing. . . . I often have no time for breaks at work.
Ysabel and Madison added that the need for continuously updating professional knowledge and managing post-discharge care also added to the workload, causing them to feel under pressure. Ysabel shared: “You have to know a lot about your area of practice to be able to grasp quickly and fully what is going on with your patients and make sense of everything. . .so you have to keep learning.” Madison stated: “There is a lot to worry. . .. If your patient is to be discharged on insulin, you have to make sure that this patient is capable of self-administering insulin, and there is community service available for him/her to seek help from.”
Difficulty in mixing socially with colleagues
The challenge of building strong social connections with colleagues was consistently voiced by participants. Melissa described her relationships with colleagues as “simple but distant.” She explained that her Australian colleagues tended to set “a clear work-life boundary” and were often not approachable after work. Similarly, Lara reported: “[In China] I used to hang out with my colleague after work quite often. . .this no longer occurs here [in Australia].” Ysabel and Hannah attributed this perceived separateness in collegial relationships to cultural differences. As Ysabel illustrated: “In the Western culture, people separate work from personal life very easily, whereas in our Asian culture, professional relationships come into play in personal lives. . .. People build trust in these relationships.”
Evolution of the Self
Participants’ professional transition journeys were accompanied by the following two areas of self-transformation: (1) embracing the authentic self and (2) embracing individual differences. These changes brought substantial personal and professional growth and facilitated their socio-professional integration into Australia.
Embracing the authentic self
A key area of self-transformation that participants experienced was a growing sense of authenticity. This was reflected in both personal career choice and self-expression at work. Sarah, Ysabel, Samantha, Evie, and Hannah revealed that previously family and social expectations weighed heavily on their minds when making career choices, but now they relied more on the self. As Hannah shared: “Now I start to think about a nursing career that suits me best, instead of following the crowd.” Ysabel’s narrative also exemplified this: “I struggled before making this career jump (to be a research nurse) . . .but finally decided to listen to my own heart. . .. It’s so worth it.” Some participants began to practice authentic self-expression in the workplace. Madison and Sophie shared that they now dared to express different opinions at work, whereas previously [in China], they tended to conform to others to maintain group harmony. Erica felt more relaxed at work because of not having to “pretend to be a people-pleaser.”
Embracing individual differences
Another area of self-evaluation participants experienced involved a higher degree of openness toward individual differences. As Ashely stated: “I have learnt to look at each person as a unique being, and not to judge them by their color, age, and culture.” For most participants, this change was directly influenced by their day-to-day experiences of multiculturalism in Australia. Hannah reported that being an ethnic minority at work allowed her to become “more open-minded” and “less judgmental” toward people from other minority groups: “I wouldn’t have thought this way if I were still in China.” Ysabel added that accepting and respecting individual differences was important in the multicultural clinical environment in Australia: “Here (in Australia) patients and health care workers come from all over the world. . .. It is normal that they have different cultural values and beliefs. . .. You have to be open to those differences.”
Discussion
This study illuminated the professional experiences of Chinese-educated nurses working in overseas clinical settings, with Australia chosen as the host country. It is evident that these nurses’ professional transitions were journeys of mixed experiences and involved progressive self-evolution, which served as both drivers and outcomes of their professional adaptation in the new country.
To a large extent, findings of this study align with those of previous research on Asian migrant nurses in Australia and other Western countries. Specifically, perceived greater work flexibility, more career options, and a higher degree of professional autonomy and independence were shared experiences of immigrant Korean, Japanese, and Chinese nurses working in Australia,14,15,21 and immigrant Filipino 12 and Chinese nurses 29 working in the USA. Additionally, communication barriers, perceived differences in nursing roles, and collegial disconnectedness were highlighted as key adaptation challenges faced by migrant Asian nurses working in Western professional settings, including those from India,13,17 the Philippines, 12 Japan, 15 Korea, 12 and China.21,29
Importantly, this study revealed multiple unique aspects of migrant nurses’ professional transition experiences which were rarely documented in the literature. First, our study demonstrated cultural underpinnings of Chinese migrant nurses’ perceptions of professional roles and workplace culture. Independent decision-making, freedom of expression, and critical thinking are values emphasized in the individual-focused culture. 30 Conversely, the group-oriented culture tends to encourage group harmony, boundary ambiguity, and interdependence in work relationships. 30 The perceived differences in nursing reported by participants in this study reflect these cultural differences in professional settings. These findings imply that migrant nurses’ cultural adaptation accompanied and facilitated their professional adaptation. Migrant nurses’ experiences of cultural dissonance have been widely reported in the literature and were recognized as a barrier to their social integration.12,13,17,18,21 Consistent with these findings, our study shows that cultural dissonance impeded Chinese migrant nurses’ forming strong workplace relationships and networks. On the other hand, adaptation to these cultural differences embedded in nursing practice also resulted in a greater sense of professional freedom and fulfillment.
Second, the increased scope of practice and associated need to expand professional knowledge and skills were highlighted as key stressors during Chinese migrant nurses’ professional adaptation. This is in contrast with previous reports of deskilling and devaluation by foreign-trained nurses working in England 11 and the USA.10,29 While previous research indicated that foreign-educated nurses tend to become deskilled in technical aspects of nursing practice,10,11,29 our study demonstrated that professional upskilling may be necessary for migrant nurses to adapt to other aspects of nursing practice, including care coordination within the multidisciplinary health care team and a holistic approach to care.
Third, migrating to work overseas allowed Chinese migrant nurses to gain new insights about the self. Consistent with Al-Hamdan, Nussera, and Masa’deh’s 18 study of Jordanian immigrant nurses in the UK, this study shows that exposure to the multicultural socio-professional environment broadened Chinese migrant nurses’ perspectives and fostered a sense of open-mindedness. These changes brought benefits on an individual level as it encouraged self-exploration to achieve professional growth. The sense of inclusiveness toward minority groups may also benefit the overall multicultural society in the host country. While previous studies have demonstrated that embracing dual-cultural identities may serve as a buffer against transition-associated cultural stress in migrant nurses,13,17,18,22 our study suggests that internalization of some host cultural values enables migrant nurses to step beyond the bounds of their own cultural beings, which serves as both drivers and outcomes of their socio-professional integration into the host country.
Several support strategies may be implemented to ease Chinese migrant nurses’ professional transitions overseas. On an organizational level, multifaceted training programs that improve migrant nurses’ communication and interpersonal skills, as well as enhance their understandings of professional roles and scope of practice, are warranted. These programs should also incorporate cultural training that address Asian-Western cultural value differences and encourage open discussion about cultural issues faced by migrant nurses. On an individual level, nurse leaders should seek to empower migrant nurses on a continuous basis by recognizing individual needs and challenges, fostering self-awareness, and providing tailored psychosocial support. They could also create social opportunities both at work and after work to facilitate interpersonal interactions between migrant and host nurses.
It should be noted that professional adaptation of immigrant nurses is likely a dynamic and multidimensional process involving changes in values and identities. Future research may benefit from longitudinal exploration of professional experiences of Chinese migrant nurses internationally to deepen understanding of professional adaptation of this cultural group.
This study has several potential limitations. First, participants who were self-selected may be those with a preexisting interest in sharing their experiences. The transferability of study results is thus qualitatively limited as findings only reflect contextualized beliefs and voices of the nurses who participated. Second, the sample did not include male nurses, so we could not examine gender differences in professional adaptation. Third, most interviews (16 out of 17) were conducted in English, a second language for participants. This may impact participants’ abilities to fully express themselves although they were given opportunities to choose a preferred language for interview. Fourth, this study relied on self-reported narrative data, which may incur bias resulting from selective memory, stereotypes, or exaggeration. Notably, some comments regarding nursing in China may not reflect the current situation given the dramatic changes in China’s nursing workforce over the past decade. 31 Fifth, the validity of this study may be affected by the secondary research design, despite rigorous efforts undertaken to ensure comprehensiveness of the primary data to address secondary research objectives. Sixth, data analysis was jointly performed by two researchers following the Braun and Clarke’s 28 thematic analysis approach. It is worth noting that Braun and Clarke 32 discourage intercoder reliability based on the stance that no single true meaning exists within data. Considering this, we tried to analyze data in a collaborative and reflexive way, aiming to attain richer interpretation of the data, rather than attempting to achieve consensus in the interpretations.
In conclusion, this study explored how Chinese migrant nurses adapted and evolved professionally while pursuing nursing careers in Australia. The findings suggest that Chinese migrant nurses’ professional adaptation experiences were multifaceted, involving continuous self-evaluation. Both individual-level and organization-level strategies should be implemented to facilitate Chinese migrant nurses’ integration to the overseas nursing workforce.
Footnotes
Acknowledgements
We would like to offer our sincere gratitude to the participants in this study, and nurses who helped with participant recruitment in this research.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The first author was supported by a Monash Graduate Scholarship, and a Monash International Postgraduate Research Scholarship, Monash University, Australia.
