Accepted: 23 December 2017 DOI: 10.1111/jocn.14257
REVIEW
Experiences of registered nurses from a refugee background: A scoping review Harrison Ng Chok MPH, BSc, PhD Candidate1,2,3 1
Director of Academic Programs - Postgraduate Senior Lecturer
1
| Judy Mannix PhD, MNurs, MEdNurs, | Cathy Dickson PhD, DN, MCN, BHlthSc,
| Lesley Wilkes PhD, MHPEd, GDipEd Nurs, BSc, Professor of Nursing1,2,3
1
School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, Australia
Aims and objectives: This scoping review presents an exploration of international
2
literature on the factors that impact refugees’ personal and professional experiences
Nepean Blue Mountains Local Health District, Penrith, NSW, Australia
during their journey to being registered nurses in a new host country.
3
Centre for Nursing Research and Practice Development, Nepean Hospital, Penrith, NSW, Australia Correspondence Harrison Ng Chok, School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, Australia. Email:
[email protected]
Background: Governments of host countries receiving refugees seek to develop strategies that facilitate the successful resettlement, employment and enculturation of refugees that arrive as skilled professionals. There is a scarcity of studies focussing on issues faced by refugees that are RNs or those pursuing nursing registration and employment in a new host country. This study is relevant for resettlement services, nursing registration authorities and education providers and informs the international nursing workforce. Design: Scoping review. Methods: Databases such as MEDLINE, EMBASE, Cochrane Library, CINAHL; Google Scholar; PubMed; Scopus and Web of Science were searched for qualitative studies published up to and including 2017. Articles that did not specify explicitly the participants as registered nurses and/or refugees were excluded. All eligible articles were analysed for collective findings, and impact factors were extracted, synthesised and illustrated diagrammatically. Results: This review explored six eligible articles and six impact factors were identified. The challenging impacts were as follows: loss of control; shock in a new environment and bleak employment prospects. Equally three impact factors: reconciling new reality; establishing a new identity and hope for the future, facilitate positive experiences for nurses in their successful transition into society and the nursing workplace. Conclusions: This scoping review reports the small number of international studies on the experiences of refugees seeking to become registered and employed as registered nurses. The six impact factors identified influence the lives of the nurse participants socio-economically in and out of the workplace. Relevance to clinical practice: Policymakers, managers and educators providing resettlement, registration and employment services could develop strategies that enhance integration and transition experiences of refugees aspiring to be registered nurses. KEYWORDS
cultural competency, professional competence, transients and migrants, qualitative study, refugees, registered nurse, scoping review
J Clin Nurs. 2018;1–9.
wileyonlinelibrary.com/journal/jocn
© 2018 John Wiley & Sons Ltd
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1 | INTRODUCTION As a vulnerable population, refugees face many complex challenges when migrating and resettling into a new host country (Ssenyonga, Owens, & Olema, 2013). By definition, refugees are forcibly removed from their homes and way of life; they lose any capacity to make informed decisions regarding control over their life and circumstance (Townsend & Polatajko, 2007). When they arrive to a new host country, refugees require access to a range of basic needs that are necessary for successful transition and resettlement, for instance, access to services for employment, health and social welfare (Beiser & Hou, 2001; Bloch, 2002). The ability to obtain employment is pertinent to an individual’s identity and to gather resources that allow one to reach their full poten-
What does this paper contribute to the wider global clinical community? • Nurses from refugee backgrounds have aspirations of continuing their profession in a newly adopted country. They are resilient beyond the ordeals faced as refugees before resettling in a new host country. • To enculturate in the workplace, nurse colleagues should welcome RNs with refugee backgrounds to allow them to flourish in new workplace environments. • The rise in refugees that are skilled professionals, in particular RNs globally, provides an opportunity for complex and diverse healthcare settings to provide supportive strategies for these new RNs to thrive.
tial (Colic-Peisker & Tilbury, 2007). This is important, particularly for refugees who arrive as skilled professionals to a new host country and are unable to gain employment in a job commensurate to skill level and expertise. Subsequent bouts of unemployment or underemployment
record numbers not seen since World War II (Australian Broadcasting
can lead to depression from a loss of professional identity and self-
Corporation, 2015). Refugees are forcibly removed or are forced to
esteem (Mestheneos & Ioannidi, 2002; Momartin, Silove, Mani-
leave their homes out of fear of being persecuted for their ethnicity,
cavasagar, & Steel, 2004). Successful resettlement for refugees that
race, religious and political beliefs (Lori & Boyle, 2015; UN General
arrive as skilled professionals relies on their ability to learn and under-
Assembly, 2015). Most refugees face the overwhelming traumatic per-
stand the predominant language of the host country. For instance, in
sonal toll of leaving behind their homes and belongings, family, friends
Australia migrants (inclusive of refugees) are twice as likely to gain
and social connections, along with their normal way of life, and deal
employment if they are competent in English (Australian Bureau of
with a loss of identity (Colic-Peisker & Walker, 2003; Correa-Velez,
Statistics, 2017). This facilitates resettlement as refugees are better
Nardone, & Knoetze, 2014; Timotijevic & Breakwell, 2000). Subse-
able to navigate and access services (Smith & Smith, 2014; Timotijevic
quent to these issues, refugees often present to host countries for ini-
& Breakwell, 2000).
tial health assessments with a sequelae of physical and mental health
Nurses are the largest workforce group in health and are both
issues (Jackson Bowers & Cheng, 2010; Yaser et al., 2016).
influenced and influential to the labour markets and tertiary education
Conversely, migrants are people who are voluntarily able to
sectors of developed countries (Buchan & Sochalski, 2004; Kingma,
choose where to travel, live and work and predominantly migrate
2001). In 2011, a data linkage initiative, Australian Census and
due to advantageous opportunities and social circumstance (Castles,
Migrants Integrated Dataset (ACMID) was initiated between Immigra-
de Haas, & Miller, 2013p. 6-18). They are a distinctly different group
tion and Census authorities in Australia to merge data on the visa type
to refugees based on their classification under immigration law, their
(skilled, family and humanitarian—refugee and asylum seeker) and
reception and processing by host countries, social welfare entitle-
population characteristics such as household family composition, high-
ments once they are resettled and most importantly their overall
est education attainment, citizenship, language, income and labour
migration experience (Cortes, 2004; Refugee Council of Australia,
force (Australian Bureau of Statistics, 2013; Smith & Smith, 2014).
2012; Settlement Services International, 2016).
Unfortunately, the level of data for employment does not go beyond healthcare and medical staff and there are no Census data on the number of RNs there are with refugee background. As a poorly
3 | AIMS
documented population that are distinct from skilled IENs, this scoping review will provide insight into the personal and professional
This scoping review will add to the evidence base on the interna-
experiences of these health professionals. This review will explore
tional literature that explores the personal and professional experi-
their experiences arriving to new host countries with full nursing
ences of RNs who travel to other host countries to become RNs in a
qualifications or subsequently gaining full nursing registration as they
new host country.
transition into the healthcare field from an international context.
4 | METHODS 2 | BACKGROUND The use of evidence-based literature forms the foundation of poliThe current state of war and unrest in the countries of Africa and the
cies and practices of nursing and the health professions in general
Middle East has pushed the displacement of refugees globally to
(Davis, Drey, & Gould, 2009; Polit & Beck, 2008). This scoping
NG CHOK
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review follows the framework by Arksey and O’Malley (2005), which
(n = 5) and refugee health nurses that work with refugees (n = 5) (see
allows the gathering of key concepts, identify gaps in evidence and
Figure 1).
to synthesise the research findings. This scoping method allows for a
Using the illustrative PRISMA framework for scoping articles (see
comprehensive search of multifaceted issues by incorporating a
Figure 1) (Moher, Liberati, Tetzlaff, Altman, & Group, 2009), a total of
broader range of articles, not narrowly screened in systematic
429 citations were found using the parameters in the search strategy.
reviews (Arksey & O’Malley, 2005). The scoping review framework
Following the first screening, search results were scanned and 410
by Arksey and O’Malley (2005) consists of five steps: identifying a
articles were excluded as they were irrelevant based on title and
broad research question, identification of relevant studies (including,
abstract. This initial screening process identified 19 articles as poten-
but not limited to, discussion papers, books, reviews and autobio-
tially eligible; a further two articles were added after checking refer-
graphical pieces) using an inclusion and exclusion criteria (see
ences to undergo another screening. The inclusion criteria were
Table 1 and Figure 1), data extraction and data analysis and presen-
applied to filter out 15 articles from the 21 articles. An in-depth anal-
tation of findings (see Table 2 and Figure 2). These steps are
ysis was conducted to explore the relevance of the articles and
depicted in the following sections in relation to this study.
whether the studies addressed the research aims. The articles that did not explore the research aims were excluded. A final set of six eli-
4.1 | Broad research question
gible articles were selected in this scoping review (see Figure 1; Moher et al., 2009). The research team had meetings to discuss the
What is reported in the international literature about the personal
findings from each of the PRISMA framework steps (see Figure 1)
and professional experiences of professional nurses who arrive as
and overall, the final six eligible articles were reviewed independently
refugees to become registered nurses in a host country?
by the research team to ensure rigour and inter-rater reliability.
4.2 | Identification of relevant studies
4.4 | Data extraction/analysis and summary
Multiple university-licensed databases were searched; these include
The data from the six eligible articles were reviewed and descrip-
MEDLINE; EMBASE; Cochrane Library, CINAHL; Google Scholar;
tively tabulated (see Table 2) reporting the articles by country of
PubMed; Scopus and Web of Science (see Figure 1). This scoping
publication, author, year, topic, method, sample size and results. The
review search was undertaken from January–June 2017 and covers
methodological quality of the included studies was appraised and
a breadth of published literature using a list of relevant search terms:
evaluated on their research designs, rigour and methodology using
“background” and “experience” and “international” and “nurs$” and
the Critical Appraisal Skills Programme (CASP) checklist tool for
“refugee” and “registered nurse” and “resettlement.”
reviewing qualitative studies. All of the eligible articles in the scoping review were scored to have high quality using the tool (Critical
4.3 | Inclusion and exclusion criteria
Appraisal Skills Programme [CASP], 2017). The factors impacting on the nurses experiences were extracted
Any identified articles in the initial search that mentioned RNs and
by the themes that were reported in the eligible articles. These
refugees were screened for further review. An inclusion criteria was
themes were coded and categorised by the research team based on
used to filter eligible electronically accessible articles that were inter-
the specific impacts that they had in affecting the experiences of
nationally published in English, up to and including those published in
RNs on a personal level and professional level. Figure 2 illustrates a
2017 and available under university-licensed electronic databases.
summary of the challenging and facilitating factors that affect the
An exclusion criteria was also used to filter out ineligible studies,
nurses’ personal or professional experiences as reported in the eligi-
for instance, if studies discussed skilled migrant nurses (n = 5) rather
ble articles. Six impact factors were identified and these were loss of
than refugees, were about junior nurse roles that were not registered
control; shock in a new environment; bleak employment prospects; reconciling new reality, establishing a new identity and hope for the future.
T A B L E 1 Inclusion and exclusion criteria of articles Inclusion criteria
The rigour of the analysis and review was established by the research team on all aspects of the PRISMA framework and crosschecked by the research team in each step of the analysis.
1. English language articles from any country 2. Employed as fully qualified and registered nurses as participants 3. Must be refugee participants Exclusion criteria 1. Skilled nurse migrants or IENs (not refugee participants)
5 | RESULTS 5.1 | Challenging impact factors
2. Nurses that are currently undergoing nurse registration education or training
5.1.1 | Loss of life control
3. Junior nurses such as Assistants in Nursing/Enrolled nurses or Clinical Nurse Educators
The nurse participants in two of the six studies described the disruption and overwhelming trauma experienced when losing homes,
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FIGURE 1
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Idenficaon
Records idenfied through database searching (n = 429)
Records excluded based on for tle and abstract (n = 410)
Screening
Records excluded aer tle and abstracts checked (n = 19)
Records added based on reference check (n = 2)
Eligibility
Full text assessed aer eligibility (n = 21)
Included
Studies to be included in literature review (n = 6)
ET AL.
Records excluded (n = 15) as ineligible- skilled migrant nurse (n = 5), non-RN (n = 5) and Refugee Health nurse stories (n = 5)
PRISMA Flow chart (n = 6)
family members, social networks and important personal documenta-
Winkelmann-Gleed, 2006; Winkelmann-Gleed & Seeley, 2005; Yang,
tion (Grant, 2014; Smith & Smyer, 2015). This is all before travelling
2009).
involuntarily to a new environment among people that speak a different language, which is important to become proficient to successfully navigate through systems and services for resettlement in a
5.1.3 | Bleak employment prospects
new host country (Smith & Smyer, 2015; Stewart, 2003). The loss of
Unemployment and underemployment were reported as a major bar-
control experienced by refugees during premigration and displace-
rier for participants in three of the six studies (Grant, 2014; Winkel-
ment from their home is reported by Grant (2014), reflected by the
mann-Gleed,
inability to make informed decisions about the availability of
Winkelmann-Gleed and Seeley (2005) reported that the newly
resources or the lack of basic needs for living that were met prior to
arrived nurses who reported that they were unable to gain employ-
being forcibly displaced.
ment due to a lack of job references and personal documentation to
2006;
Winkelmann-Gleed
&
Seeley,
2005).
vouch for past experience and qualifications. As reported in the UK
5.1.2 | Shock in a new environment Nurses arriving to a new host country as refugees experience an
study by Stewart (2003), registered nurses that are refugees in this predicament, out of necessity, venture into non-nursing-related occupations or attain junior nursing roles.
overwhelming cultural shock as they become accustomed to new environments, become proficient in the English language, experience indifferent perceptions in society and navigate systems to gain nursing registration and employment in a host country (Smith & Smyer, 2015; Stewart, 2003). It was reported that participants experience
5.2 | Facilitating impact factors 5.2.1 | Reconciling a new reality
the negative challenges of social isolation, lack of emotional support
Participants referred to in the review papers pursued registration
and discrimination being referred to as “foreigners,” “migrants” and
assessment and job seeking for employment as an RN. Participants
“aliens” (Grant, 2014; Stewart, 2003; Winkelmann-Gleed & Seeley,
in Winkelmann-Gleed’s (2006) book were able to secure employ-
2005; Yang, 2009). Further, participants experienced disrespect by
ment as an RN, and it was reported that successful integration
workplace colleagues and managers, felt not listened to, disillusion-
requires strong interpersonal relationships between participants as
ment in the conduct of nursing practice and professional loss being
RNs, with mentors and their supervisors and managers.
deskilled as employers placed the participants in unfamiliar areas in
Gathering resources and a circle of social connections during
the hospital (Grant, 2014; Smith & Smyer, 2015; Stewart, 2003;
resettlement, reported in Grant’s (2014) historical study of Russian
Winkelmann-Gleed, 2006). Cultural insensitivity was reported in the
refugee nurses post-WWII, showed that the participants estab-
workplace as the participants experienced discomfort, despair and
lished community groups and cultural centres to preserve their
post-traumatic stress when employers would push for personal
heritage in new host countries. They also built hospitals, schools,
information from participants to recount their time as refugees and
societies and other institutions to create civic hubs. The formation
make insensitive comments about patients (Smith & Smyer, 2015;
of social networks and connections enables nurses to better
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T A B L E 2 Articles related to refugees working in host countries as RNs (sorted by country and year) Superscript no.
Country Author (Year)
1.
UK (Stewart, 2003)
2.
3.
4.
5.
6.
Topic
Method (Sample size)
CASP appraisal
Retrospective discussion paper on sociopolitical experiences of German Jewish refugees who were RNs from 1930s to the end of WWII.
Discussion paper
UK (Winkelmann-Gleed & Seeley, 2005)
Experiences of migrant nurses, among them, a refugee Somalian nurse who is a British RN and one refugee Ghanaian RN.
Qualitative interviews
High score
In-depth interviews (n = 22) and follow up interviews (n = 7). Of the seven, two were refugees that are RNs
8/10
UK (Winkelmann-Gleed, 2006)
Experiences of migrant nurses, among them, a refugee from Burundi who is a RN.
Qualitative book
High score
(n = 12 refugee surveyed, 8.57% of surveys) of these three Congo and two Rwandan RNs
8/10
USA (Yang, 2009)
Exploring the author’s experience as a RN and also her experiences faced as a nurse student, educator and researcher.
Autobiographical chapterpersonal story
Unable to be assessed. Article included due to dearth of literature and used to identify key concepts.
Historical discussion paper on individual accounts or refugee nurses that left the Soviet Union before and to the end of WWII.
Discussion paper
Exploring African RNs who are former refugees about their experiences in the United States of America
Qualitative interviews
High score
(n = 9) all RNs from sub-Saharan Africa
9/10
USA (Grant, 2014)
USA (Smith & Smyer, 2015)
(n = 2) German Jewish refugees that received state registration in 1940
(n = 1) account of author as a refugee and RN
(n = 11) refugees that are Russian RNs
Unable to be assessed. Article included due to dearth of literature and used to identify key concepts.
Unable to be assessed. Article included due to dearth of literature and used to identify key concepts.
situate themselves in society and further support steps to pursu-
their work. Grant (2014) reported that the refugee Russian nurses
ing a nursing career (Stewart, 2003). This “optimistic determina-
in China were also able to re-establish their identity and sense of
tion” (Smith & Smyer, 2015, p. 72) was found to facilitate the
value in the workplace through hard work and roles as translators
building of relationships to navigate competing work demands and
among Russian speaking patients in China.
daily life among sub-Saharan African refugee RNs in the USA. This study also reported that personally, the social support and family obligations of these nurses were found to be major facilitators in
5.2.3 | Hope for the future
their persistence and speedy reconciliation of their new environ-
The participants highlighted in this review strive to make a better
ment.
life for themselves and their families in a new host country. Across the eligible articles, there is an underlying sense of resilience that is
5.2.2 | Re-establishing new identity
driven by intrinsic motivation to capitalise on new opportunities while reconciling the trauma experienced through premigration
Successful resettlement and integration into society are important
(Smith & Smyer, 2015; Stewart, 2003; Winkelmann-Gleed, 2006;
for refugees who are linked in with timely and suitable employ-
Winkelmann-Gleed & Seeley, 2005; Yang, 2009). Smith and Smyer’s
ment opportunities. This is important for the successful transition
(2015) participants aspire to a career in nursing by managing educa-
and resettlement of refugees and forms a major part of their
tion, family life and work with other competing demands. Profes-
identity, especially in a new host country (Grant, 2014; Winkel-
sionally, working with culturally sensitive staff that respect the past
mann-Gleed & Seeley, 2005). In the workplace, RNs in the study
experiences of the participants was reported to impact positively on
by Winkelmann-Gleed and Seeley (2005) were able to establish an
participants in the workplace (Winkelmann-Gleed, 2006; Winkel-
identity through hard work and “valuable contributions” (p. 903)
mann-Gleed & Seeley, 2005; Yang, 2009). Once the nurses had inte-
among staff and patients. This recognition bolstered their sense of
grated and established themselves in society nurses stated that
identity and allowed them to gain respect and feel appreciated for
despite the challenging factors, the hard work and dedication
6
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Loss of control4,5
•No control over life & decision makinga •Loss of emoonal support systemsfamily & friendsa •Concentraon camp and work in military hospitalc
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Shock in a new environment1,2,3,5,6
Bleak employment prospects1,2,3,4,5
Reconciling a new reality5,6
Re-establishing a new identy1,2,3,5,6
Hope for the future
•Host country language barrierc •Discriminaon and racism in the workplaceb •Addressing cultural insensivityc
•Unemployed- lack of skills recognionc •UnderemploymentWork in non-nursing jobsc
•Forming social networks, building resources and conneconsc •Opmisc determinaonc
•New purposeful role in workplaceb •Gaining self confidence and self esteemb
•Resiliencec •Reselement- pursuit of beer life b •Posive support from paents and employersc
4,5,6
F I G U R E 2 Impact factors related to refugees’ experiences extracted from articles of the scoping review (a. Affect personal experience, b. Affect professional experience, c. Affect both personal and professional experience. Numbered superscripts are related to eligible articles in Table 2.)
working as RNs overall were commended by patients and employers
facilitating impact factors experienced during resettlement and
(Stewart, 2003).
employment by skilled migrant nurses in Australia (Chun Tie, Birks, & Mills, 2017; Ng Chok, Mannix, Dickson, & Wilkes, 2017). However, due to their forced migration, refugees are more vulnerable than
6 | DISCUSSION
skilled migrants, frequently experience premigration trauma and require greater intervention and must “catch up” to their skilled
The small number of eligible articles in this scoping review reflects
migrant counterparts during resettlement and integration. Refugees
the dearth of evidence on the experiences of RNs who travel to
for the most part travel to new host countries with fear, despair, loss
other host countries as refugees or pursue education to become
and uncertainty, and to integrate sufficiently, ongoing services to
RNs in a new host country. The participants in this review experi-
address PTSD and other psychosocial issues (Momartin et al., 2004;
enced common issues faced by resettling refugees that are skilled
Winkelmann-Gleed, 2006).
professionals (Huot, Kelly, & Park, 2016; Hussein, Manthorpe, & Ste-
In the mainstream media, refugee resettlement is a sociopolitically
vens, 2011; Iredale, 2005). In particular, issues faced by refugee
charged topic that can elicit anti-foreigner sentiment in the public
nurses included getting accustomed to a new environment; gaining
(Semyonov, Raijman, & Gorodzeisky, 2006). This anti-foreigner senti-
proficiency in the host language; gaining nurse registration; integrat-
ment was experienced by participants who reported that they experi-
ing into the workplace and the challenges of obtaining adequate
enced discrimination, subordination and racism during resettlement
employment as an RN (Grant, 2014; Neiterman & Bourgeault, 2013;
from both patients and staff (Grant, 2014; Stewart, 2003; Winkel-
Smith & Smyer, 2015).
mann-Gleed & Seeley, 2005; Yang, 2009). This was similar in the find-
In retrospect, the upheaval and loss of control depicted by refu-
ings of articles that do not explicitly describe the registration status of
gees that have been forcibly removed from their homes are spoken
nurses that are refugees (Brandt, 2010; Dumper, 2002; Jirovsky, Hoff-
about in articles addressing the trauma, persecution and struggle of
mann, Maier, & Kutalek, 2015).
their premigration experience. In this review, one article of the six
Yang (2009) in her autobiographical piece stated that, as a
covered the premigration treatment and conditions of the partici-
Hmong refugee, curbing this stigma in the workplace requires cul-
pants as refugees. For instance, it was reported that in World War I
tural sensitivity training and education among staff as progressive
and II, refugee Russian nurses were reported to have been “tortured,
steps towards respect and raising cultural awareness in the nursing
violated and executed. . . languishing in prisons and concentration
workplace.
camps” (Grant, 2014, p. 17), and experienced hopelessness, fear and
Gaining adequate employment is significantly important for the
despair along with the traumatic experience. No other articles in this
social and economic status of refugees and enables them to build on
review delve into premigration treatment and there are no articles of
their confidence and re-establish their identity (Colic-Peisker & Til-
contemporary RNs and their experience in refugee camps or con-
bury, 2007; Colic-Peisker & Walker, 2003). It was reported that
finement centres.
along the journey to gaining employment as nurses, some refugees
The identified impact factors that challenge and facilitate the
would undertake volunteering roles, skills training and bridging pro-
RNs in this scoping review are similar to the challenging and
grammes to get familiar with the new environment, create new
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social connections and build on work experience (Neiterman & Bour-
potentially relevant papers were excluded as they did not specify
geault, 2013; Willott & Stevenson, 2013).
whether the nurse had full registration; see, for example, Dumper
In the workplace, positive reinforcement and acknowledgement
(2002) and Brandt (2010).
of the nurses’ role from peers, facilitated integration into the workplace (Jirovsky et al., 2015). Winkelmann-Gleed and Seeley (2005) and Grant (2014) showed that nurses who added value in the work-
8 | CONCLUSION
place and had additional roles such as a translator for staff and patients were rewarded and given a boost in self-esteem, and devel-
This scoping review has added to the evidence base of literature
oped a sense of importance and purpose in their workplace.
exploring the personal and professional experiences of refugees that
The majority of positive experiences reported in this review were
are RNs or look to pursue nursing registration in a new host country.
based on the nurses’ resilience and optimistic determination to con-
Key impact factors were identified to challenge as well as facilitate
tinue pursuing their aspired career in nursing (Brandt, 2010; Dumper,
participants’ migration and resettlement experience along their jour-
2002; Grant, 2014; Jirovsky et al., 2015; Smith & Smyer, 2015;
ney to becoming working RNs in a new host country (see Figure 2).
Winkelmann-Gleed, 2006). In a related study, Brandt (2010) found
Grant’s (2014) study touches on aspects of the “refugee” experience
Liberian nurses (that were not RNs) downplayed their resettlement
of participants during their premigration during WWII and describes
struggles in the USA, in comparison with their traumatic 30-day
the loss of control over life circumstance, turmoil, despair and uncer-
struggle through jungles to a shelter, facing the risk of rape and gang
tainty felt in concentration camps and military hospitals before travel-
violence as refugees before coming to the USA. The study reported
ling to the UK. However, the world has changed considerably since
the rapid process of resettlement in an urban area which involved
WWII with the recent conflict in Syria in 2016, where 13.5 million
juggling non-nursing jobs with multiple shifts while attending classes
people are displaced of the 22 million prewar population (United
for training and maintaining family life.
Nations Office for the Coordination of Humanitarian Affairs, 2017).
This paper is important as it highlights the similar negative chal-
None of the articles delve into the current refugee experience during
lenging factors that impact IENs is also faced by refugees and those
premigration to a new location, for instance the experiences of refu-
aspiring to become RNs in a new host country. It also highlights the
gees in detention centres and refugee camps (Steel et al., 2006).
resilience of these RNs that are refugees and reveals that despite all
The ongoing plight of refugees and the increasing demand for
the setbacks, the RNs manage to find a way as they resettle and
skilled nurses internationally (Buchan & Sochalski, 2004; Hawthorne,
work in supportive and more facilitating environments that allow
2012; International Council of Nurses, 2011) necessitates the explo-
them to successfully resettle and integrate into society.
ration of people similar to the participants in this scoping review as time goes on. Studies highlighting their journey from displacement to successful integration into society will provide evidence of what they
7 | LIMITATIONS OF THE REVIEW
experience on a personal and professional level and allow decisionmakers to understand how they contribute and provide unique value
In this review, English language articles were sourced and the
to the healthcare workforce. There is a lot of ground to be covered
authors took every effort to locate all articles on RNs that are refu-
given the small number of international articles available and the lack
gees (see Figure 1); however, there is no assurance that all the avail-
of any studies exploring RNs as refugees in Australia. The challenging
able articles were located.
and facilitating impact factors that affect the participants’ experiences
The lack of available data collection on the number of RNs that
during resettlement and transition to employment are similar to the
arrive as refugees or refugees seeking prenursing registration as aspir-
experiences of IENs who also undergo feelings of disillusionment, cul-
ing RNs in a host country has implications for studies looking to explore
tural shock, discrimination and sociocultural adjustments living and
this particular vulnerable group. The fact that they are a group that is
working in a new environment (Chun Tie et al., 2017; Ng Chok et al.,
not identified can devalue their contribution to society and their invisi-
2017). The contention remains, however, that refugees’ experiences
bility affects the ability of resettlement services to cater to them and
should be categorised separately from migrants as a vulnerable popu-
their position in the wider labour workforce and economy (Bilsborrow,
lation will require distinct resources and services for their integration
1997; Spring et al., 2003; Winkelmann-Gleed, 2006). This is important
into employment in the nursing workforce. Like most refugees in a
as the looming RN shortage worldwide has forced host countries to
new host country, participants in this review should become compe-
improve working conditions and recruitment strategies for skilled
tent in English, as it is the main barrier to accessing services, integra-
nurses (Brush & Sochalski, 2007; International Council of Nurses,
tion in society, obtaining registration and employment as an RN (Huot
2011).
et al., 2016; Smith & Smyer, 2015; Stewart, 2003).
Participant categorisation in five articles and the clumping of
It is important to recognise that RNs who are refugees have
refugees in with “migrant” groups such as including IENs with nurses
intrinsic motivation and are resilient in the face of all challenging fac-
that are refugees were eliminated from the final scoping review.
tors presented to them. The participants in this review are equipped
Similar to this issue, the lack of explicitness around the nurse regis-
in cultural awareness, emotional strength and optimistic determina-
tration status led to five articles being excluded (see Figure 1). Also,
tion that allows them to work towards bettering their future in a
8
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NG CHOK
new host country and use available opportunities. This is important as many that arrive with aspirations of being RNs are hindered by the challenges reported in this review. The fact is these health professionals contribute in knowledge and life experience, as was seen in the RNs who were relied on above other staff when handling cases of tuberculosis (Winkelmann-Gleed, 2006). Overall, decisionmakers in policy and programmes that manage the migration and resettlement of refugee RNs to a host country, and managers and mentors in the workplace need to consider cultural awareness courses that educate health staff in fostering supportive environments, encourage inclusion and diversity to the workplace.
9 | RELEVANCE TO CLINICAL PRACTICE In a complex and diverse healthcare system that is ever changing, the value of skilled refugees in the workforce is increasingly important. The overall message from this study is that nurses from refugee backgrounds are resilient and survivors beyond the ordeals and hardships faced before they settle in a new host country. Because of their resilience and survivorship this review reveals that they will bring value to the international nursing workforce. In the workplace, nurse colleagues welcoming RNs with refugee backgrounds should be cultivated to cope with the increasing refugees in the population that provides a supportive workplace environment and culture that allows new RNs to flourish. Professional registration authorities across the world need to review how nurses from other countries become registered in another country.
ACKNOWLEDGEMENTS The author would like to thank the editing support from Tyrine Sebastian and Corinne McFarland.
CONFLICT OF INTEREST The authors declare no conflict of interest.
CONTRIBUTIONS Study design: HN, JD, CD, LW; data collection and analysis: HN, JD, CD, LW; and manuscript preparation: HN, JD, CD, LW.
ORCID Harrison Ng Chok
http://orcid.org/0000-0003-1351-373X
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How to cite this article: Ng Chok H, Mannix J, Dickson C, Wilkes L. Experiences of registered nurses from a refugee background: A scoping review. J Clin Nurs. 2018;00:1–9. https://doi.org/10.1111/jocn.14257
