Watch the Towers Watson video and read the Kawi article on international nursing. Provide two examples of points made by the Towers discussant as they apply to the Kawi paper. No more than 200 words.http://www.youtube.com/watch?v=aFA4BNX6FwI&feature=youtu.be
Lecturer/Clinical Instructor, Department of Physiological Nursing,
Associate Professor and PhD Coordinator, Department
of Psychosocial Nursing, School of Nursing, University of Nevada, Las Vegas, NV, USA
KAWI J. & XU Y. (2009) Facilitators and barriers to adjustment of international nurses: an integrative review.
International Nursing Review
There is a scarcity of research focusing on issues encountered by international nurses (INs) in
their adjustment to foreign health-care environments. Increasingly, INs are relied upon to address staffing
shortages in many Western countries. As such, it is vital to identify what facilitates and what the barriers are to
the successful adjustment in order to assist their integration into new workplace environments.
This integrative review identifies facilitators and barriers encountered by INs as they adjust to foreign
Based on Cooperâ€™s Five Stages of Integrative Research Review, a systematic search of eight electronic
databases was conducted, combined with hand and ancestral searches. Two authors independently reviewed
each qualified study for relevance and significance. Subsequently, facilitators and barriers were identified and
categorized into themes and subthemes.
Twenty-nine studies conducted in Australia, Canada, Iceland, UK and the USA were included in
this review. Findings indicated that positive work ethic, persistence, psychosocial and logistical support,
learning to be assertive and continuous learning facilitated the adjustment of INs to their new workplace
environments. In contrast, language and communication difficulties, differences in culture-based lifeways,
lack of support, inadequate orientation, differenc
es in nursing practice and inequality were barriers.
The review findings provide the basis for the development and testing of an evidence-informed
programme to facilitate the successful adjustment of INs to their new work environments.
: Adjustment, Barriers, Facilitators, Integrative Review, International Nurses
Global migration of nurses has been ongoing for decades
(Kingma 2006). The gap between demand and supply has sus-
tained the worldwide migration of nurses to relieve chronic
nurse shortages (Aiken et al. 2004; Buchan & Calman 2004;
Kingma 2006). International nurses (INs), defined as foreign-
trained and/or foreign-born, or recruited nurses from overseas,
constitute a significant proportion of the nursing workforce in
many Western countries. For example, INs made up 12â€“15.2%
of nurses in the United States of America (USA) (Aiken et al.
2004; Polsky et al. 2007). Similarly in the United Kingdom
(UK), about 8% of nurses came from other countries. In 2001â€“
2002, there were reported to be more INs than UK nurses
added to the nursing registry (Buchan 2003). The dependence
on INs in Canada and Australia demonstrated a similar trend.
A 2005 statistics suggested that INs comprised 34.1% of new
registered nurses in Ontario, Canada (Baumann et al. 2006),
while 23.6% of the Australian nurse workforce was INs (Omeri
& Atkins 2002).
Jennifer Kawi, School of Nursing, University of
Nevada, Las Vegas, 4505 Maryland Parkway, Las Vegas, NV 89154-3018, USA;
Tel: (702) 895-5935; Fax: (702) 895-1543; E-mail: email@example.com.
Â© 2009 The Authors. Journal compilation Â© 2009 International Council of Nurses
While INs have supplemented Western workforces, their
adjustment into new work environments frequently posed
unique, multidimensional challenges (Xu 2007). Evidence sug-
gests that inadequate transitional programmes were related to
undesirable outcomes, including compromised patient care
(Zizzo & Xu 2009). What facilitates INsâ€™ adjustment to their new
work environments? Further, what barriers do INs experience as
they adjust? Conceptually, Piletteâ€™s (1989) model of adjustment
provides a framework for this review study. However, Piletteâ€™s
model only covers the first 12 months of employment. Based on
the literature (Xu 2007; Yi 1993), this period is more accurately
termed transition or the acute phase of adjustment because
adjustment is usually longer for INs. Therefore, for the purpose
of this paper, adjustment is operat
ionally defined as the period of
time needed for INs to become comfortable with their new jobs,
which may take more than a year after hire. In essence, adjust-
ment involves adaptation to personal, professional, social, cul-
tural and organizational experiences in new environments.
Review studies on international nurses
Four review studies were retrieved from a growing body of
research examining the experiences of INs, including facilitators
and barriers of adjustment. Alexis & Vydelingum (2005a) exam-
ined black and minority INs in the UK. Likupe (2006) analysed
African nursesâ€™ experiences in the UK. Konno (2006) focused on
the adjustment of INs to Australian nursing practice. Lastly, a
metasynthesis identified the facets of lived experiences of immi-
grant Asian nurses working in Western countries (Xu 2007).
While providing background information on the adjustment of
INs in foreign health-care environments, these reviews focused
primarily on given group(s) of INs or specific geographical loca-
tions. Studies with an international scope focusing on the facili-
tators and barriers to the adjustment of INs as one collective
group are lacking.
This integrative review synthesizes what is known about the
specific facilitators and barriers when INs adjust to foreign
Cooperâ€™s (1989) Five Stages of Integrative Research Review
guided this study. According to Cooper: â€˜Integrative reviews
summarize past research by drawing overall conclusions from
many separate studies that are believed to address related or
identical hypothesesâ€™ (p. 13).
The online databases searched up to September 2007 included
Cumulative Index to Nursing and Allied Health Literature,
Medline, ProQuest Dissertations and Theses, PsychINFO,
Sociological Abstracts, Education Resources Information Center,
Scopus and Academic Search Premier. Search words used were
â€˜foreign-trained nurses,â€™ â€˜foreign-born nurses,â€™ â€˜overseas nurses,â€™
â€˜internationally recruited nurses,â€™ â€˜internationally educated
nurses,â€™ â€˜adjustment,â€™ â€˜integration,â€™ â€˜adaptation,â€™ â€˜transitionâ€™ and
their combinations. Five additional studies were included via
personal referrals. Additionally, hand searches of selected jour-
nals regularly publishing studies on INs (i.e.
Journal of Trans-
Journal of Nursing Scholarship
) and ancestry
searches tracking references in obtained studies were carried out.
Empirical studies published in English describing adjustment
issues of INs were included. Dissertations and theses were also
included. Non-research articles and demographic studies were
excluded. This review focused on INs as defined at the beginning
of this paper because they were the focus of most included
studies, rather than those voluntarily leaving their home
Cooperâ€™s procedures for integrative review
It is necessary to follow systematic guidelines in the appraisal of
research studies to ensure a rigorous review and validity of out-
comes (Cooper 1989). There are five stages in Cooperâ€™s proce-
dures for an integrative review. The first stage is
. For this review, the focus was facilitators and bar-
riers to INsâ€™ adjustment into foreign health-care environments.
The second stage is
. Primary studies were
retrieved using the aforementioned sources. The third stage is
. The two authors independently reviewed the
findings from each qualified study for relevance and significance.
Specifically, all identified facilitators and barriers were extricated
and tabulated. Findings were subsequently compared and dis-
cussed, with discrepancies resolved through consensus. The
fourth stage is
data analysis and interpretation
. Obtained data
were compared and subsequently synthesized. Specifically,
related concepts and ideas were identified and categorized into
themes and subthemes. Consistency of these steps in data analy-
sis and interpretation was maintained throughout the review of
each article. Caution was exercised to prevent losing valuable
insight and alternative interpretations. The final stage is
for dissemination of review findings.
Profile of selected studies
Of the 42 publications retrieved, 29 met the inclusion criteria
(18 primary studies, four reviews, five doctoral dissertations, two
Facilitators and barriers