Integrating internationally qualified nurses: a qualitative exploration of nurse managers’ influence from nurses’ experiences

Within an overarching research initiative “Nurse Migration Project” (in the Department of General Practice and Health Services Research of the University Hospital Heidelberg, Germany focused on generating in-depth knowledge on the experiences of both DQNs and IQNs during workforce integration) a qualitative study was undertaken with regards to the perceived impact of the role of nursing management on workplace integration by DQNs and IQNs. In this study, the methodological approach of qualitative research was applied due to the explorative nature of the research question How do nurse managers influence workplace integration of internationally qualified nurses. Phenomenology is a discipline concerned with exploring the experiences and perspectives of individuals who are directly influenced by a social phenomena. It was therefore considered as appropriate as an underpinning theoretical framework in order to answer the research question [30]. The aim of this approach was to explore the perspectives of domestically and internationally qualified nurses, taking social structures into account. Thus, the perspectives of those affected by recruitment and integration of IQNs were the centre of the research interest. Two studies (exploring different but related research questions) have already been published as part of the project [18, 29].

Four executive Directors of Nursing from four different German hospitals were approached and agreed to conduction of this study at their institutions; (a) Centre 1 (1.600 beds, 2601 nurses) a university hospital in the South of Germany that provides tertiary level healthcare, (b) Centre 2 (319 beds, 200 nurses) specialty thoracic hospital in the South of Germany, (c) Centre 3 (234 beds, 280 nurses) a regional public hospital, and (d) Centre 4 (200 beds, 200 nurses) a regional public hospital.

The following eligibility criteria had to be fulfilled by DQNs and IQNs in order to participate:

Both DQNs and IQNs were required to be at least 18 years old, to have a contract with the involved hospitals and have a reasonable command of the German and/or English languages (written and spoken). Nurses from different general and specialty practice settings were invited (e.g. general wards, intermediate care units, and intensive care units) in order to maximise participant diversity. No minimum employment working hours was set. Student nurses, other healthcare professionals (e.g. physicians, physiotherapists, nurse aids), or domestically and internationally qualified nurses who did not consent to participate were excluded from the study.

The principle of purposive sampling was applied in this study. Different sampling and recruitment methods were applied at the four hospitals based on preferences of the approving bodies.

A primary contact person (appointed by the Director of Nursing) introduced the study and its purpose to the nursing managers of eligible wards at Centre 1. At Centre 2, a meeting was organised by the Director of Nursing in order to inform nursing managers of eligible wards about the study. In Centres 1 and 2, nursing managers were responsible for distributing information on the study to eligible nurses. Nursing managers of eligible wards were responsible to identify nurses within their nursing teams who met the inclusion criteria. In total, 130 DQNs and 96 IQNs met the inclusion criteria and were initially invited to participate at Centre 1 and Centre 2 combined. Each nurse received an envelope with informational materials, including an invitation to participate in the study, an information sheet, an informed consent form, and a return envelope. The folder also contained contact information of the research team. Nurses who decided to participate in the study were asked to contact the research team directly via email or phone.

The Director of Nursing of Centres 3 and 4 informed the nursing managers of eligible wards about the study, who in turn informed their nursing teams and decided collaboratively with the team who could potentially want to participate in an interview. These nurses also received the information material, including the invitation to participate in an interview, an information sheet, a consent form, and the response envelope. In total, five DQNs and one IQNs were willing to participate and were initially invited to take part in an interview at Centre 3 and Centre 4 combined. The Director of Nursing and a research team member made appointments for interviews with the interested nurses.

Reminders were sent to each hospital’s Director of Nursing to increase response rate at four and six weeks after the initial distribution of the study material. In addition, nursing managers of wards were asked to promote the research project and encourage eligible nurses at regular team meetings. In addition, snowball sampling as a method within purposive sampling was applied due to difficulties in accessing a sufficiently large sample as recruitment partially took place during the first year of the COVID-19 global pandemic. Nurses who participated in interviews were encouraged to share the study invitation with colleagues. Snowball sampling, also known as network sampling, can be helpful if study participants belong to a group that is difficult to recruit or reach. Usually, recruitment begins with some study participants. These initial participants are used to identify and recruit additional participants [31, 32].

In total, 135 domestically qualified and 102 internationally qualified nurses were invited to participate in an interview. At Centre 1, 50 DQNs were initially invited to participate in an interview, nine contacted the research team and proceeded to interview. Via the snowball sampling technique five further DQNs were recruited (n=14). In addition, 50 IQNs were invited to participate, three agreed and encouraged two more via snowball sampling (n=5). At Centre 2, 80 DQNs were initially invited to participate in an interview, two nurses proceeded to interview (n=2), no other nurse was recruited using snowball sampling. In total 46 IQNs were initial invited at Centre 2, three agreed to participate in an interview (n=3), no other nurse was recruited using snowball sampling. At Centre 3, four DQNs and six IQNs decided to participate, at Centre 4, only one DQN participated due to the SARS-CoV-2 pandemic and the increased measures to contain the spread of the virus (n=1). In total nineteen interviews were conducted at Centre 1, ten at Centre 3, five at Centre 2, and one at Centre 4. In all centres combined, a total of 21 interviews with DQNs and 14 interviews with IQNs were conducted (Fig. 1). No nurses who initially agreed to participate withdrew their consent. Seven of the participating nurses (employed at Centre 1 and Centre 2) were known to the researcher through clinical work.

Semi-structured individual face-to-face or telephone interviews were conducted by a female health services researcher with a background in nursing and public health (CR) between September 2019 and August 2020. Data collection was interrupted and prolonged due to the COVID-19 global pandemic.

The first author (CR) initially developed the interview guide based on a literature review. The initial version was discussed with other researchers in a qualitative research colloquium at the Department of General Practice and Health Services Research, University Hospital Heidelberg. Adaptions to the interview guide were made based on feedback and recommendations from the colloquium participants (other health services researchers and sociologists). The interview questions were designed to be open-ended. Interview questions addressed experiences related to workplace integration of IQNs from the perspective of DQNs and IQNs. The interview guide was developed to provide data regarding several research questions in the “Nurse Migration” project. Accordingly, the interview guide was also used in previously published studies [18, 29]. The English version of the interview guide is attached as supplementary file 1.

Face-to-face interviews were either conducted in a separate and quiet room on the ward or at the Department of General Practice and Health Services Research, University Hospital Heidelberg. Participants that had elected to take part in a telephone interview were called by the interviewer. Most of the interviews took place before or after the participants shifts. Interviews with DQNs and IQNs were conducted simultaneously. Interviews were digitally recorded, pseudonymised and transcribed verbatim by the first author of this study and a research assistant. Each interview transcript was reviewed whilst listening to the digital recording to ensure accuracy. The transcription software “f4transkript” was used to transcribe the interviews. In addition to the interviews, information such as age, gender, work experience, and place of work were collected. Only the interview participant and the interviewer were present during the interview. No additional field notes were taken during or after the interview.

Interview data was analysed according to Qualitative Content Analysis [33] by two female health services researcher (CR and AB). The data analysis process started during the early stages of data collection. Data sets were analysed the two coders (CR and AB). Figure 2 shows the data collection and analysis process.

Step 1: All interview transcripts (DQNs and IQNs) were formatted uniformly to improve readability. The first transcripts of both groups were read and essential text passages were marked by CR and AB (data coders). Step 2: CR and AB then familiarised themselves with both data sets (Set 1 DQNs and Set 2 IQNs) by reading further transcripts. Transcripts of the first three interviews of both data sets were coded independently by CR and AB. Constructed codes were discussed, and an initial coding system was developed by consensus for both data sets separately. Step 3: Each interview transcript was then coded line-by-line by CR and AB Step 4: In further discussions, each coded interview transcript was then compared against the coding framework by CR and AB. Disagreements about codes were resolved in consensus discussions with CR, AB and SB (senior health services researcher with a background in nursing). Central themes were developed based on the codes and sub-themes from the content analysis. Both researchers analysed all interview transcripts using the same methodology. Step 5: The final coding system (codebooks) included codes, subthemes, themes, and illustrative quotes. This analysis procedure was applied to both data sets (DQNs and IQNs) separately, resulting in two separate codebooks, including several similar subthemes and themes. The final codebooks were discussed between CR, AB, and SB to ensure consensus as part of the quality management process for qualitative data analysis. Each interview transcript was analysed using the same method. This analysis resulted in two different codebooks (Codebook 1: DQNs and Codebook 2: IQNs). During this analysis, ideas emerged regarding potential agreeing and disagreeing statements between DQNs and IQNs. Step 6: Both codebooks were scanned in detail to explore agreeing and disagreeing statements. Step 7: A table was created that included statements made by either or only one group. This table consisted of the initial codes, subthemes and themes developed during the first analysis (Step 1–5). Step 8: Based on the initially developed codebooks, these statements were structured into common subthemes and themes. Step 9: The separately presented findings of both study groups (Codebooks) of the first analysis steps, including the raw data, were scanned again and compared to the table that included deductively developed common subthemes and themes to ensure that no data was lost during this analysis step. The final coding framework including themes and sub-themes and illustrative quotes was discussed between the three researchers (CR, AB, and SB) to ensure consensus Fig. . 1). Interview data were analysed using MAXQDA, version 2020.1, a computer-assisted quality data management software [34].

Interview data collected in this study was assigned a unique STUDY ID number for each participant. Personal identifying information is stored in a separate database from the study data that was used for analysis. There is a code sheet/key linking participants’ personal identifying information to the unique study ID code. Only specific research team members had access to this code sheet. All databases used for analysis were de-linked from personal identifying information using the STUDY ID. Data was stored pseudonymised in a secure location, with the key to personal identifiers in a separate place. All data collected in this study was protected by the EU General Data Protection Regulation (Regulation (EU) 2016/679) as well as the German Federal Data Protection Act (Bundesdatenschutzgesetz (BDSG)).

In order to enhance the credibility of results the following steps were applied: using more than one data coder during data analysis (CR and AB) as well as consensus discussions between the two coders (CR and AB) and a senior researcher (SB). Confirmability was established by developing an audit trail of the research process. Transferability was ensured by describing the setting of data collection as precisely as possible. Dependability was established by the following steps: peer debriefing (colloquium with colleagues) and external audit (qualitative research colloquium). During the research colloquiums, the process of data collection, data analysis and preliminary findings were discussed. However, participants of both colloquiums were given no insight into raw data adhering to data protection regulations.

The study was approved by the Medical Ethics Committee of the Medical Faculty of Heidelberg University (S-367/2019). The staff council of each hospital also gave permission for the study to be undertaken on their site. Written informed consent was provided prior commitment to the interviews by each participant. Confidentially was ensured for each participant by assigning a pseudonym. Only specific members of the research team had access to the pseudonymisation key and the associated personal data. This was explained in detail in the information leaflet that was handed out to each participant. Additionally, participants were assured that they could withdraw their consent to take part at any time. Personal data that had not yet been included in the data analysis or that had been anonymised could be deleted on request. Research conducted in this study was performed in accordance with the Declaration of Helsinki [35]. The study was reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist for qualitative research [36].

DQNs highlighted that a key facilitator to successful workplace integration was appropriate placement based on previous clinical experience, nursing qualifications, and educational level. Appropriate placement was perceived as not only an essential factor for IQNs to develop professionally but also for DQNs to organise the integration process as efficiently as possible. DQNs mentioned that it was very challenging for IQNs, for example, to adapt to working in an intensive care setting (ICU) without previous ICU experience in combination with language barriers and cultural differences in nursing practice standards impeded ICU workplace integration. DQNs concluded that it would positively influence workplace integration if IQNs first worked on regular wards to improve their German language proficiency level, gained work experience in the German healthcare system, and got to know the hospital structures in a non-critical care environment. IQNs agreed with their domestically qualified colleagues. They explained that working in a new clinical setting significantly different from the one they had previously worked on at home was difficult and led to frustration and fear, these feelings negatively impacting workplace integration.

I would not let IQNs work directly in an intensive care unit. Let them work in a normal ward where the patients are not quite complex. Then they can first get to know the hospital, learn the language, and arrive here […] and also become familiar with the work processes here, […] learn ward management and time management. In my opinion, these are all tasks that can first be learned on a normal ward, and, as I said, the language can first be learned before they are sent to an intensive care unit where the work tasks are so much more extensive that there will probably be more problems and complications because you simply have to rely on every staff member that you have there to do the work well and then to take care of the patients. (DQN 6, Age 35).

[…] I have the fear I have the fear when I work on outpatient care unit or at the OR. I think that’s my weakness, yeah. […], but I like to work on a normal ward. (IQN 35, Age 29).

DQNs indicated that the recruitment process of IQNs played an essential role in successful integration to the workplace. They pointed out that too many IQNs starting at once made the integration process more difficult for the host nursing team, but this could be moderated depending on factors such as previous work experience or personal characteristics. Greater professional experience and internal personal motivation facilitated workplace integration. DQNs indicated that involving senior nurses who worked on the ward in the recruitment and integration process e.g., allowing them to express their opinion on the IQN’s suitability for the position was seen as a strategy to enhance workplace integration. IQNs, on the other hand, mentioned that starting together with other IQNs enhance workplace integration. They felt that peers’ support was valuable and helped them to overcome feelings such as homesickness, loneliness, and being an outsider.

Important for me is the right balance, for example, how many internationally qualified nurses and how many domestically qualified nurses are on the team, really good German-speaking nurses, […] that one can perhaps compensate for the other, also in terms of how we appear to the outside […]. (DQNs 29, 42).

We are the first group from the Philippines. I1:” Yes.” IQN 27: “Filipino, but I think it is better if others, for example, we have this second Filipino group, and I think it is better for them…. uh for the other group because we have… we have the other group support, we support, yeah.” I1: “Yeah, so the ones already there can support the ones coming, yes.” IQN 27: “Yes, exactly.” (IQN 27, Age 30).

DQNs highlighted that it was important to show IQNs that they were welcome and important team members, however, this was made more difficult if too many IQNs were started at once, as perceived workload increased with each additional IQN.

Yes, you must support the new employees. You must do something to make them feel comfortable. […] That’s why it’s so important that there are not too many at once, because otherwise you simply overburden the nursing team, you overburden yourself personally, and because they want to be noticed and taken seriously, and that’s a good thing. (DQNs 22, Age 40).

A few DQNs felt disadvantaged by the intense recruitment of IQNs. They mentioned that the funds spent on international recruitment could also be used for recruiting DQNs (e.g., targeting returners) and for improving the working conditions of nurses in Germany in general.

[…] they’re throwing a lot of money at recruitment of IQNs, but you can also give us more money, then maybe a lot more DQNs would come […].” (DQN 18, Age 30).

The importance of following ethical guidelines when recruiting nurses internationally was highlighted by both groups. Recruiting internationally qualified nurses exclusively from one country was seen as ethically unacceptable, as there was an equal need for qualified nurses the home countries. IQNs agreed with this. Yet individual choice and opportunities for professional advancement were recognised. IQNs stated that they emigrated to Germany for different reasons, mainly higher income, improved working conditions, job security and the opportunity to support their family in home country.

However, I believe that you have to do it in a targeted way and consider from which countries […] what I see critically is that the amount that is recruited, depending on which countries they come from, naturally also brings a disadvantage for the countries themselves at some point. (DQN 22, Age 40).

I think there are shortages of nurses all over the world and I think [migration of nurses] that’s good because we can exchange interculturally, we can learn something new from each other and we can change our… how can I say this? Our way of healthcare delivery if we work from for example international care, I think that’s good, but also in the Philippines there is a lot of staff shortage, but we don’t get enough money there, so we have to work in other countries.. (IQN 33, Age 29).

DQNs emphasised that it would positively influence workplace integration if the hospital management would regularly seek exchange with IQNs and DQNs to intervene early in case of workplace integration challenges. In addition, DQNs would appreciate it if their opinions and experiences regarding the integration of IQNs were recognised especially being given an opportunity to participate in decision-making related to workplace integration. Some DQNs indicated that nursing ward managers needed to be more actively involved in workplace integration and support IQNs’ professional development. DQNs concluded that workplace integration can only be successful if hospital management, nursing ward manager, and the nursing team collaborated effectively.

I have already spoken to the management about [the internationally qualified] staff. More attention could be paid to the [domestically qualified] staff when I say ‘but he/she [the IQNs] can actually do it’, that they [the management] consider it more and don’t say ‘no, he/she needs half a year of training’. There is too little flexibility. You have people who can already do a lot, why don’t I just let them? (DQNs 7, Age 38).

Yes, but otherwise nothing is done. And from the ward management, from some people, it doesn’t matter because they see that the work is being done, but of course no one looks over their fingers to see how you do it and it is just carried on like that. (DQNs 35, Age 30).

IQNs who participated in this study supported this view. They stated that they appreciated the support they received from their nursing ward managers. The majority of IQNs indicated that they felt supported and respected by their nursing leaders (regardless of the management level) most of the time. In addition, regular meetings were seen as helpful, especially in identifying and addressing problems early. In addition, IQNs highlighted that a supportive relationship with their nursing ward manager positively impacted on their integration process and their decision to stay in or leave their position, although some IQNs wished for more support and recognition during their integration process.

Yes, my ward manager has given me good support […] I have already said that I am very satisfied. […] Therefore, yes, I would like to stay here […]. What do I mean? One factor that a person like me, an employee, stay because the people or the… supervisor. (IQN 34, Age 28).

DQNs saw advantages due to the recruitment and integration of the IQNs related to nursing workforce management. They mentioned that due to the migration of nurses, a sufficient number of nurses were available to fill roster gaps and deliver patient care. However, only some DQNs shared this opinion. Others believed that more needed to be done than recruiting IQNs alone to address the nursing workforce shortage in Germany. Nevertheless, a diverse nursing team was perceived as advantageous. For example, as the number of patients who did not speak German increased, IQNs could translate if they were from the same country of origin or spoke the same language as the patient. In addition, DQNs spoke of the great support they received from IQNs caring for patients and that they enjoyed working with the IQNs and valued their expertise. However, DQNs stressed that a constant lack of nursing staff had a negative impact on the integration process. They explained that IQNs often had to take responsibility for patients too early in the orientation period because of the lack of nursing staff. This situation increased the perceived workload for both groups and led to frustration. The IQNs supported this view and pointed out that staff shortages increased personal workload.

[…] Well, he is Italian [the IQNs], for example, if we have Italian patients and we do not understand them, and they do not understand us, he [the IQNs] is worth his weight in gold because he translates everything, […]. (DQN 18, Age 30).

Yes, and then there is also the difficulty that sometimes arises when there are few staff, IQNs may have to take on a lot of responsibility early on […], or do I have to check now when I am working on the ward and doing my area whether he or she is doing everything right in that area. […] that can be stressful for everyone. (DQN 8, Age 56).

So, that’s more for me…. means more responsibility for me and I have already worked alone without a responsible registered nurse. […] Nursing is a lot of responsibility for me […] I can say, “I can do it.” But I always have a lot of fear in my head, but I find that a lot of fear, but I can still control and I find that good, that when I’m afraid, I’m more careful and so, yeah. (IQN 33, Age 29).

DQNs stated that workplace integration of IQNs promoted cultural learning and led to beneficial reflective questioning of their working methods. However, due to various constraints, the perceived workload of the DQNs increased. Some DQNs, for example, explained that information was lost in translation during handovers. As a result, DQNs had to find other sources of information to provide appropriate care to their patients, which increased their perceived workload. In addition, training and integrating IQNs required patience and time and this was perceived as challenging for the nursing team as a whole, particularly during intense shifts with high workloads. Furthermore, DQNs explained that one key challenge was determining whether their internationally qualified colleagues understood them correctly. They gave examples of IQNs completing nursing activities incorrectly because they did not understand what they were being asked to do or at least did not admit it. Some DQNs reported the need to double-check understanding, which placed an additional burden on them. IQNs indicated that workplace pressure had a negative impact on their integration. They described feeling overwhelmed due to caring for seriously ill patients, adapting to a work environment and learning a new language simultaneously.

[…] if I then hand someone over or have been handed over and it is then difficult to understand or I also find it difficult to understand what exactly is meant and queries can sometimes not be clarified and then even if no one else was there, no one else can answer the question, it then also makes it difficult or your own work process more protracted if you then have to get the information again from somewhere else. (DQN 16, Age 22)

[…] that they learn how to talk to the patients, that they also understand them and that they are also open and honest and say ‘Oh, I did not understand anything’, that is always a barrier. That they try to say ‘yes’ or even if you give an order or want them to do something, they say ‘yes’ and then you go and say ‘did you do it’ and then they did not understand, so that’s difficult for me.[…]. (DQNs 4, Age 35).

Yes, my work is a bit difficult, is complex, has to do a lot of talking to people and you need a lot of experience, and I don’t always manage what to do in my job […] (IQN 17, Age 35).

The aim of this study was to explore how DQNs and IQNs experienced the role of nursing management during workplace integration. Although integration is a two-way process, many studies have investigated only the experiences of IQNs without considering those of the DQNs. A key strength of this study was the exploration of shared and/or contradictory experiences for both DQNs and IQNs included in the qualitative interview study. The selection of interviews as data collection method was seen as appropriate due to the explorative character of the research question. To minimise bias and reduce the risk of losing content, data analysis was guided by standardised methodological procedures, and the COREQ checklist was used to guide reporting qualitative findings [36].

A limitation that needs to be considered when interpreting the findings is that although experiences were relatively consistent in the study participants, findings may not be transferable outside the study setting. The results of this study may not apply to countries where migrant and host nurses speak the same language or share the same cultural or ethnic background. The same is true for countries with similar undergraduate nursing (or graduate entry programmes) education programmes to qualify nurses. National and regional factors may have influenced results and represent a limitation. Studies conducted elsewhere may produce different results even if a similar methodology were used. Although a higher number of nurses recruited from different hospitals and/or different regions may have led to more diverse results, at some point no new codes or themes were identified, which indicated that data saturation had been reached. In addition, nurses who chose voluntarily to participate may hold different thoughts and opinions compared to nurses that chose not to participate. For example, nurses who did not participate may evaluate the role of their nursing management completely differently. In addition, social desirability may have influenced participant responses, at least this potential cannot be excluded. Nevertheless, these findings give insights into how DQNs and IQNs perceive and experience the impact of nursing management on workplace integration into the German nursing workforce.

The findings of the study highlight the vital role of nurse managers in successful workplace integration of IQNs in the German nursing workforce. This study shows that appropriate placement of IQNs is a supportive factor. Nursing managers should be mindful of clinical specialty experiences IQNs have gained in their home country and where possible assign them to a similar ward within their new hospital based on this experience. The skillmix and ratio IQNs to DQNs per nursing staff should be assessed and an imbalance should be avoided. Appointing too many IQNs to a clinical area at once may have a negative impact on pace and effectiveness of integration and may increase the workload and work-related stress of the existing nursing team. Furthermore, the benefit of peer support for IQNs should not be underestimated. Compliance with international ethical guidelines (e.g., from the International Council of Nursing) in the recruitment of IQNs is advised. The choice of the country from which IQNs are recruited actively should therefore be based on international guidelines and regular re-evaluation by the nursing management. In addition, the active support of organisational leadership can have a positive effect on job satisfaction of the nursing team as a whole and thus influence workplace integration positively. Shared decision-making and recognition of both the challenges and the benefit experienced by DQNs during workplace integration of IQNs is crucial, especially considering the consequences of the shortage of qualified nurses. Although recruitment of IQNs is a strategy to address nursing workforce shortages in Germany, the impact of shortages of staff on the ward during the process of workplace integration cannot be underestimated. Integration of IQNs is accompanied by an additional burden for DQNs on top of an already high workload. In summary, nursing managers can positively influence the integration of IQNs into the German nursing workforce in many ways. These ways need to be explored in more depth in further qualitative and quantitative studies to improve the integration of IQNs and to facilitate their retention.