Internationally educated nurses experiences of rural nursing practice in Western Canada

Consistent with the literature, study participants talked about how their scope of practice changed to meet the health care needs of community members.^{[15, 16]} For the participants, like expert generalists, this meant working in “in all spaces” (Possible) that is, in multiple patient care areas with patients across the lifespan, who have a myriad of health challenges.^{[17, 18, 19]} They also quickly realized that there were limited resources (human and material) which meant they identified “lifelines” (Jason) like telephones, text messaging, and access to paramedics to provide safe patient care. However, because they might not have worked in some patient care areas or their experience was a bit dated, to adjust to a wider scope of practice, the participants explained having to assess their own knowledge and skill level to provide safe patient care.

Scope of practice, how do I say? Here we do lots, we do tons of assessment, we do tons of figuring things out. Whereas back in [my home country], skills, clinical skills, is 90% of your job. The assessments are pretty much the doctor’s job. So, somebody’s going south, call the doctor right away, he does, pretty much the assessments, give orders, “OK, start this, start an IV, get me this, this, this and that.” Whereas here, before you even call the doctor, you have to do your full assessment first before even bothering the doctor. Back in [my home country], you can’t do anything without doctor’s orders, pretty much. And coming in as a fresh rural nurse, there’s this thing in me that, “Do I need to call the doctor now, or do I need to do this first?” So, before I even call the doctor for an opinion, I have to be really sure I’ve done everything in my scope, I’ve done all the assessments that I could to say that “OK, this patient needs a doctor right away” (Jason).

To meet the challenge of having a wider scope of practice with limited resources, the participants discussed some strategies they independently used to refresh their competencies like engaging in independent reading, observing how colleagues completed various tasks, and asking questions. They were also very willing and happy to engage in learning opportunities their employer provided to advance their knowledge and competence.

I would say, the main thing I did was go back to my books. I had to read through my books again to enhance my assessment skills, just so that anything I see it is like, “Hmm, this could be this, this could be that do I need to call the doctor now, or do, can this wait?”. So, that’s what I’m doing right now to really thrive. I sharpen up my assessment skills, critical thinking skills by asking more experienced nurses about their skills, about their experiences, because every day is a learning, every day is a learning process, rural learning process (Jason).

There are some courses I have done online though AHS and then also did a lot of courses through Alberta Mental Health too. It’s quite a lot because I have had a lot of things added to my knowledge so far, and I’m still having more. So, I think I’ve really, really advanced in some other things. I’ve learned a lot, there are a lot of experiences, a lot of things I’ve learned (Peter).

[The employer] gave us a lot, a lot of study guides, a lot of websites to check, a lot of guidelines and procedure manuals to check on how to do different things. So once I am done at work, then I come back home to study and watch those videos. I’m more confident, more independent, and I’m versatile because in just seven months now, I’ve had a lot of training. I can do a lot of things independently now that I wasn’t doing back home (Possible).

One participant stated it was essential and helped to bolster her confidence when their work buddies were immigrants who understood the challenges of integrating into the work environment and anticipated her needs.

Everybody I have asked questions to have answered my questions. But these two [referring to colleagues who are also immigrants] are kind of unique, they are willing to explain and still ask you – when you explain something to someone and that person is asking, “Do you really understand it now?” So they give extra time to really explain things in-depth. And they will say, “Oh, don’t worry, I know that things might be challenging now, but don’t worry, I was once like you.” And stuff like that. They were willing to share their experience. One of them came from, I think Jamaica, and the other came from the U.S. So it wasn’t easy for them when they first came, and they were able to relate with whatever it is I’m going through, or to foresee things that might happen in some weeks or some months time and to quickly push me through and prepare me on how to overcome some challenges. They have been able to fill the space, to fill the gap. If my mentor is not around, these are the two other people I’m comfortable speaking with and explaining and they will take their time to explain things and push me through. So, I can say they are my work buddies. When you have somebody that has worked in this specific space before, that person has an idea, has the experience of whatever it is you are going through. The Canadians are nice, but they don’t have, they might not be able to relate with my present space, with what I am going through because they have never been in that situation. They have never been in that kind of space before (Possible).

Although all the participants recognized the importance of maintaining and/or advancing their level of competency because of the generalist practice required in rural hospitals, they also point out that they come to their role with pre-existing skills and knowledge. Because of that, they can and are, contributing team members.

There are some things that I don’t know anything about, and that’s OK; I’m willing to ask questions and learn. But there are some things I do know about and for them to be able to recognize and say, “OK, maybe I can go and ask David about this” helps me to feel like I’m still contributing in that way; I think helps a lot (David).

Sometimes though, even if the participant possesses knowledge and skills that can contribute to patient care, the workplace environment does not recognize their competence.

I got hired as a registered nurse in [name of community]. I work in Acute Care and Medicine. So, initially, when I started, it was kind of fun loving, and I really loved what I was doing. But the sad part about it is, I work five months, and I was never independent. They just kept me for on orientation shifts, not really doing anything, not really guiding me but they just never approved me. I am able to work independently. I had almost seven years of experience back in [my home country], so I was familiar with all the procedures, and I did know how to access resources (Lisa).

For some participants where their level of competence was always being evaluated and questioned and where there was limited support from colleagues, the potential to doubt themselves resulted in putting their mental health at risk.

There are some fantastic nurses who ask “[Wendy] have you done it before? Have you done it here before? This is how we do it.” [But] you have someone else who knows you don’t know how to do it and the next thing they write a report, “She doesn’t know what she’s doing.” [There are] people who were not ready to see that this person actually came with skills. You are not passing knowledge to her. She knows how to handle a patient. And you become stressed, personally gave me so much anxiety (Wendy).

Adjusting to cultural norms that were different from their previous experience of being part of a healthcare team was expected although there were some “professional surprises…when you see people who believe things differently from the way you believe and see things” (Wendy). Against this background, the participants also recognized the importance of establishing good working relationships with their colleagues since becoming part of the team was not a given: it was a process that required support from managers, colleagues, and particularly their registered nurse guide/mentor. Indeed, their guide/mentor seemed to have a significant influence on participants’ ability to become part of the team by assisting them to navigate expectations of the nurse’s role.

I worked with a guy, and I explained to him the first day, my first day at work, I made it known to him that working back from home, I was working in a very big hospital. I made him know I have a specific unit I was working. Yes, I’m a registered nurse but I wasn’t in all the different departments in the hospital so there might be some things I might not know. And he said, “There is no problem.” He said, “I am willing to help you, if you are willing to learn.” I said, “Learning is not a problem, we keep learning every day.” So, what he did was, we are supposed to have five patients each, so he will take two patients and give me three patients. But the three patients he assigned to me, he will still be there to check, to review whatever it is I am doing. But he allowed me to do them, if I make mistakes, not mistake that is harmful to the patient though, maybe I’m supposed to do something first and I’m doing it second or whatever. He will just say, “OK, for now, let me do this and observe me.” So, if I do this particular thing to this particular patient, and he took over, maybe he did it, when I’m going to the next person, I will be the one to do it and do it from the beginning to the end. Then after each day, we used to have our review time maybe 15, 30 minutes or one hour before the end of the shift, he would always have the time to sit with me and discuss and have a review of the day. So he really, really, really helped me. I can categorically say that being on my own now it was easy for me, because of the preceptor I had, because of the buddy I had when I came, because he took his time to explain things from A to Z. And if I have any challenge, I just go to him to let him know (Possible).

Along with having a preceptor/mentor, the participants spoke about the importance of connecting with other IENs working in the facility. They explained that these more experienced IENs understood the challenges they were facing and could provide guidance on navigating them.

I can categorically say that my work buddies are simply the best: they sacrifice their time to make sure I’m okay. We all agree that nursing is the same everywhere in the world but the way nursing is practiced, the technologies, and the culture in different countries, differ. My work buddies make integration very easy for me, especially with using some technologies different from what we use in [my home country] Possible.

The participants were also acutely aware that to become part of the team they needed to take initiative in establishing relationships with their colleagues albeit at times, they used caution: I know that I should open up to the extent that I know [it]will not come back to backfire on me (Possible). Consequently, they were able to clearly identify instances that for them, demonstrated they had become a member of the team.

I have also my own responsibility to try to develop interpersonal relationships with my colleagues. I try as much as possible to make sure I develop work relationship with as many as I work with so that the environment is cordial, and we will be able to work as a team (Wendy).

That was the first time when I felt like they recognize us, they count us as a staff. That was the first time when I saw they had my name on there [referring to a Christmas stocking]. And I was kind of like – because they were hanging the names on there. A few days back I was like “Will be my name be there as well or just their names?” And there is my name as well. And that was like kind of they count us as well. That was the biggest happiness that I felt. But yes, they include us in their culture (Lisa).

Unfortunately, though, the consequences of not being able to become a member of the team could be devastating for the individual and a loss for the hospital and community.

I did not really talk much with people. So, with those I was orientating if the person is kind of talking to me and kind of trying to mix with me, then I am good with that. There are some people who don’t want to talk to you and do not feel like talking to you. There were some instances when people make you feel like you don’t belong in their community. So at those moments it’s like kind of hard to communicate with a person, I felt somewhat like there was kind of like a gap between us, because I felt like, sometimes they were kind of trying to get away from [me], not really want to talk much. And that was – mentally, I did not feel good. It was very devastating. I did not feel good at all, I just wanted to leave. I was not happy at all: for mental health, I was not feeling very good about it. I feel like my mental health was kind of compromising because of that (Lisa).

When you go to the work environment it’s like you came to take people away from your position, and it’s like, people came, you came to grab, and there was no welcoming from the people you are to work with. For me as a person, it puts me off. It was like, “Did I make the right decision? Should I go back? Because I didn’t come because I was poor. I didn’t come because I was not settled. I didn’t come because I was in danger. No, I moved because I wanted a new thing to try out. I see they were not prepared to have us. I’m talking about one-on-one interaction with colleagues that you work with, as if they were not ready. As if they were not prepared for such a colour and, unfortunately for me. So you have people with their own different perspective and how they view us, some view us as those people [know] nothing, so much knowledge gap. Some even said horrible things (Wendy).

Relocation challenges varied among the participants, which might reflect the geographical location of the rural community, its size, and available amenities like public transportation (Peter) or not having a Costco (Brad). That said, the most challenging aspect of relocating to small rural communities every participant spoke about, was the scarcity of appropriate housing. The scarcity of housing resulted in one participant having to border with a local family for a time in “order to survive” (Lisa). The scarcity of housing also created financial burdens as well as extensive stress for the participants and their families. If participants were more tentative about permanently moving to the rural community, they quickly found out that finding a rental was very difficult as well as financially stressful especially if they also retained some form of accommodation in the city.

There is quite a bit of difficulty related to housing and general livability just because of the cost of living and things. It is significantly more expensive here. Even if you do the conversion factoring in, it’s still a good 15% to 20% more here than back home. When we came in December, housing options were very limited. In my case, large enough for a family of five, which is not always easy. In the actual community that the hospital is in, there was nothing being rented out, there was nothing available. We knew it would be more expensive. So back home, we had three-bedroom 2,400 square feet, half acre place. Very nice. And we were paying 1600 Canadian a month for it. Here, it’s $2,700 for a three-bedroom main floor with zero yard, and to rent. So we actually are in the community over from where the hospital is which brings in a whole new scheme of issues of having to have a vehicle. You can’t just bike there, you can’t walk there, you have to have something to drive (David).

There’s apprehension of like, “Would I be staying there for a long time or, or if it doesn’t go well then I can move back.” We’re kind of anxious if things go well with us, or work for us living here, so we didn’t move all our stuff right away. So we’re kind of like – as we feel comfortable with our job, we go do another trip to [name of community], pick up some stuff, until we get everything. But it cost us a lot paying for a place there and here – it could have been better if we can do the move one time, but since there’s this anxiety, this uncertainty (Brad).

Along with limited housing options, the participants shared challenges related to finding employment opportunities for their spouse either because of language barriers or because employment was only feasible in large cities. These challenges resulted in families living apart from one another.

He’s a [name of profession] [referring to spouse]. Back home it is a very, very lucrative job. As it is they have different centres he consults for because we don’t have a lot of [specialists] back in our town where we were. I’m in a rural area, for now, even my hospital here doesn’t have [this type] of center. If you work in Alberta, maybe it will be somewhere, [name of community] or [name of community]. Although we have submitted applications, when he came, we went round to [name of community], we submitted some applications, and then we submitted some virtual applications in [name of community]. So, we are hopeful that if he finally gets a job, then he will come here permanently. It will be easier knowing that he’s in Canada, even if we are not together in the rural community. During my off days me and my kids can go say hello then come back rather than going back to [country of origin]. So that’s the plan for now. We are hopeful that something nice will come up soon, then he will join us here in Canada (Possible).

Two participants with young children found the limited number of childcare programs or the time of year they relocated, meant childcare was difficult to secure.

Here in [name of community], we have just one government-funded childcare. Since I’ve been here, in September, there has been no space. No space, it is full. Even though they said no waiting list at all. So, it’s that bad. I need a safe space for them. So how can I get a safe space for the kids? I was fortunate enough to meet with someone that is willing to keep my kids while I’m at work. Although I pay, but then it’s part of the sacrifice I need to do to make everything work out so well (Possible).

Our oldest will start kindergarten next year. Coming in the middle of the year they weren’t able to jump into anything (David).

Although the harshness of winter is not unique to rural Alberta, all the participants spoke of needing to adjust to a Canadian winter. While they appreciated the beauty of what a winter day can bring, they also spoke of the dangers and possible isolation because of the winter conditions.

[In] my country, I am not sure whether we’ve even gotten to minus two or minus three. So, it’s really a very big adjustment, I will have to run into my room and switch on the heater. And I can’t walk on the road for a long time. I remember the first day I tried it, I didn’t know it was so cold. I just came out of my house then I had no vehicle. It was not easy. I had to stroll to a very nearby shopping mall to get some groceries. So while on my way my ears were already frozen. I was like – I looked around me, I couldn’t see anybody walking on the road. I was like, “Why am I doing this?” (Peter).

The last challenge the participants spoke about regarding relocating to rural Alberta, dealt with being an ‘outsider’. As visible minorities, entering predominantly Caucasian Christian communities required patience and fortitude from all family members. For one participant, if at some point in their journey they felt that the community could not accept them, they would leave.

In their school, they are the only Blacks. So, it’s a transition for them. My first son has a lot of friends already and he’s fitting in very well. But the last two boys, especially the third son, is the one that is still trying to transition. I promised, I said, “If you are not comfortable with and you decide you don’t want to stay, then you can come back home, if you want to.” I give him [referring to her son] the option that it’s not a matter of life and death. If at any point they feel that it is too much on them, then they can go back with their dad, and then I’ll finish up my tenure contract I signed and I will join them if it is too difficult for them. So, I gave them that option (Wendy).

The participants in this study were committed to making their move to rural Alberta successful. For at least one participant, the connections they made with professional colleagues was a conduit to creating relationships within the community. Others participated in community events to connect to the community.

You can understand them better is to join them and see how they do their things, to associate with them when they are having their cultural anniversaries, just to be able to integrate properly and see how things are going with them. So, it was very important to me because it helped me to associate with them, see their culture, the type of things they do, what they like, how they dance. I see it as a way of just having fun, being around people, and enjoying the moment (Peter).

The people are very kind and open. People have taken an interest in me and my family, interest in where we’re from, what we’re doing, why we’re here; these sorts of things. So all the interactions with people have been very positive. We’ve been able to create friendships within the community. The hospital is my main point of connection in the community. So, we see a lot of communication happening through that for myself. A couple of our friendships have started here and then they’ve introduced us to other people in the community, is how most of it happened. We’ve had people over to our house for dinner, and vice versa. So I think there’s definitely a process of knowing and being known there (David).

The participants were also quick to point out that two other factors helped facilitate their transition and integration into the community. The first was the support their employer provided them by linking them to key community members who had social capital as well as providing practical guidance for becoming part of the community.

One of the things they [AHS recruiters] encourage us to do is be part of your community. Get engaged in the things they do. Get involved. Be part of the community because that will give you a sense of responsibility, that you are responsible for your action, for the safety of the community and your neighbour. And you will not do things that will put anybody within your location at risk. So they encourage us, “Don’t lock yourself inside, go out, interact.” (Wendy)

I was able to discuss with the person AHS linked me with, because AHS gave me a contact to say, “Well when you get to this community this is [name of person], he can put you through if you need to buy groceries, if you need to do this, he can explain stuff to you.” Then I opened up to him to say, “Well my kids will be a major concern to me.” I will say the guidelines AHS provided for newcomers, and then meeting people in the community, I will say are the two major things that helped me settle down fast (Possible).

The second factor that helped them transition and integrate into the community was the support from family and friends who were going through similar experiences.

Honestly, it’s really hard to find friends in such a small community. Luckily, I met my friend, and we moved together, she got a position in [name of community] as well and we moved together. She quit the same time I left [but] yes, it was lovely. We stayed together. We did talk about our experiences, and we went through together with all that stuff. We did talk a lot about experience in our hospital and outside the hospital. We used to talk about certain procedures and how we feel about it, and how confident we are, where we stand in perspective of our experiences. And we did have similar experience. She felt the way that some people are feeling, judgment on the basis of their experience, judgment on the basis of their knowledge. So, she was very depressed about knowing that, and she did share a lot to our manager as well regarding those things. It was kind of–sharing with your day with someone is kind of a good experience. We spend lots of memories together, when we were getting emotional missing our family, we shared a bond. We shared some very beautiful memories (Lisa).

So that was the first thing I did to meet with the person that will be taking care of the kids. I did that with the parents of the other three children. And now we are like friends, because we share that in common. All of us, we are new. Although they have been here before me, at least they are not Canadians. So, we shared that in common. And I think I’m OK with their kids, the way they are training their kids as well. So, I’m comfortable that way (Possible).

Although tempered by cold winter weather, the natural beauty that surrounded their local community and how that natural beauty extended into their workplace, impacted the participants’ experience of integration into the community.

I like the environment, I like the vibe, it was always wildlife here and there. The drive towards [name of facility] hospital is about 20 minutes, it’s just a two-lane highway. On the left you see the Rocky Mountains, on the right you see cattle, you see farms. It’s just so relaxing, takes away all that stress that you’ve accumulated over your shift. On a day shift, it’s just me on the highway. There’s basically nobody else, aside from trucks hauling their cattle. I can see maybe one or two cars ahead of me, that’s it. I just love it. I can’t explain the feeling when you go out, clear skies. The people here they keep mentioning, “Big Sky. Alberta has big skies.” I’m like, “What does that mean?” Then I got it when I drove up to the small towns. When I’m driving, I’m like, “Yes, there is kind of a big sky here.” I don’t know, I can’t explain the feeling when I’m going out to a rural town, it’s really hard to explain (Jason).

Out here in the rural facility I’m used to – well, so back home, if you open the window, usually you’re looking at another building, which is awful. Here, we have the most beautiful scenery of the mountains in all the patients’ rooms, and big windows, and it’s just a much more serene kind of feeling. It doesn’t feel like you’re always in a hospital setting. It’s not so sterile all the time, because you do have that to look out to, which is nice(David).

Wide open spaces, sparse traffic, and fewer people created a sense of physical safety for some participants enhancing the appeal of living in rural Alberta.

Go out, to the forest for a walk, you can do that here. Because first there’s no forest there, second there’s that fear of getting mugged, right? Here the only fear you have is what if a bear pops up. 100%, yes. I would say 120%, I feel way safer (Jason).

The place is safe. You are not in an overcrowded environment. You know your neighbours. You get to meet people and know them one-on-one. People can be so lenient with you; people can feel free and feel at home with you more than in cities where everybody’s like a foreigner. Everyone is afraid of his colleague or his community members because you’re like, “I don’t know him well” (Peter).

You don’t hear whoosh-whoosh-whoosh-whoosh all the time shooting, shooting, shooting. It’s [referring to Canada] an organized society. Everybody obeys the rules. Nobody needs somebody to push them around to do it (Wendy).