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Nurs Outlook 60 (2012) S24eS26
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Empowering expatriate nurses: Challenges and opportunitiesda commentary Afaf I. Meleis, PhD, DrPS (hon), FAAN*, Caroline G. Glickman, MIM University of Pennsylvania School of Nursing, Philadelphia, PA
The use of media to tell stories about nurses’ roles and vulnerabilities as they cross countries and as they practice in different parts of the world is long overdue. Although this story about the Bulgarian nurses in Libya is compelling and must be exposed, there are many sides to nurses’ stories as they practice their profession globally. As well, it is important to remember that nurses are the largest health care work force internationally and that, historically, nurses have been global ever since Rufaida Al-Aslamia traveled with the prophet Muhammad to many parts of the Arabian Peninsula and Florence Nightingale joined those who were fighting in the Crimean War in Turkey to care for the English soldiers. When we think of nurses who leave their own countries to work in others as expatriates, we always remember the professors at the University of Alexandria. They came from the United States (US), Portugal, and Canada to help establish a baccalaureate education program and enhance the quality of nursing practice in Egypt. As students, we felt privileged to have these strangers in the land of Egypt, who, despite their limited knowledge about Egyptian culture, norms, values, and practices, did their utmost to educate us and prepare us for a career of scholarship, leadership, and quality care. They left their families, their colleagues, and their familiar environments to extend their reach and make a difference in a land that was foreign to them. Whether they did it for financial, professional, or personal gains, as their students and as the recipients of their generosity of spirit, we did not care. What we cared about was that we were being educated by the best of minds. Also, along with our university and government leaders, we trusted and respected their motives, accepted their own version of rationale, and
believed they wanted to prepare us for leadership positions. Just like their predecessors who came from the United Kingdom (UK) more than 100 years before them to establish diploma education programs, this new generation of educators vowed to support university education. That is only part of the story of expatriates, who are primarily women who work as nurses in clinical institutions as clinicians, managers, or leaders. Whether in Libya, Saudi Arabia, the United Arab Emirates, Brunei, the UK, Bangladesh, or the US, and regardless of whether they were recruited or sought the expatriate status, whether their decision was driven by their desire to improve their economic situation or advance their professional career, or because they were ready for an adventure, they faced several hurdles that made them most vulnerable. We choose to focus on the following: gender inequity, professional disparities, country of origin hierarchy disparities, and transitional traumas. Gender inequality is a global phenomenon that may manifest itself in different forms in different countries. However, although explicit in many countries, it is implicit in all countries, including our own. It is manifested in the rights of female nurses to travel freely in a country and their right not to be sexually harassed, exploited, and socially rejected. The second-class citizenship of women is blatant in some countries, accepted in others, and expected in still others. What that means is that this view and practice of inequality makes it unsafe for female nurses in the work environment as well as on the streets. If and when they voice their concerns about how they are restricted and treated as womendor even molested and rapeddthey are not believed or they are silenced, blamed, or criminalized. Female nurses are constantly reminded of the
* Corresponding author: Dr. Afaf I. Meleis, University of Pennsylvania, Margaret Bond Simon Dean of Nursing, Professor of Nursing and Sociology, Claire M. Fagin Hall, S. Heyman Dean’s Suite, Room 430, 418 Curie Blvd., Philadelphia, PA 19104-4217. E-mail address:
[email protected] (A.I. Meleis). 0029-6554/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.outlook.2012.04.002
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values, beliefs, mores, or practices of women in the societies in which they are expatriates, and they are expected to accept them even when it robs them of their own rights as human beings. Female nurses have mostly succeeded in transcending the gender inequality barriers by accepting the status quo, selecting the right opportunities to dialogue about inequalities, and gently making a difference wherever they can. The second major area of vulnerability is the position and status of nurses in the occupational hierarchies in the different countries. The pyramidal hierarchy of health care professionals places physicians at the apex of the pyramid and nurses toward the base of the pyramid in many countries. Unless in a managerial or a leadership position, nurses become subject to verbal as well as physical abuse, with limited opportunities for recourse or correction of their situation. In disputes about patients’ rights or quality of care, nurses tend to lose if they argue with other professional members who are higher in the pyramidal hierarchy. It takes a nurse leader with the courage to have a voice and who has established his or her credibility to perhaps provide a just and equitable dialogue related to the dispute. There are also disparities created by the status of the country of origin as judged and determined by the host country. Countries are perceived to be on a hierarchal scale of wealth, importance, and value. In some host countries the hierarchy puts nurses from Western countries such as the UK, the US, and Canada at the top as manifested in pay scale, rights, privileges, and how they are treated. Although racism is prevalent, nationalism is even more prevalent. Sri Lankan or Indian nurses are treated differently from US or Canadian nurses. Hence, it is easy to see why some nurses are more often used as scapegoats and are subject to more injustices than others. A case in point is the Eastern European nurse, who does not have the backing of a strong embassy voice, such as in the US or Canada. This nationalism is as powerful in dividing nurses internationally as racial discrimination has been in countries that continue to deal with racism. Transitions render people vulnerable in other ways. During transitions, people lose support systems, networks, and familiar environments. During geographic, institutional, and organizational transitions, there is a paucity of knowledge of the rights and privileges, policies, and contexts. Until networks are established, until contexts are clarified, and until policies are discerned, nurses are controlled by those who hold the knowledge, their voices are silenced, their advocacies are curtailed, and their care is compromised. It is easier to marginalize them. They become even more vulnerable to the secretiveness, alleged confidentiality, and unclear guidelines and criteria for evaluation. Nurses’ ambiguity and uncertainty about policies and occupational norms increases their chances of being judged as poor performers based on personal reasons. If they report instances of
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harassment or if they refuse to abide by requests for personal favors, their performance becomes suspect and they once again become scapegoats for unsafe practice and become subject to subsequent harassment. Nurses will continue to travel the world and make a difference in health care. The question that remains is how to enhance their safety? Knowledge is power, being connected is empowering, and having a collective voice is transforming. Let us elaborate.
Knowledge is Power Lack of knowledge of cultures limits nurses’ abilities to practice culturally competent care. To enable foreign nurses to practice culturally competent care and provide quality care to patients, we need to continue to study and disseminate research findings on the lived experiences of expatriate nurses to design and implement effective interventions and frameworks to facilitate their adaptation to their host countries. Health care institutions hiring foreign nurses need to be culturally sensitive to the challenges they face and provide transitional orientation and cultural competence programs, which would familiarize the expat nurses to the differences in nursing practice as well as the culture-based beliefs, values, and communication patterns of the host country (Xu, 2007). Obtaining this knowledge empowers and enables foreign nurses to practice at optimum capacity and ability and provide the utmost quality care to patients. It is also important to provide opportunities for expatriate nurses to continue their education to advance their knowledge and competencies, ultimately resulting in better quality patient care (Kim-Godwin, Baek, & Wynd, 2010).
Connections are Empowering Empowerment of nurses is inextricably intertwined with the empowerment of women because nursing is still predominantly a women’s profession (95% of all nurses are women). Foreign nurses may be more vulnerable to injustices and inequalities because of the combination of their gender and expatriate status. This disempowerment hinders the effective delivery of patient-centered care. Nurses are ideally situated to be the driving force of the safety and quality agenda within health care because they are the front-line providers of patient care. Therefore, if nurses, including foreign nurses, are not empowered, quality and patient safety is compromised. Forming partnerships, connections, and support mechanisms facilitate the empowerment of foreign nurses. For example, this could include mentoring programs and partnering expatriate nurses with a “buddy” (Xu, 2007). Promoting professional membership to organizations also offers
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a sense of “belonging” and a higher sense of professionalism (Kim-Godwin, Baek, & Wynd, 2010) and provides exchange opportunities for foreign nurses to come together to share their common problems and generate solutions.
Having a Collective Voice is Transforming There is transformative power in the experiences and cultural identities of foreign nurses in our increasingly globalized world. Expatriate nurses should be encouraged to use their experiences, education, and identities to engage and be voiced as well as be empowered to use their voices to influence policy. Nurses must be equal partners with equal voice to have an impact on decision-making, policy-making, and development. The marginalization and disempowerment of women and nurses hinders them from their rights as human beings to reach their full potential to flourish and effectively contribute to their societies. “Only when all countries provide women with the tools they need to be equal partners will all nations flourish as part of a global community sharing a fragile planet” (Jones, Malcom, & Hrynkow, 2011). Universities have the capability to increase research on empowering women. At the University of Pennsylvania School of Nursing, we have established a Center for Global Women’s Health, led by Professor Marilyn Sommers, PhD, RN, FAAN. The Center will contribute to global research in women’s health scholarship, education, practice, empowerment, and leadership using an equitable and human justice framework. The opening of the Center corresponds with the United Nations’ initiatives for the empowerment of women globally and with national attention to women’s health from President Obama and Secretary of State Hillary Rodham Clinton, who have made girls and women
central in US global health programs. The Center for Global Women’s Health will chart new directions in the domains of safety from violence and harm, equity, empowerment, advocacy, health promotion, and disease prevention. The film, The Benghazi Six, will bring to the international stage the abominable human rights violations that occurred against these brave health workersd5 Bulgarian nurses and a Palestinian physician. Throughout the making of this film, producer Richard Harding promotes change by giving voice to the voiceless and by tearing down the walls of silence and oppression constructed by the Libyan dictator, Muammar Ghaddafi. This inspirational film will illuminate the challenges and inequities foreign nurses face and will demonstrate that to make a difference we must become morally enraged against gross injustices and champion policies to correct them. As global citizens, we have a moral obligation to never let injustices go unchallenged. The Benghazi Six will serve as a powerful vehicle in accelerating change and empowerment of foreign nurses. We are in awe of the strength and bravery of the Benghazi Six and commend Mr. Harding for sharing their empowering stories with the world and mobilizing us to take action.
references
Jones, K., Malcom, S., Hrynkow, S. (2011). Merged cultures to empower women. Science Magazine, 332, 149. Kim-Godwin, Y. S., Baek, H. C., Wynd, C. A. (2010). Factors influencing professionalism in nursing among Korean American registered nurses. Journal of Professional Nursing, 26(4), 242e249. Xu, Y. (2007). Strangers in strange lands: A metasynthesis of lived experiences of immigrant Asian nurses working in western countries. Advances in Nursing Science, 30(3), 246e265.
