lived experiences of Overseas Trained Nurses from Kerala, India working in Mental Health in Australia
The aim of this explore the lived experiences of Overseas Trained Nurses from Kerala, India working in Mental Health in Australia. This study was undertaken in different states of Australia. Participants of the study were overseas trained nurses from Kerala, India and working in mental health in Australia with 2-10 years of experience in Australia. This study followed Hermeneutic phenomenology informed by van Manen. Data collection was by in-depth unstructured audio taped interviews. A total of sixteen overseas trained nurses from Kerala participated in this study. The average interview time was 3 hours. The researcher has taken field notes and maintained a reflective journal. Throughout the process of data collection and analysis, the researcher has followed six steps suggested by van Manen. The results of this study identified four main themes; became a nurse by chance and continuing as a mental health nurse by choice, past: struggled for existence, present; the reality, ongoing mixed feelings, Future; dreams versus apprehensions. Findings of this study indicated the need for ongoing support for overseas trained nurses working in Australia. Lived experiences of overseas trained nurses highlighted the specific unique challenges and hurdles they tackle with during the transition period and ongoing.
This study explored the lived experiences of Overseas Trained Nurses from Kerala working in Mental Health in Australia. The heightened demand of nurses in Australia during the last decade has caused a sudden influx of nurses’ migration especially from India and it’s likely to continue. Statistics on migration of foreign educated nurses identified a significant number of Indian nurses have also relocated from Europe, United Kingdom and the Middle East. The majority of Indian nurses are from Kerala, a small south Indian state of India. Although there are many international studies on Overseas Trained Nurses working in mainly the US and Canada, none of those dealt with Kerala nurses experiences of working in speciality areas
This research follows Hermeneutical Phenomenological approach and van Manen’s six steps as methodological framework. Data collection was by in depth interviews. A total of 16 Kerala nurses from all over Australia were interviewed. Data analysis explored the subjective meaning of lived experience by reading, re reading, thematic analysis and interpretive analysis using lifeworld existentials.
This chapter elaborates the interests and foundation for this thesis. This includes the background, justification for the research, significance of the study, its objectives and research questions. It also provides brief outline of research methodology, entire thesis structure and presentation.
Mental health nursing in Australia
Mental illness represents a leading cause of disability burden in Australia (Australian Institute of Health and Welfare, 2009). It is confirmed that 45% Australians aged 16-85 years had a life time mental disorder and one in five have experienced a mental disorder in 12 months (The Royal Australian & New Zealand College of Psychiatrists, 2011). This situation demands a strong need for an increase in the number of mental health professionals, but research confirms that Australia is one of the least self-sufficient nations in the group of ‘Organisation for Economic Co-operation and Development’ (OECD, 2010) countries in terms of meeting health workforce needs. Australia currently relies on the migration of health professionals from other countries to meet the workforce demand of the health care sector (Health Workforce Australia, 2012; Konno, 2008; Jeon & Chenoweth, 2007; Hawthorne, 2001; Zhou, 2010; Omeri, 2006). In other words, Australia currently has a multicultural nursing workforce with a recent increase in the number Indian nurses. There exists a strong nexus between ageing workforce, less number of domestic nurses with specialisation in mental health nursing and migration of overseas trained nurses. This study used Phenomenology informed by van Manen and four lifeworld existentials to explore and interpret the deeper meaning of lived experiences of overseas trained nurses from Kerala, working in Mental Health.
My fascination towards the experiences of overseas trained nurses begun in 2006 and slowly grown ever since. I myself is a migrant nurse from Kerala started working in Mental Health in Australia from 2005. I found my experience as a mental health nurse from overseas as challenging and rewarding at the same time. My experiences in Australia were different from my expectations and imaginations. It was un-identical to my experience as a student and as a registered nurse in mental health India. My unfamiliarity with the Australian mental health system, legal boundaries, culture, society, practice and some aspects of language were confronting. My strength was my strong theoretical knowledge. Before commencing my job in one of the adult acute Mental Health Services in Australia, I had to complete three months adaptation program with one of the Victorian universities which include four weeks of theory classes and eight weeks clinical placement. I personally felt, the adaptation program was generic. Even though, I had experience in mental health, I never had an exposure or orientation to the Australian mental health system until I started my first job in the adult acute in patient unit.
My experience as a mental health nurse in Australia was unique and distinct from my Kerala colleagues started working in general health. I found ‘fitting in’ to the new culture, living in a new country, being away from family and working in the stressful environment as demanding. I was alone in the new country. Being away from family and adapting to the new place at the same time was difficult. Once I started reflecting on my personal experience, I became passionate about lived experiences of nurses with similar background as mine and started considering this as my research topic to identify if there is commonality in the lived experiences of overseas trained nurses from Kerala nurse working in mental health. It came to my attention that there is a clear gap in the literature in this particular topic. I believe that this study will contribute to the existing body of knowledge.
1.2 The research background
India; Mental Health Sector
India has a strong and widely used private health sector. Prevalence of mental illness is in India is one in 20 (WHO, 2007). India has thirty seven major public mental health hospitals, with bed capacity of 18000. Surprisingly half of those beds are occupied by long term clients. This reveals on third of people with mental illness is not receiving any treatment (National Human Right commission, 2007). Legislative frame work around mental health in India are, the Narcotic Drugs and Psychotropic Substances Act, 1985; Mental Health Act, 1987; and the Persons with Disability Act, 1995. Mental health care delivery system in India are basically four levels. They are;
• Primary care services at the village level
• Primary care centres
• District hospitals
• Psychiatric units in medical colleges.
India and Kerala State: health indicators
Kerala the model state of India
This study was conducted on Kerala nurses and for that reason it is important to orient the readers to Kerala, its cultural context, nursing in Kerala and its health care system.
Kerala in comparison with National level
Life expectancy 70.93 years 64.9 years
Infant mortality rate 5.6/1000 live births 72/1000 live births
Maternal mortality rate 0.8/1000 live births 4.37/1000 live births
Perinatal mortality rate 18.9/1000 live births 47.5/1000 live births
Neonatal mortality rate 11.3/1000 live births 51.1/1000 live birth
Death rate children 4.3/1000 live births 6.5/1000 live births
(Status report 2004–2005. Thiruvananthapuram, District Mental Health Programme).
Mental health nursing is considered as speciality. Specialisation include post graduate certificate in mental health nursing, diploma in mental health nursing and maters of mental health nursing. Mental health system in India and Kerala majorly follows medical model of care.
Kerala nurses are well known for their global representation. Australia is not an exception. Migration of Kerala nurses to Australia has increased dramatically in the last few years. This study will explore lived experiences of overseas-trained nurses from Kerala and working in mental health in Australia. Australia currently relies on the migration of health professionals from other countries to meet the workforce demand of the health care sector (Health Workforce Australia, 2012; Konno, 2008; Jeon & Chenoweth, 2007; Hawthorne, 2001; Zhou, 2010; Omeri, 2006). Thirty three percent of Australian health work force is overseas trained (AIHW, 2010). Until 2001, the UK was the major supplier of overseas trained nurses (ABS, 2011). The pattern of inflow has changed. Current report on migration reveals the most numbers of overseas trained nurses have migrated from India (ABS, 2011). In fact, the rates of overseas born nurses from India increased from 2% in 2001 to 8% in 2011, “one of the largest proportional increases over this period” (ABS, 2011). Kerala nurses represents 80% of Indian nurses (Percot, 2012).
Kerala, also referred as ‘Keralam’ is a state in the south west of India. Kerala is the state from where the highest number of Indian nurses have graduated and migrated to other countries (Indian Express, 2012). Kerala, the state with lowest population growth among other Indian states has the highest human development Index, highest life expectancy and literacy. The culture of this state is one of the ancient ones and developed over centuries. Kerala has strong religious tradition with half of the people practicing Hinduism followed by Islam and Christianity. Other rich traditions of Kerala include unique cuisine, literature and various art forms. Kerala people are traditional but modern and at the same time very protective of their culture. Participants of this research have revealed that during various stages of interviews. Historically Kerala is well known for internal and external migration. More than 30% of Kerala’s population with higher education qualification live overseas (CDS, 2012).Kerala‘s economy majorly depends on emigrants working in foreign nations. According to Percot (2006), p9:
“In a typical Kerala family, it is common to have a brother in Gulf, another one in Dubai, a sister in Kuwait, an uncle or aunt in Canada, America, Australia or the UK”
Post-independence India adopted British infrastructure in various areas including health care system, education including nursing. History of formal nursing education begins in India with School of Nursing, General Hospital Madras in 1871, followed by many and the evolution started. Four year University degree program for nursing first commenced in 1946 at the Christian Medical College, Vellore by a foreign Missionary. Till 1956, Master of Nursing program wasn’t available in India. There were various schools of nursing offered 3 years Diploma Nursing program in Kerala since 1950’s. These were mainly run by nuns, who were trained as nurses in foreign nations such as Ireland. The pioneer of four years nursing degree program in Kerala is College of Nursing Trivandrum founded in 1972. To summarize, in Kerala there exists two main types nursing training; non-university program and university nursing programs. Three and half year’s hospital based Diploma Nursing and Midwifery program is the main non-university training program. The basic level university based nursing training in Kerala is four year’s Bachelor of Nursing program. Currently both of these basic nursing qualifications lead to ‘Registered Nurse’ licence by Kerala and Indian Nursing Council. Both these courses are mainly offered by private sector. And these two courses offer eligibility to apply for registered nurse qualification in most of the foreign nations also.
Nursing is not considered as reputable and highly paid profession in India (Nair, 2012). Yet, post independent India, mainly Kerala produced increasing number of nurses, mainly Christians, and the number steadily increased over the years. This was mainly for the purpose of migration. Various surveys conducted by different academics (Thomas, 2006; Dicicco-Bloom, 2004) among Kerala nurses identified that more than 50% of Kerala’s nursing graduated have the intention to migrate. It has been estimated that between 3 to million Keralites are migrants (Samuel, 2008). This number excludes second and third generation migrants.
The experiences and challenges faced by migrant professionals are different those of domestic professionals. Research on experiences of migrant nurses highlight themes such as isolation, separation issues, communication related problems, underestimation by patients and colleagues, issues related to enculturation and lack of orientation to the new health care system and new culture (Department of Health, 2009; Walters, 2005; Konno, 2008; Jeon & Chenoweth, 2007; Hawthorne, 2001; Omeri, 2006). It is widely acknowledged that, working in mental health is more stressful than generic nursing practice due to challenging behaviours and other psychosocial challenges associated with mental illness, issues related to communication and also the need for the establishment of the therapeutic relationship (Currid, 2008; Jenkins & Elliot, 2004). The cumulative result of these factors can lead to burnout and leaving jobs. However, few scholars have undertaken research to understand the essence of experiences and challenges of migrant professionals working in the speciality of Mental Health.
1.4 Significance of this research
AIHW (2009), highlighted that mental health nurses are the largest group of mental health workforce while nursing shortage is a well-known phenomenon, in mental health (Walters, 2005). There have been discussions and various reasons have been identified for the issue such as, ageing work force, poor image of the nursing profession and lack of education availabilities (Gerrish& Griffith, 2004). Additionally, the average age of a general nurse is mid-40s, whereas the average age of a mental health nurse is late 50s (Nurses and Midwives Association, 2011). At the same time, mental health workers have a strong affirmative impact on mentally unwell clients and carers (The Victorian Mental Health reform strategy 2009- 2019). The mental health system has extensively reformed over the past decade (Victorian Mental Health Reform Strategy 2009-2019, Department of Health 2009). Contemporary mental health practice in Australia focuses on primary care and client-led recovery models of care with ongoing carer participation and collaborative planning. It also demands teamwork, assessing clients in their cultural context, engagement, communication and working within the specific legal boundary. This could be a new experience for migrant professionals, since most of the developing countries still follow a ‘medical model’ rather than a ‘recovery model’. Additionally, a few scholars suggested that the domestic work force and patients may show mixed feelings towards the migrant professionals, and this possibly makes them feel undervalued (Zhou, 2010; Alexis &Vydelingum, 2004; Konno, 2008 & Hawthorne 2000).
It is asserted by various scholars that India has a major role in the supply of nurses in the global market (Kodoth& Jacob, 2013; Nair & Percot, 2005; Percot, 2012; Walton-Roberts, 2010). Despite of the stigma attached to nursing in India ((Nair &Percot, 2005), India produces approximately 100,000 nurses per year, and 20% of India’s graduates migrate to a foreign nation at a given year (Sinha, 2007). In Australia, during 2005 – 06, of total overseas trained registered nurses, 7.7% was from India (top of the list), where as in 2011 – 2102, it has increased to 35.5% (Health Workforce Australia, 2011). Moreover, research suggest that 80 – 90% of Indian nurses are from Kerala (Kodoth& Jacob, 2013; Nair & Percot, 2005; Walton-Roberts, 2010). Furthermore, it is assumable, a significant number of those overseas trained nurses’ work in Mental Health.
1.5 Aims and objectives of this research
The overall aim of this qualitative phenomenological research is to explore the experiences of being an overseas trained nurse from Kerala, India and working in mental health in Australia. The scarcity of experienced mental health nurses in Australia has direct impact in the recruitment of overseas trained nurses with minimal no experience in mental health. This phenomenon itself can bring along a few additional hurdles. Jose (2008) points out role confusion, lack of understanding of expectations of the particular role, and communication as some common difficulties faced by overseas trained nurses. Mental health nursing in Australia and India are dissimilar along with the culture. The research question of this study is “what is like to be an overseas trained nurse from Kerala, India and working in mental health Australia?”
Objectives of the study are to:
• Explore and interpret the experiences and challenges of overseas trained nurses from Kerala, India working in mental health in Australia.
• Interpret the migration and transition experiences of overseas trained nurses from Kerala using life world existentials
The first objective is to uncover the experiences of overseas trained nurses from Kerala and is achieved by narratives about transition to life in Australia, narratives about working as a registered nurse in Kerala and in Australia, narratives about working in mental health in Kerala and in Australia and narratives about the transition from the past to the present and expectations of the future.
Second objective is to interpret the migration and transition experiences of overseas trained nurses from Kerala using life world existentials. This is by narratives about lived space, lived time, lived relations and corporeality in being an overseas trained nurse working mental health in Australia.
1.6 Research Method
This study followed qualitative research methodology, phenomenology, informed by van Manen. Phenomenology, as a method, aim to explore the lived world of the individual and the personal meaning of their experiences. According to van Manen (1990), phenomenological research expects thoughtful sensitive reflection on experiences. It will also look into the “heart of things” (p12). This study explored lived experiences of overseas trained nurses from Kerala, India and working in mental health in Australia.
Ethics approval for this study was obtained from Monash University Human Research Ethics Committee. Participants of this study were nurses from Kerala with 2-10 years of experience and currently working in mental health in Australia. A purposive sample of 16 Kerala nurses participated in this study. This research was advertised in Main Hospitals and also through educators’ network. But most of the participants were recruited through ‘word of mouth’ and snowball sampling. Participants were from different states of Australia. Data collection was conducted by in depth audio recorded interviews. Verbal explanation was provided during first contact with the participants. Informed consent was obtained prior to the interview. Interview locations were determined after consulting with participant, venue of their convenience. Interviews were informal, in depth and unstructured but there were guiding questions (Appendix A). Interviews were mainly led by the participants. Participants were informed about the possible risks and their right to withdraw the participation before publication. Even though here was a clear distress management protocol in place, no one reported distress or any related issues. The interviews were transcribed and analysed.
This research followed van manen’s six steps process for phenomenological research. According to van Manen (1990), step one is ‘Turning to the nature of lived experience’, the step was completed by the formulation of research question ‘what is it like to be an overseas trained nurse from Kerala, India and working in mental health in Australia’. Second step is ‘Investigating experience as we live it’. This step involve choice of method. This research used phenomenology informed by van Manen, since it explored the lived experiences of overseas trained nurses from Kerala, India and working in mental health in Australia. Third step is ‘Reflecting on the essential themes’ and this step involve data analysis. In this researcher read and read the transcripts multiple times to capture the essential themes and meanings. Fourth step is ‘Describing the phenomenonin the art of writing and rewriting’ and this stage also involves analysis and writing, in order to make the personal meaning of lived experiences of participants. This is an important step in phenomenological research. Fifth step is‘Maintaining a strong and orientated relation to the phenomenon’ and in this stage the researchershould pay attention to stick with the research question. Sixth step is ‘Balancing the research context by considering the parts and the whole’. According to van Manen (1990), these steps are linear, but the researcher should be able to move back and forth throughout the process.
The researcher had process in place to establish rigour. The researcher paid attention to have regular meetings with supervisors throughout and whenever necessary. The researcher took field notes during interviews and maintained a reflective journal. The transcripts were checked and confirmed by the participants.
1.7 Thesis Structure
In this thesis,chapter tworeviews the literature around on experiences overseas trained nurses working overseas. This chapter include an overview of migration of health professionals, Kerala in the context of migration, historical overview of nursing in Kerala, acculturation and assimilation of overseas trained nurses and experiences of overseas trained nurses. The review of the literature eventually identified the extend of the problem and the existence of the gap in the knowledge about overseas trained nurses working in specialist areas, especially Kerala nurses working in mental health in Australia.
Chapter three provides the theoretical framework of this research which include research methodology, research questions, participants and ethical considerations. This chapter portraits the evolvement of research question, rationale behind the choice of hermeneutical phenomenology.
Chapter four, describes the method employed in this study and rationale behind the choice of particular method. This chapter provide detailed description of ethical aspects, data collection and data analysis process involved in this research.
Chapter five, of this thesis is research findings. This chapter will give detailed description of themes and evolvement of those themes.
Chapter six, the discussion chapter describes research findings in the current context and implications of this study.
Chapter seven; summary, conclusion and recommendations provide details of contributions this research made to the existing body of knowledge. This chapter also will highlight the key findings of this research.
1.8 Summary of the chapter
This chapter presents a brief outline of this research. In order to set the context, a brief description about mental health nursing in Australia and India were provided earlier in this chapter. It has assumed that personal interest and back ground information of researcher are significant and it is important to make visible for the readers since the starting point of a phenomenological research can be lived experience of the researcher (van Manen, 1990). Background and significance of this research is described with supporting literature and statistics. This chapter also has given overview of aims and objectives of this research, methodology and thesis structure.
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