Adaptation in working among immigrant Vietnamese nurses in Taiwan

Nguyễn Công Hoàng và Đtg Tạp chí KHOA HỌC & CÔNG NGHỆ 118(04): 43 - 49 43 ADAPTATION IN WORKING AMONG IMMIGRANT VIETNAMESE NURSES IN TAIWAN Nguyen Cong Hoang1*, Pham Thi Phuong Thao2 1College of Sciences – TNU, 2College of Medicine and Pharmacy - TNU SUMMARY This phenomenological study explores the experiences of Vietnamese nurses working in Taiwan healthcare context. In-depth interviews with 15 Vietnamese nurses were conducted in Vietnamese language and transcribed verbatim. The results contribute three main themes emerged from the data including (a) communication difficulty; (b) work stressor; (c) injustice. This study supported the findings in the general literature on international nurses, especially those from Asia. It also point out the uniqueness of this group of Vietnamese nurses in new working environment, namely their hope and ingenuity to turn challenges into opportunities, their job (un) satisfaction, their desire for learning for performance and career enhancement through further education, and their adaptation to workplace demands. The implications for both practice and future research are elaborated, particularly in the context of the accreditation standards of healthcare organizations, for health professionals and government agencies to institute strategies and policies for providing culturally sensitive and appropriate plans for qualified international nurses in Taiwan. Keywords: Vietnamese nurse, adaption, work stressor, Taiwan INTRODUCTION * The average life-span in Taiwan has increased since the National Health Insurance was implemented. According to the report by the Taiwan Ministry of the Interior, the population over the age of 65 will have grown from 10% of the total population in 2006 to 13% in 2014, and it will only continue growing to 37% in 2051 [2]. And therefore, many elderly people have to live in long-term care facilities and depend on nurse aides to provide their direct care. Moreover, the population of people over the age of 75 will increase from 950,000 people in 2006 to 1,260,000 people in 2014 and 3,690,000 people in 2051 [3]. With the increasing elderly population comes a change in family structure. The younger population will no longer be able to care for their elderly parents [6]. As a result, they will have to employ caregivers or send their parents to long-term care facilities. Since 1992, foreign laborers have started immigrating to Taiwan, including 167,980 foreigners who became foreign nurse aides * Tel: 0967 919183 and caregivers [7]. Foreign nurses have become an important human resource in long- term care facilities. However, the differences of language, living habits, and cultures might cause some problems and friction between the foreign nurse aides and the Taiwanese elderly, which affects the quality of care and, subsequently, the work adjustment for foreign nurse [1]. In previous study, it was mentioned that the barriers to quality of care could be language and communication inadequacy as well as cultural differences [9]. Most of the foreign nurses are from Vietnam, the Philippines, or Indonesia [6]. Different cultural backgrounds of people from different countries might cause them to think, experience life, and behave differently. As a result, working in another country is an important event for foreign nurses, and it can alter their life dramatically. Because of the different customs and cultures and different ways of thinking, workers from different nations will experience working in a new environment in different ways. Foreign nurses as other international employees leaving their country and family came to an unknown place for work; the Nguyễn Công Hoàng và Đtg Tạp chí KHOA HỌC & CÔNG NGHỆ 118(04): 43 - 49 44 difference of culture, personal conditions, society background, and etc. [8] also the difficulty of finding assistance will impact their adaptation and transformation in working process. If the related issues did not have an ideal way to release it, it will affect these foreign nurse aides on the adaption of work, and then affect to the quality of cares. Therefore, a deeper understanding and from different viewpoint of how foreign nurses adapt and transform their work is necessary for theoretical advancement and for more foreign worker employment practices. This study aims to investigate the foreign nurses‟ evaluation perception on their own work in the local healthcare system through their working experience. To gain insights in this important research area, an exploratory research was conducted among the non-local nurses (e.g. foreigners). Given to the context of this study, an empirical study applying the critical incident technique (CIT) was conducted. To further facilitate the present study, we focus healthcare facilities and Vietnamese nurses as its foreign employees in Taiwan. RESEARCH METHOD AND DATA COLLECTION Research Method In order to explore Vietnamese nurses‟ specific positive and/or negative incidents in their working experience in full detail which they perceive as significant, a qualitative approach using the Critical Incident Technique (CIT) employing content analytic methods was employed. Following, as a result, analysis typically focuses on the classification of such reports by assigning incidents into descriptive categories to explain events using a content analysis approach. The authors began by collecting the actual incidents that were experienced by Vietnamese nurses in their work in Taiwan‟s healthcare system. After the collection, the incidents are analyzed in a multi-stage process of interpretation and sorted into groups with similar topics. A proprietary computer program XSight version 2 running on Windows 7 was used for qualitative data management. Data gathered on audiotape were transcribed verbatim by the researcher and uploaded to XSight. Data Collection Procedures Purposive sampling method was applied to collect participants. We selected critical cases on the basis that they are nurses who hold Vietnamese identity and have been working in healthcare facilities in Tainan, Taiwan. Finally, fifty participants were selected to take part in our semi-structured face-to-face interviews during two month of January and February in 2013. According to Patton [10], the „logic and power of purposeful sampling lies in selecting information-rich cases for study in depth. Information-rich cases are those from which one can learn a great deal about issues of central importance to the purpose of the research”. Semi-structured approach was used because interviewers enable a facilitator to enter participants‟ realities and collect their interpretations, which are crucial to understanding experience incidents. As such, semi-structured approach is a way to get “in tune” with consumers or, more accurately, with consumers‟ realities. Interviewees were recalled to their experience on their work adaption and transformation process since they arrived in Taiwan. To be included in the study, an incident needs to meet certain criteria. Each incident had to be (1) related to their work in healthcare facilities, (2) experienced by interviewees and become their perception on their work-related issues in a foreign environment. The survey instruments used in our study were designed to explore the participants‟ working experiences. All of the instruments were provided in Vietnamese. These instruments were tested in pilot stage and were revised to find satisfactory, reliable, and valid. All of the interviews were audio-taped and transcribed verbatim. Prior to the final data collection, a pilot study was conducted Nguyễn Công Hoàng và Đtg Tạp chí KHOA HỌC & CÔNG NGHỆ 118(04): 43 - 49 45 with four participants from the target population to check the quality of the questions and generally concentrate on often- faced experience. And then some critical questions were modified and clarified. The data of this pilot study – undertaken to gather additional information with respect to our literature review – also strengthened most of our convictions concerning the relevance of Vietnamese nurses‟ experiences. Validity and Reliability Since multiple (two) interviewers took part in data collection, validation was needed to overcome the possibility of data inconsistency. After completing all the interviews, the participants were randomly selected by the researcher to (1) validate the responses that were given during the interview (2) to identify the factor related to adaption and transformation in their working experience. Subsequently after the process of repeated, careful readings and sorting of incidents by the researchers, the similarities among the incidents begin to become apparent. Two judges independently developed mutual exclusive and exhaustive for 75 critical incidents. To be consistent with previous studies employing the CIT in the marketing domain, the intrajudge rater was used [5]. Finally, a third judge was used to conduct a final sorting on the categories. And 68 of them were selected by all three coders. Thus the degree of inter-coder agreement was 95%, and their reliability was 97.4%. The final interjudge reliability in our study was very satisfactory. The classification among the judges presented a consistent viewpoint with regard to the thematic analysis. RESULTS AND ANALYSIS Sample Characteristics Demographically, all of participants are female in age from 20 to 30 years. They are all educated in nursing with college‟s degrees and vocational school degrees. Twenty five percent of participants have just stayed in Taiwan for about one year, the rest spent at least one year to three year for their work in Taiwan. Most of participants talked about their experience in communication difficulty, difference in nursing practice, work stress, discrimination, and cultural adjustment. Incident Statistics Categories and hierarchical subcategories are discussed in detail subsequently. Table 1 shows the classification scheme from the 67 critical incidents and the number of critical commentaries and their frequencies. Table 1. Incidents Classification Perception Category N of Critical Incidents % of Critical Incidents Communication difficulty 32 47% a. with peers/supervisor 18 (G) 26% b. with patients 14 (G) 21% Work stressor 26 38% a. Task stressor 14 (G) 20% b. Relation stressor 5 (V) 8% c. System stressor 7 (V) 10% Injustice 10 15% a. Lack of support 6 (T) 9% b. Discrimination 4 (V) 6% Total 67 100% Note: We identified a category and subcategory as G (General) if it applied to over 10 cases, T (Typical) if it applied to 6-9 cases, and V (Variant) if it applied to 2-5 cases Nguyễn Công Hoàng và Đtg Tạp chí KHOA HỌC & CÔNG NGHỆ 118(04): 43 - 49 46 CLASSIFICATION DATA AND DISCUSSION Communication difficulty The challenge of communication for Vietnamese nurses in Taiwan‟s healthcare facilities becomes the primary cause for a plethora of derivative issues both at work and in daily life. This challenge originated not only from the inadequacy of language preparation and the lack of knowledge regarding the host country‟s culture but also from the unfamiliarity with the slang, accent, and other language nuances [6]. Although all nurses were required to learn Chinese language before arriving Taiwan, the interviewees still feel difficult in communication in Chinese, especially at the early stage of coming. For example, an interviewee reported: “I already learned Chinese in Vietnam for 3 months before coming here but it‟s still really difficult for me to understand what my supervisor said”, or other said „that was at the first time I came here, now my Chinese get better and I can feel confident to work with Taiwanese staffs” Language deficiency also impeded the ability of Vietnamese nurses to advocate for their patients. Therefore, many Vietnamese nurse tried their best to learn to speak in the ways of native speakers, which was perceived as a positive indicator of adaptation. For instance, “I and other friends have tried to practice Chinese in work and daily life, we have to practice to improve our Chinese, it‟s the first method for us to stay and work here easier”. Moreover, accent and language inadequacy affected negatively the perception of the competence of Vietnamese nurses by patients, peers, and supervisors, and was used as a convenient vehicle for mistreatment and discrimination, such as “one time I could not understand what the patient said because she talked in Taiwanese, so I still stood and waited, then she shouted and other nurses started at me, I still could not know what happed”, or „I know that sometimes there is/are new information about incentives or benefits to nurses, but I did not know anything because they announced in Chinese writing”. Language was frequently an area of contention and conflict between Vietnamese nurses and host country nursing staff when the former was found to speak their indigenous languages at the workplace. Work stressor Work stressor is when a person face to his work during his/her adaptation including work content, work characteristics, working time, work contract, relationship with co- worker, management from boss, adapt environment differences, working compatible, and working regulations, and etc. [6]. In this study, we gather related incidents into a subcategory, and in each subcategory there exist factors or aspects of work-related issues. Task stressor is caused by the different perception and practices in role of nurse, scope of practice. Most of task stressor comes from general job tasks and patient care tasks [4]. Sometimes it arises from job requirements or from having to do inappropriate tasks, for example, “I often had to respond to patient emergencies because they often put themselves in dangerous accidents”. Or it starts from problems associated with providing care to patients and their families “we take care of patients here, they seldom appreciate the things we did for them, it‟s alright for us, but we feel stress when talking with their complaining family member about our tasks” . For most of Vietnamese nurses, “we were trained to become a nurse but still need to learn more here in practice, we learn by doing everyday to keep with the situation here”. Relationship stressor happened in the situation of the Vietnamese nurses getting along with their supervisor or coworkers. Most of problems arising from relationships with co-workers and with staff on other shifts, units or in other departments were caused by Nguyễn Công Hoàng và Đtg Tạp chí KHOA HỌC & CÔNG NGHỆ 118(04): 43 - 49 47 language misunderstanding and difference in nursing practices „many times I had misunderstanding with Taiwanese staffs because I could not understand what they explain. From experience, now I often try to ask again until I understand all, but sometimes it‟s not very suitable when my colleagues cannot be patient”. It‟s also similar to supervisor/physician relationships. Many problems stems from interactions with supervisors and physicians because of language barriers, therefore we could not received help from doctors when we needed. For instance, a nurse expressed that “I asked twice a doctor about his skills in treating patients but he ignored my words, I think he does not like foreign workers” System stressor is the Vietnamese nurse‟s opinions about the facilities environment. That includes workload/scheduling and facility design/maintenance/technology. Many Vietnamese nurses feel stressful from workload, staffing and scheduling problems, and from the way the facility is managed. They explained that the healthcare facility still lack of labor, they do not have enough staffs to care for patients properly, so „we have to increase our working shifts and not been able to get time off when we wanted”. Other stressors are related to the advance in new technology, the adequacy of the work space and physical amenities and upkeep of the facility. For Vietnamese nurses, they never practiced on the modern healthcare technology before, thus they feel unfamiliar with equipment in their work place and that needs them put more effort and time to learn. “Most of equipments in this center are very modern and advanced, we could not see it in Vietnam, then we just learn how to use it when we arrived here”; or „when there is new technology application, I had to spend a period of time to learn it”. Some interviewees blamed that there is no quite place to discuss patient care or do charting, and sometime it is inconvenient physical layout or work and patient care areas for themselves. Injustice Vietnamese nurses encountered marginalization and lack of support from peers, supervisors, and employers. They also experienced unfair treatment including stereotyping and rejection by patients and peers. For example, “many times I was rejected by Taiwanese patients or their family members because I am not Taiwanese nurse”. Other times being passed over for promotion and educational opportunities, and being paid for a lower position while performing duties of a higher one. “We all know that we choose to work here for higher salary, but I think we work very hard, even harder than what we should receive”. Consequently, the feeling of outsider was common, which negatively impacted their work performance and integration into the workforce. This perceived injustice was compounded by language difficulties in expressing themselves and advocating for their rights [11]. CONCLUSION The study results found 68 critical incidents included in three main categories of communication difficulty, work stressor, and injustice as dimensions of lived experience by Vietnamese nurses in Taiwan‟s healthcare facilities. Most of the participants were likely to express their difficulties and concerns in their work experience which are the common challenges during their working adaption and transformation in Taiwan. Vietnamese nurse aides leaving their country and family came to an unknown place for work; the difference of culture, personal conditions, society background, and etc., also the difficulty of finding assistance will cause the stress problems on work. If the work stressors did not have an ideal way to release it, it will affect these foreign nurse aides on the adaption of work, and then affect to the quality of cares. During the work, Vietnamese nurses always express their willing to improve their skills and cooperation in Nguyễn Công Hoàng và Đtg Tạp chí KHOA HỌC & CÔNG NGHỆ 118(04): 43 - 49 48 nursing practice, communication, and complete their job tasks. Their efforts are the main potential to help them adapt and transform themselves in a new working environment. This study revealed both real and potential issues to human resource management and quality of care. First, foreign employees like Vietnamese nurses in Taiwan may face some difficulties during their work due to cultural difference, language difficulties or difference working practices. This may cause them „shock‟ and difficult to adapt unless there are understanding and supports from managers or other peers. It‟s necessary to provide some programs to promote Vietnamese nurses‟ willing to transform their work and lives in Taiwan, which could cooperate with their employers or other associations. Second, language deficiency could potentially affect the communication accuracy between the Vietnamese nurses and patients, families, physicians, pharmacists, and other healthcare team members, especially during telecommunication. The risk to patient safety and quality of care was even greater when other situational factors were considered. Fear of making medical errors from communication mistakes, medical emergencies, could exponentially magnify the risk of miscommunication. Therefore, a sympathy and support from colleagues is still necessary. Moreover, employers should set up their plans to evaluate and improve their Vietnamese employees and provides supports for them to complete their job tasks successfully. At the individual level, Vietnamese nurses should make continuous efforts to narrow the gap of job demands and their current competencies. For example, they must seek every opportunity to improve their language proficiency. In light of the recent research identifying communication as the root cause for most medical errors and sentinel events, the urgency to improve communication effectiveness is even greater to ensure patient safety and quality of care. LIMITATION Some limitations could affect the results. Firstly, this study is limited by interviewers and finds existing gaps in their cognitive, judgments of the subjects. Secondly, the sample is limited to only Tainan city; therefore, our results can not cover the entire immigrant population over Taiwan. Thirdly, the results of qualitative data analysis depend on the researcher‟s experience. Even if we use the same data analysis methods, different people may analyze the data differently and thus produce different results. In the future, these issues can be managed by enlarging the subjects and using more interviews. Also, more conditions and factors can be included to increase the value of study. Deeper analysis can be done by different surveys in each category of lived experience of working. Finally, this study focuses on work with the CIT data for an exploration research. In the following-up study, a survey should be conducted to test the model. REFERENCES 1. Administration of foreign worker, Taipei County Government, (2007), 16-17. 2.Council for economic planning and development, Plan of 2006 to 2151 for National Development in the New Century, Taiwan Government, (2006), Taipei. 3.Council of labor affairs, The report of foreign work application and administration, Taiwan Government, (2008), Taipei. 4. Dawis, R. V and Lofquist, L. H (1984). A psychological theory of work Adjustment, Minneapolis, University Minnesota. 5. Gremler, D. D. (2004), “The critical incident technique in service research”, Journal of Service Research, Vol. 7, No. 1, 65-89. 6. Huang, F. F and Yang, H. H (2011). The Effects of Nationality Differences and Work Stressors on Work Adjustment for Foreign Nurse Aides. BMC Health Services Research, 11 (192). 7. Hsia, H. C. (2008). The development of immigrant movement in Taiwan: The case of Nguyễn Công Hoàng và Đtg Tạp chí KHOA HỌC & CÔNG NGHỆ 118(04): 43 - 49 49 alliance of human rights legislation for immigrants and migrants. Development and Society, 37(2), 187-217. 8. Hsieh, C. Y., and Wang, C. Y. (2008). Immigrant wives and their cultural influence in Taiwan. Journal of National Taiwan Normal University: Humanities & Social Sciences, 53(2), 101 - 118. 9. Lai, L. Y., and Tian. M (2001). The problem encountered by foreign nurse aides imported by the nursing homes in Taiwan, The Journal of Long-Term Care, 5(1), 41-47. 10. Patton, M. Q (1990), Qualitative Evaluation and Research Methods (2ed), Sage, Newbury Park, California. 11. Xu, Y and Kim, S. H (2008). Adaptation and Transformation Through (Un)Learning Lived Experiences of Immigrant Chinese Nurses in US Healthcare Environment. Advances in Nursing Science, 31 (2), 33-47 SUMMARY THÍCH ỨNG CÔNG VIỆC CỦA CÁC ĐIỀU DƢỠNG NGƢỜI VIỆT NAM TẠI ĐÀI LOAN Nguyễn Công Hoàng1*, Phạm Thị Phƣơng Thảo2 1Trường Đại học Khoa học – ĐH Thái Nguyên, 2Trường Đại học Y Dược Thái Nguyên Nghiên cứu hiện tƣợng này khám phá những kinh nghiệm của các điều dƣỡng Việt Nam làm việc trong bối cảnh y tế Đài Loan. Trong cuộc phỏng vấn sâu với 15 điều dƣỡng Việt Nam đƣợc thực hiện bằng tiếng Việt, kết quả thể hiện ba vấn đề chính tồn tại ảnh hƣởng tới quá trình thích nghi trong công việc của họ bao gồm (a) khó khăn giao tiếp , (b) căng thẳng công việc , (c) sự bất công. Nghiên cứu này hỗ trợ những phát hiện trong các tài liệu chung về điều dƣỡng quốc tế , đặc biệt là từ châu Á. Nghiên cứu cũng chỉ ra sự độc đáo của nhóm điều dƣỡngViệt Nam trong môi trƣờng làm việc mới, cụ thể là niềm hy vọng và sự khéo léo để biến thách thức thành cơ hội, mong muốn của họ trong học tập để nâng cao hiệu suất và phát triển nghề nghiệp, và thích ứng hơn với nhu cầu nơi làm việc. Những đề xuất kiến nghị đƣợc xây dựng, đặc biệt là trong bối cảnh các tiêu chuẩn kiểm định của các tổ chức chăm sóc sức khỏe , cho các chuyên gia y tế và các cơ quan chính phủ để thiết lập chiến lƣợc và chính sách cho việc cung cấp các kế hoạch thích hợp cho các điều dƣỡng quốc tế tại Đài Loan. Keywords: Vietnamese nurse, adaption, work stressor, Taiwan Ngày nhận bài:13/3/2014; Ngày phản biện:15/3/2014; Ngày duyệt đăng: 25/3/2014 Phản biện khoa học: PGS. Wi-vun T. Chiung – Trường Đại học Quốc gia Cheng Kung, Đài Loan * Tel: 0967 919183