Adaptation in working among immigrant Vietnamese nurses in Taiwan

Nguyễn Công Hoàng và Đtg<br /> <br /> Tạp chí KHOA HỌC & CÔNG NGHỆ<br /> <br /> 118(04): 43 - 49<br /> <br /> ADAPTATION IN WORKING<br /> AMONG IMMIGRANT VIETNAMESE NURSES IN TAIWAN<br /> Nguyen Cong Hoang1*, Pham Thi Phuong Thao2<br /> 1<br /> <br /> College of Sciences – TNU, 2College of Medicine and Pharmacy - TNU<br /> <br /> SUMMARY<br /> This phenomenological study explores the experiences of Vietnamese nurses working in Taiwan<br /> healthcare context. In-depth interviews with 15 Vietnamese nurses were conducted in Vietnamese<br /> language and transcribed verbatim. The results contribute three main themes emerged from the<br /> data including (a) communication difficulty; (b) work stressor; (c) injustice. This study supported<br /> the findings in the general literature on international nurses, especially those from Asia. It also<br /> point out the uniqueness of this group of Vietnamese nurses in new working environment, namely<br /> their hope and ingenuity to turn challenges into opportunities, their job (un) satisfaction, their<br /> desire for learning for performance and career enhancement through further education, and their<br /> adaptation to workplace demands. The implications for both practice and future research are<br /> elaborated, particularly in the context of the accreditation standards of healthcare organizations,<br /> for health professionals and government agencies to institute strategies and policies for providing<br /> culturally sensitive and appropriate plans for qualified international nurses in Taiwan.<br /> Keywords: Vietnamese nurse, adaption, work stressor, Taiwan<br /> <br /> INTRODUCTION*<br /> The average life-span in Taiwan has increased<br /> since the National Health Insurance was<br /> implemented. According to the report by the<br /> Taiwan Ministry of the Interior, the<br /> population over the age of 65 will have grown<br /> from 10% of the total population in 2006 to<br /> 13% in 2014, and it will only continue<br /> growing to 37% in 2051 [2]. And therefore,<br /> many elderly people have to live in long-term<br /> care facilities and depend on nurse aides to<br /> provide their direct care. Moreover, the<br /> population of people over the age of 75 will<br /> increase from 950,000 people in 2006 to<br /> 1,260,000 people in 2014 and 3,690,000<br /> people in 2051 [3].<br /> With the increasing elderly population comes<br /> a change in family structure. The younger<br /> population will no longer be able to care for<br /> their elderly parents [6]. As a result, they will<br /> have to employ caregivers or send their<br /> parents to long-term care facilities. Since<br /> 1992, foreign laborers have started<br /> immigrating to Taiwan, including 167,980<br /> foreigners who became foreign nurse aides<br /> *<br /> <br /> Tel: 0967 919183<br /> <br /> and caregivers [7]. Foreign nurses have<br /> become an important human resource in longterm care facilities. However, the differences<br /> of language, living habits, and cultures might<br /> cause some problems and friction between the<br /> foreign nurse aides and the Taiwanese<br /> elderly, which affects the quality of care and,<br /> subsequently, the work adjustment for foreign<br /> nurse [1]. In previous study, it was mentioned<br /> that the barriers to quality of care could be<br /> language and communication inadequacy as<br /> well as cultural differences [9].<br /> Most of the foreign nurses are from Vietnam,<br /> the Philippines, or Indonesia [6]. Different<br /> cultural backgrounds of people from different<br /> countries might cause them to think,<br /> experience life, and behave differently. As a<br /> result, working in another country is an<br /> important event for foreign nurses, and it can<br /> alter their life dramatically. Because of the<br /> different customs and cultures and different<br /> ways of thinking, workers from different<br /> nations will experience working in a new<br /> environment in different ways.<br /> Foreign nurses as other international<br /> employees leaving their country and family<br /> came to an unknown place for work; the<br /> 43<br /> <br /> Nguyễn Công Hoàng và Đtg<br /> <br /> Tạp chí KHOA HỌC & CÔNG NGHỆ<br /> <br /> difference of culture, personal conditions,<br /> society background, and etc. [8] also the<br /> difficulty of finding assistance will impact<br /> their adaptation and transformation in<br /> working process. If the related issues did not<br /> have an ideal way to release it, it will affect<br /> these foreign nurse aides on the adaption of<br /> work, and then affect to the quality of cares.<br /> Therefore, a deeper understanding and from<br /> different viewpoint of how foreign nurses<br /> adapt and transform their work is necessary<br /> for theoretical advancement and for more<br /> foreign worker employment practices. This<br /> study aims to investigate the foreign nurses‟<br /> evaluation perception on their own work in<br /> the local healthcare system through their<br /> working experience. To gain insights in this<br /> important research area, an exploratory<br /> research was conducted among the non-local<br /> nurses (e.g. foreigners). Given to the context<br /> of this study, an empirical study applying the<br /> critical incident technique (CIT) was conducted.<br /> To further facilitate the present study, we focus<br /> healthcare facilities and Vietnamese nurses as<br /> its foreign employees in Taiwan.<br /> RESEARCH METHOD AND DATA<br /> COLLECTION<br /> Research Method<br /> In order to explore Vietnamese nurses‟<br /> specific positive and/or negative incidents in<br /> their working experience in full detail which<br /> they perceive as significant, a qualitative<br /> approach using the Critical Incident<br /> Technique (CIT) employing content analytic<br /> methods was employed. Following, as a<br /> result, analysis typically focuses on the<br /> classification of such reports by assigning<br /> incidents into descriptive categories to<br /> explain events using a content analysis<br /> approach. The authors began by collecting the<br /> actual incidents that were experienced by<br /> Vietnamese nurses in their work in Taiwan‟s<br /> healthcare system. After the collection, the<br /> incidents are analyzed in a multi-stage<br /> process of interpretation and sorted into<br /> groups with similar topics. A proprietary<br /> 44<br /> <br /> 118(04): 43 - 49<br /> <br /> computer program XSight version 2 running<br /> on Windows 7 was used for qualitative data<br /> management. Data gathered on audiotape<br /> were transcribed verbatim by the researcher<br /> and uploaded to XSight.<br /> Data Collection Procedures<br /> Purposive sampling method was applied to<br /> collect participants. We selected critical cases<br /> on the basis that they are nurses who hold<br /> Vietnamese identity and have been working<br /> in healthcare facilities in Tainan, Taiwan.<br /> Finally, fifty participants were selected to<br /> take part in our semi-structured face-to-face<br /> interviews during two month of January and<br /> February in 2013. According to Patton [10],<br /> the „logic and power of purposeful sampling<br /> lies in selecting information-rich cases for<br /> study in depth. Information-rich cases are<br /> those from which one can learn a great deal<br /> about issues of central importance to the<br /> purpose of the research”. Semi-structured<br /> approach was used because interviewers<br /> enable a facilitator to enter participants‟<br /> realities and collect their interpretations,<br /> which are crucial to understanding experience<br /> incidents. As such, semi-structured approach<br /> is a way to get “in tune” with consumers or,<br /> more accurately, with consumers‟ realities.<br /> Interviewees were recalled to their experience<br /> on their work adaption and transformation<br /> process since they arrived in Taiwan. To be<br /> included in the study, an incident needs to<br /> meet certain criteria. Each incident had to be<br /> (1) related to their work in healthcare<br /> facilities, (2) experienced by interviewees and<br /> become their perception on their work-related<br /> issues in a foreign environment.<br /> The survey instruments used in our study<br /> were designed to explore the participants‟<br /> working experiences. All of the instruments<br /> were provided in Vietnamese. These<br /> instruments were tested in pilot stage and<br /> were revised to find satisfactory, reliable, and<br /> valid. All of the interviews were audio-taped<br /> and transcribed verbatim. Prior to the final<br /> data collection, a pilot study was conducted<br /> <br /> Nguyễn Công Hoàng và Đtg<br /> <br /> Tạp chí KHOA HỌC & CÔNG NGHỆ<br /> <br /> with four participants from the target<br /> population to check the quality of the<br /> questions and generally concentrate on oftenfaced experience. And then some critical<br /> questions were modified and clarified. The<br /> data of this pilot study – undertaken to gather<br /> additional information with respect to our<br /> literature review – also strengthened most of<br /> our convictions concerning the relevance of<br /> Vietnamese nurses‟ experiences.<br /> Validity and Reliability<br /> Since multiple (two) interviewers took part in<br /> data collection, validation was needed to<br /> overcome<br /> the<br /> possibility<br /> of<br /> data<br /> inconsistency. After completing all the<br /> interviews, the participants were randomly<br /> selected by the researcher to (1) validate the<br /> responses that were given during the<br /> interview (2) to identify the factor related to<br /> adaption and transformation in their working<br /> experience. Subsequently after the process of<br /> repeated, careful readings and sorting of<br /> incidents by the researchers, the similarities<br /> among the incidents begin to become<br /> apparent.<br /> Two<br /> judges<br /> independently<br /> developed mutual exclusive and exhaustive<br /> for 75 critical incidents. To be consistent with<br /> previous studies employing the CIT in the<br /> marketing domain, the intrajudge rater was<br /> <br /> 118(04): 43 - 49<br /> <br /> used [5]. Finally, a third judge was used to<br /> conduct a final sorting on the categories. And<br /> 68 of them were selected by all three coders.<br /> Thus the degree of inter-coder agreement was<br /> 95%, and their reliability was 97.4%. The<br /> final interjudge reliability in our study was<br /> very satisfactory. The classification among<br /> the judges presented a consistent viewpoint<br /> with regard to the thematic analysis.<br /> RESULTS AND ANALYSIS<br /> Sample Characteristics<br /> Demographically, all of participants are<br /> female in age from 20 to 30 years. They are<br /> all educated in nursing with college‟s degrees<br /> and vocational school degrees. Twenty five<br /> percent of participants have just stayed in<br /> Taiwan for about one year, the rest spent at<br /> least one year to three year for their work in<br /> Taiwan. Most of participants talked about<br /> their experience in communication difficulty,<br /> difference in nursing practice, work stress,<br /> discrimination, and cultural adjustment.<br /> Incident Statistics<br /> Categories and hierarchical subcategories are<br /> discussed in detail subsequently. Table 1<br /> shows the classification scheme from the 67<br /> critical incidents and the number of critical<br /> commentaries<br /> and<br /> their<br /> frequencies.<br /> <br /> Table 1. Incidents Classification<br /> N of Critical<br /> Perception Category<br /> Incidents<br /> Communication difficulty<br /> 32<br /> <br /> % of Critical<br /> Incidents<br /> 47%<br /> <br /> a. with peers/supervisor<br /> <br /> 18 (G)<br /> <br /> 26%<br /> <br /> b. with patients<br /> <br /> 14 (G)<br /> <br /> 21%<br /> <br /> 26<br /> <br /> 38%<br /> <br /> a. Task stressor<br /> <br /> 14 (G)<br /> <br /> 20%<br /> <br /> b. Relation stressor<br /> <br /> 5 (V)<br /> <br /> 8%<br /> <br /> c. System stressor<br /> <br /> 7 (V)<br /> <br /> 10%<br /> <br /> 10<br /> <br /> 15%<br /> <br /> a. Lack of support<br /> <br /> 6 (T)<br /> <br /> 9%<br /> <br /> b. Discrimination<br /> <br /> 4 (V)<br /> <br /> 6%<br /> <br /> Work stressor<br /> <br /> Injustice<br /> <br /> 100%<br /> Total<br /> 67<br /> Note: We identified a category and subcategory as G (General) if it applied to over 10 cases, T (Typical) if<br /> it applied to 6-9 cases, and V (Variant) if it applied to 2-5 cases<br /> <br /> 45<br /> <br /> Nguyễn Công Hoàng và Đtg<br /> <br /> Tạp chí KHOA HỌC & CÔNG NGHỆ<br /> <br /> CLASSIFICATION<br /> DATA<br /> AND<br /> DISCUSSION<br /> Communication difficulty<br /> The challenge of communication for<br /> Vietnamese nurses in Taiwan‟s healthcare<br /> facilities becomes the primary cause for a<br /> plethora of derivative issues both at work and<br /> in daily life. This challenge originated not<br /> only from the inadequacy of language<br /> preparation and the lack of knowledge<br /> regarding the host country‟s culture but also<br /> from the unfamiliarity with the slang, accent,<br /> and other language nuances [6]. Although all<br /> nurses were required to learn Chinese<br /> language before arriving Taiwan, the<br /> interviewees<br /> still<br /> feel<br /> difficult<br /> in<br /> communication in Chinese, especially at the<br /> early stage of coming. For example, an<br /> interviewee reported: “I already learned<br /> Chinese in<br /> Vietnam for 3 months before coming here but<br /> it‟s still really difficult for me to understand<br /> what my supervisor said”, or other said „that<br /> was at the first time I came here, now my<br /> Chinese get better and I can feel confident to<br /> work with Taiwanese staffs”<br /> Language deficiency also impeded the ability<br /> of Vietnamese nurses to advocate for their<br /> patients. Therefore, many Vietnamese nurse<br /> tried their best to learn to speak in the ways of<br /> native speakers, which was perceived as a<br /> positive indicator of adaptation. For instance,<br /> “I and other friends have tried to practice<br /> Chinese in work and daily life, we have to<br /> practice to improve our Chinese, it‟s the first<br /> method for us to stay and work here easier”.<br /> Moreover, accent and language inadequacy<br /> affected negatively the perception of the<br /> competence of Vietnamese nurses by patients,<br /> peers, and supervisors, and was used as a<br /> convenient vehicle for mistreatment and<br /> discrimination, such as “one time I could not<br /> understand what the patient said because she<br /> talked in Taiwanese, so I still stood and<br /> waited, then she shouted and other nurses<br /> started at me, I still could not know what<br /> 46<br /> <br /> 118(04): 43 - 49<br /> <br /> happed”, or „I know that sometimes there<br /> is/are new information about incentives or<br /> benefits to nurses, but I did not know<br /> anything because they announced in Chinese<br /> writing”. Language was frequently an area of<br /> contention and conflict between Vietnamese<br /> nurses and host country nursing staff when<br /> the former was found to speak their<br /> indigenous languages at the workplace.<br /> Work stressor<br /> Work stressor is when a person face to his<br /> work during his/her adaptation including<br /> work content, work characteristics, working<br /> time, work contract, relationship with coworker, management from boss, adapt<br /> environment differences, working compatible,<br /> and working regulations, and etc. [6]. In this<br /> study, we gather related incidents into a<br /> subcategory, and in each subcategory there<br /> exist factors or aspects of work-related issues.<br /> Task stressor is caused by the different<br /> perception and practices in role of nurse,<br /> scope of practice. Most of task stressor comes<br /> from general job tasks and patient care tasks<br /> [4]. Sometimes it arises from job<br /> requirements or from having to do<br /> inappropriate tasks, for example, “I often had<br /> to respond to patient emergencies because<br /> they often put themselves in dangerous<br /> accidents”. Or it starts from problems<br /> associated with providing care to patients and<br /> their families “we take care of patients here,<br /> they seldom appreciate the things we did for<br /> them, it‟s alright for us, but we feel stress<br /> when talking with their complaining family<br /> member about our tasks” . For most of<br /> Vietnamese nurses, “we were trained to<br /> become a nurse but still need to learn more<br /> here in practice, we learn by doing everyday<br /> to keep with the situation here”.<br /> Relationship stressor happened in the<br /> situation of the Vietnamese nurses getting<br /> along with their supervisor or coworkers.<br /> Most of problems arising from relationships<br /> with co-workers and with staff on other shifts,<br /> units or in other departments were caused by<br /> <br /> Nguyễn Công Hoàng và Đtg<br /> <br /> Tạp chí KHOA HỌC & CÔNG NGHỆ<br /> <br /> language misunderstanding and difference in<br /> nursing practices „many times I had<br /> misunderstanding with Taiwanese staffs<br /> because I could not understand what they<br /> explain. From experience, now I often try to<br /> ask again until I understand all, but<br /> sometimes it‟s not very suitable when my<br /> colleagues cannot be patient”. It‟s also similar<br /> to supervisor/physician relationships. Many<br /> problems stems from interactions with<br /> supervisors and physicians because of<br /> language barriers, therefore we could not<br /> received help from doctors when we needed.<br /> For instance, a nurse expressed that “I asked<br /> twice a doctor about his skills in treating<br /> patients but he ignored my words, I think he<br /> does not like foreign workers”<br /> System stressor is the Vietnamese nurse‟s<br /> opinions about the facilities environment.<br /> That includes workload/scheduling and<br /> facility<br /> design/maintenance/technology.<br /> Many Vietnamese nurses feel stressful from<br /> workload, staffing and scheduling problems,<br /> and from the way the facility is managed.<br /> They explained that the healthcare facility<br /> still lack of labor, they do not have enough<br /> staffs to care for patients properly, so „we<br /> have to increase our working shifts and not<br /> been able to get time off when we wanted”.<br /> Other stressors are related to the advance in<br /> new technology, the adequacy of the work<br /> space and physical amenities and upkeep of<br /> the facility. For Vietnamese nurses, they<br /> never practiced on the modern healthcare<br /> technology before, thus they feel unfamiliar<br /> with equipment in their work place and that<br /> needs them put more effort and time to learn.<br /> “Most of equipments in this center are very<br /> modern and advanced, we could not see it in<br /> Vietnam, then we just learn how to use it<br /> when we arrived here”; or „when there is new<br /> technology application, I had to spend a<br /> period of time to learn it”. Some interviewees<br /> blamed that there is no quite place to discuss<br /> patient care or do charting, and sometime it is<br /> inconvenient physical layout or work and<br /> patient care areas for themselves.<br /> <br /> 118(04): 43 - 49<br /> <br /> Injustice<br /> Vietnamese<br /> nurses<br /> encountered<br /> marginalization and lack of support from<br /> peers, supervisors, and employers. They also<br /> experienced unfair treatment including<br /> stereotyping and rejection by patients and<br /> peers. For example, “many times I was<br /> rejected by Taiwanese patients or their family<br /> members because I am not Taiwanese nurse”.<br /> Other times being passed over for promotion<br /> and educational opportunities, and being paid<br /> for a lower position while performing duties<br /> of a higher one. “We all know that we choose<br /> to work here for higher salary, but I think we<br /> work very hard, even harder than what we<br /> should receive”. Consequently, the feeling of<br /> outsider was common, which negatively<br /> impacted their work performance and<br /> integration into the workforce. This perceived<br /> injustice was compounded by language<br /> difficulties in expressing themselves and<br /> advocating for their rights [11].<br /> CONCLUSION<br /> The study results found 68 critical incidents<br /> included in three main categories of<br /> communication difficulty, work stressor, and<br /> injustice as dimensions of lived experience by<br /> Vietnamese nurses in Taiwan‟s healthcare<br /> facilities. Most of the participants were likely<br /> to express their difficulties and concerns in<br /> their work experience which are the common<br /> challenges during their working adaption and<br /> transformation in Taiwan.<br /> Vietnamese nurse aides leaving their country<br /> and family came to an unknown place for<br /> work; the difference of culture, personal<br /> conditions, society background, and etc., also<br /> the difficulty of finding assistance will cause<br /> the stress problems on work. If the work<br /> stressors did not have an ideal way to release<br /> it, it will affect these foreign nurse aides on<br /> the adaption of work, and then affect to the<br /> quality of cares. During the work, Vietnamese<br /> nurses always express their willing to<br /> improve their skills and cooperation in<br /> 47<br /> <br />