Title. Migrant nurses’ perceptions and attitudes of integration into the perioperative setting.
Aim. This paper is a report of a study conducted to examine migrant nurses’ perceptions and attitudes of integration into the perioperative setting.
Background. Adapting to a new culture can be overwhelming for many nurses working in foreign countries. Currently, the Republic of Ireland appears to rely heavily on migrant nurses because of persistent nursing shortages over the last decade. To date, there is little research on how the integration process affects migrant nurses in Ireland.
Method. A quantitative descriptive design was used. Data were collected in 2007 using questionnaires distributed to 220 migrant perioperative nurses working in four hospitals in Ireland.
Results. There were communication issues between migrant nurses and their work colleagues. Forty-nine percent of migrant nurses found that work practices were different from those in their home countries. Cultural differences were also an issue. Ninety percent of respondents found the support of preceptors beneficial and 96% found hospital orientation programmes valuable.
Conclusion. Workshops and in-service education are needed on key practices and procedures performed in the perioperative setting for all new staff. Specific learning outcomes and an achievement timeframe should be developed for each new nurse, based on their previous experience and level of knowledge. Migrant nurses not accustomed to delegating and being assertive need to be supported and given time to acquire these skills and to gain confidence.
• Both the migration and international recruitment of nurses has become a global issue in the nursing profession in recent years.
• Working in a new culture can be overwhelming for many nurses working in foreign countries.
• Qualitative research has uncovered some issues related to integration, but there is a lack of measurement of the extent of the challenges of integration.
What this paper adds
• Migrant nurses perceived that the non-nursing professionals were the most difficult to communicate with, particularly when this involved being assertive and delegating tasks.
• There is a strong need for cultural education for both staff and patients about migrant nurses.
Implications for practice and/or policy
• Workshops and in-service education are needed on key practices and procedures performed in the perioperative setting for all new staff.
• Specific learning outcomes and an achievement timeframe should be developed for each new nurse, based on their previous experience and level of knowledge.
• Migrant nurses not accustomed to delegating and being assertive need to be supported and given time to acquire these skills and to gain confidence.
Over the past decade, there has been a steady trend in the migration of nurses to Ireland. Currently, Ireland appears to rely heavily on nurses who completed their professional education in other countries in order to sustain the growing healthcare system. For the purpose of this study, these nurses will be referred to as ‘migrant nurses’. There appears to be little literature on the challenges that migrant nurses can encounter during their integration. However, it is evident that recruiting nurses from different countries and cultures can raise some challenges for both migrant and host nurses. Although, the nursing shortage is evident in all nursing specialties, perioperative nursing was examined in the study reported here. No published literature about integration within perioperative nursing was located.
Timeframes for the integration process can span anywhere from 12 months to 10 years (Yi & Jezewski 2000, Ryan 2003). Withers and Snowball (2003) found that migrant nurses who received support from their managers found integration less challenging. Nevertheless, they felt open to exploitation because of their lack of assertiveness. In relation to adaptation in the United Kingdom (UK), a minimum period of supervised practice is required for migrant nurses to gain registration according to the Nursing and Midwifery Council (the regulatory body for the UK). However, some needed a longer period to be deemed competent and gain registration (Daniel et al. 2001, Withers & Snowball 2003).
In the UK, from a cultural perspective the need for cultural education to meet the demands of a multicultural society became apparent (Duffy 2001, Button et al. 2005). In Ireland, McAdam et al. (2004) found that the education of host nurses is vital to ensure harmony and respect between nurses with different cultural practices. Nurses can also experience ‘culture shock’ when they migrate and when there is a difference between their expectations of their role and their actual experience (Daniel et al. 2001). Challenges for migrating nurses include feeling like an outsider, and a need to be trusted and valued by the host nurses (Magnusdottir 2005). Differences relating to the degree of autonomy and assertiveness of nurses in clinical practice in the UK were noted, as many migrant nurses had previously relied heavily on the doctors to make decisions (Witchell & Osuch 2002). Structured clinical placements to ensure that the environment is conducive to learning and provides sufficient variety to enable the nurses to gain skills and knowledge are recommended (Hancock & Hopkins 2002).
One of the most obvious and difficult challenges facing migrant nurses who migrate to countries where a different language is spoken is communication. Communication difficulties relating to both language and becoming accustomed to local dialects and colloquialisms exist and can cause frustration for not only migrant and host nurses, but also for other staff and patients (Allan & Larson 2003, Sparacio 2005). Communication barriers and the potential risks to patient safety in the clinical environment have also been highlighted (Flynn & Aiken 2002).
The aim of this study is to examine and measure migrant nurses’ attitudes and perceptions of integration into the perioperative setting.
A descriptive design was employed to capture the migrant nurses’ attitudes and perceptions of integration to the Irish perioperative setting. A quantitative method was included to collect measurable data about the extent of any integration difficulties.
The sampling frame was 220 migrant perioperative nurses. The inclusion criteria specified that nurses were eligible to be included if they had trained outside Ireland, were registered with An Bord Altranais (the Irish regulatory body) and had been working in the perioperative setting in four chosen hospitals in Ireland for 6 months or more. A response rate of 52% was achieved. The four hospitals chosen for the study were major teaching hospitals in the Republic of Ireland.
Data were collected over a 2-month period in 2007 using an anonymous 34-item questionnaire constructed following a review of the literature. The questionnaire contained a range of closed and open-ended statements. Respondents were asked to rate their level of agreement on a 5-point Likert Scale. Based on current induction and adaptation programmes, items in the questionnaire related to communication, assertiveness and nurses’ role in relation to delegation as these are the areas that appear to be the most difficult for migrant nurses during integration into the perioperative setting. Work practices, the accessibility of policies and procedures and the time and level of support received in order to achieve competency was also examined. In addition, participants were asked to determine how they would rate host nurses’ understanding and consideration of their cultural needs. The final two open-ended items offered respondents an opportunity to relay any information they felt would be important to assist in the integration process.
A pilot study was conducted with 20 migrant nurses, and issues relating to content and clarity were addressed prior to distribution to the main sample. In addition to the pilot questionnaire, these participants were given a list of seven questions to evaluate the content and relevance of each of the questions, including the length of time it took to complete the questionnaire. This was used to determine if the timeframe for completion was realistic.
Validity and reliability
Face and content validity were considered appropriate measures to assess validity. A panel of six clinical experts in perioperative nursing were invited to examine the questionnaire for validity. They were asked to rate each item using an Index of Content Validity. Returned questionnaires were examined and items amended as appropriate. Cronbach’s Alpha was used to determine the internal reliability of the final instrument and this gave a score of 0·89, which was considered satisfactory.
Ethics approval was granted by the appropriate committees. Assigned gatekeepers distributed the anonymous questionnaire packs. The pack included a cover letter inviting participants to take part in the study and an information leaflet which gave the purpose of the study, aim and objectives and instructions for returning the questionnaires.
The questionnaire was analysed using the Statistical Package for Social Sciences (spss) version 14. Data collected in this study were at nominal and ordinal levels. The qualitative data obtained from the open-ended items were analysed using a thematic approach to add depth to the quantitative results.
The study participants were predominantly female and of Asian origin, ranging in age from 20 to 60 years. The majority had over 10 years’ experience and over half were educated to bachelor’s degree level, with a small percentage having a qualification in perioperative nursing.
Communication/assertiveness/delegation and cultural issues
The most important findings related to communication, assertiveness, delegation and cultural issues. The findings relating to communication appear to suggest that some difficulties existed, in particular regarding different accents. Six nurses reported challenges in relation to communication with both colleagues and patients. The descriptive data uncovered additional challenges of integration. Four migrant nurses stated that they felt the need to reassure patients of their competence and skills in caring for them: ‘Patients ask about previous experience for reassurance then relax once they see you’re skilled and knowledgeable’. Lack of assertiveness and delegation became evident, particularly in relation to ancillary staff. The overall majority rated been assertive towards nursing and medical colleagues as easy. However, the least amount of agreement and a number of disagreements were reported in relation to ancillary staff. Almost three-quarters of respondents found it easy to delegate to their nursing colleagues; however, a number of them found it difficult (see Table 1).
Table 1. Perceived ease of assertiveness and delegation between multidisciplinary team members
Strongly disagree (%)
Strongly agree (%)
Ease of assertiveness towards nursing colleagues (n =113)
Ease of assertiveness towards medical colleagues (n =113)
Ease of assertiveness towards ancillary staff (n =113)
Ease of delegation to nursing colleagues (n =113)
Ease of delegation to ancillary staff (porters, household staff) (n =113)
A strong emphasis was placed on cultural differences, particularly in responses to the two open-ended questions. Five nurses described cultural issues and traditions as challenging. An apparent need for more cultural education, for both host and migrant nurses was strongly highlighted in the descriptive data: ‘More education of nursing staff about all cultures and for non-nationals about the Irish Culture’ Although (n = 68) 60% of respondents reported that their work colleagues understood and considered their cultural needs, a number (n = 21) said that they did not.
The orientation and induction programmes and the support received from preceptors had proved beneficial, although many did not receive this support during integration (see Figure 1). These findings were heavily supported by the descriptive data. For example, one person wrote: ‘Stay with someone of the same nationality as it will be easier to ask questions’. On the other hand, another suggested that: ‘Overseas nurses should be integrated with colleagues who speak English in order to practise English comprehension’.
Almost half (49%) of the respondents highlighted different work practices. Interestingly, in the descriptive data one suggested ‘a review of the nursing practices in Ireland (e.g. nurses been allowed to cannulate), as overseas nurses’ skills are being suppressed’. There were positive findings regarding the amount of time and level of support that migrant nurses received during their integration period (see Table 2). Approximately 80% (n = 82) felt that they were given adequate time and support to achieve competence. Further support was identified in the descriptive data, one nurse reporting that ‘staff take the time and put in the effort to ensure we adjust to the new environment’.
Table 2. Number of nurses reporting similar nursing practices and time and support received during integration
Strongly disagree (%)
Strongly agree (%)
Similar work practices (n =113)
Adequate time & support to achieve competence (n =113)
A quantitative method was used and may have limited the descriptive nature of the study. However, the objective of the study was to measure migrant nurses’ attitudes to and perceptions of integration. While some of the findings reflect those of other studies, they cannot be generalized, as they are limited to the perioperative nurses working in the four urban hospitals in the study. Lack of a comparator group of host nurses to tease out to what extent the issues raised are common among all nurses new to the perioperative setting can also be considered a limitation of the study. The research instrument used for the study was new and therefore its validity and reliability may be limited.
Overall, the orientation and induction programmes and support received from preceptors was reported to be beneficial. The findings clearly imply that a support mechanism such as preceptorship or a buddy system provides valuable support to migrant nurses during their integration, as supported in previous studies (Ryan 2003, Parry & Lipp 2006).
The nursing regulatory board decides whether a nurse requires a period of adaptation, depending on their level of education and experience. In this study, the majority of migrant nurses required the minimum 6 weeks’ adaptation, and 66% (n = 74) agreed that this was adequate to fulfil their needs Yet these findings conflict with previous reports, which suggest that nurses from different cultural backgrounds require longer to adapt and to absorb a new culture, lifestyle, work environment, home and friends (Daniel et al. 2001). It may be that that in the years between Daniel’s study in 2001 and this study in 2007 orientation programmes have improved and are now better suited to meet nurses’ needs during adaptation.
In relation to communication and ease of assertiveness, a number of migrant nurses found being assertive and delegating difficult. They found communicating with other professionals less challenging than with non-professional staff. The reason for this was not investigated; however it could be attributed to lack of awareness and respect for other cultures from non-professional staff; this suggestion was supported by the descriptive data: ‘Some ancillary staff will delegate to the foreign nurses but not to the Irish’. The perioperative environment can be a highly stressful area to work in and requires nurses to be assertive but also to work well in a multidisciplinary team. The dangers of poor communication and misunderstandings between patients and nurses can ultimately affect work practices and patient care, as highlighted in previous studies (Haloburdo & Thompson 2001).
Half of the migrant nurses in this study found that work practices differed from their previous ones, which concur with previous studies (Witchell & Osuch 2002, Allan & Larson 2003, McAdam et al. 2004). These findings and those of previous studies suggest that the role of the nurse, scope of nursing practice and model of nursing used can differ between countries (Witchell & Osuch 2002). As a result, the migrant nurses may find adjusting to new work practices based on a different model of nursing challenging.
The need for cultural awareness in the form of cultural education of nurses and patients was strongly emphasized in this study. Perioperative nursing can uncover many cultural differences and beliefs among nurses and patients during critical stages of undergoing surgery. It is important to remember when working in this multicultural society that a dual adaptation phase exists, and host nurses must also learn to adapt to other cultures. The need for cultural education to promote awareness and understanding is strongly supported in previous reports (Duffy 2001, Haloburdo & Thompson 2001, McAdam et al. 2004, Button et al. 2005).
In conclusion, issues persist around communication, assertiveness, delegation and culture in the clinical setting. Migrant nurses appear to find communicating with ancillary staff challenging; therefore further studies need to be undertaken to investigate the reasons. In addition, the use of a comparator group of host nurses should be included to investigate the extent to which the issues raised are common among all nurses in the perioperative setting. Cultural education for all staff and patients is needed for a harmonious working environment. This issue also requires more in-depth analysis as Irish society becomes increasingly multicultural. Induction programmes and preceptorship play a vital role in assisting nurses to integrate and these should be standardized in all institutions. Healthcare workers must move with the times and appreciate cultural diversity as a strength that can enrich our society. Cultural appreciation and understanding of our diverse workforce within the perioperative setting could enrich perioperative nursing practice, so that all nurses benefit from their colleagues’ experiences.
I would like to thank all the nurses who participated in this study. I would also like to thank my supervisor and my work colleagues for their assistance during my research.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
No conflict of interest has been declared by the author.