Applied Nursing Research 46 (2019) 57–66

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Work-related barriers and resources of migrant and autochthonous T

homecare nurses in Germany: A qualitative comparative study
⁎
Benjamin Schilgen (B.A. Nursing, M.Sc. Health Sciences, RN)a, ,
Oriana Handtke (M.Sc. Psychology)a, Albert Nienhaus (MD, MPH)b,c, Mike Mösko (PhD)a
a
Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
b
Competence Centre for Epidemiology and Health Service Research in Nursing, Institute for Health Service Research in Dermatology and Nursing, University Medical Centre
Hamburg-Eppendorf, Bethanien-Höfe Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
c
Department of Occupational Health Research, German Social Accident Insurance Institution for the Health and Welfare Services, Pappelallee 33/35/37, 22089 Hamburg,
Germany

A R T I C LE I N FO A B S T R A C T

Keywords: Background: There is substantial research about the occupational health of nurses worldwide. However, em-
Occupational health pirical evidence about the psychosocial health of migrant and minority nurses in outpatient settings in Germany
Qualitative research in comparison to that of autochthonous nurses is lacking.
Foreign professional personnel Objectives: This study aims to identify work-related stressors, resources and the corresponding coping strategies
Comparative study
of migrant and minority nurses in comparison to autochthonous nurses.
Home health nursing
Design: 24 migrant and 24 autochthonous nurses employed in the German homecare sector were interviewed in
qualitative explorative manner while a distinction was made between non-commercial and private-commercial
services.
Settings: The interviews took place in the nursing services' premises or in the nurses' private homes.
Participants: Services were randomly chosen among all homecare providers in the second largest German federal
city-state Hamburg. Nurses were invited for an interview, once their management agreed to participate in the
study. Registered nurses and nursing assistants as well as those with a foreign certificate but validated or in
process were eligible to participate.
Methods: Relevant literature findings formed the base for the semi-structured interview guide. Key areas in the
interview guide were barriers, resources and coping strategies in the collaboration with colleagues, superiors and
clients as well as in the collaboration within a linguistically and culturally diverse team and clients. The con-
ventional approach to qualitative content analysis by Hsieh and Shannon guided the analysis.
Results: Regardless of their origin or culture, nurses perceive time pressure, lifting patients, lack of appreciation
or the client's personal fate as burdening. In the intercultural context, the divergent understanding of behavioral
patterns as well as of nursing care and a non-functioning communication impede the collaboration within a
diverse nursing workforce. Migrant and minority nurses suffer prejudices, verbal and sexual harassment pro-
ceeding from their clients. However they keep it to themselves and don't broach it to their supervisors or col-
leagues. The interaction with humans, the verbal exchange with colleagues and supervisors at eye level as well as
the sensemaking of being a nurse helps nurses to cope with occupational stressors.
Conclusions: Differences in language is a main stressor which impedes a functioning team collaboration as well
as a positive nurse-client relationship. Migrant and autochthonous nurses share similar coping strategies to
master occupational burdens. A good collaboration within the team and having an appreciative supervisor are
resources that support migrant and minority nurses as well as autochthonous nurses to face the stressors and to
cope with those. Migrant nurses of different origin perceive their status as migrants as a sense of community by
sharing commonalities.
Contribution of the paper: What is already known about the topic?

• The growing demand for care due to the demographic change leads to an increasing trend to hire healthcare
personnel such as nurses from abroad.
• The nurses' workplace is characterized by physically and psychologically demanding tasks leading to mus-
culoskeletal pain and job dissatisfaction.

⁎
Corresponding author.
E-mail addresses: b.schilgen@uke.de (B. Schilgen), o.handtke@uke.de (O. Handtke), a.nienhaus@uke.de (A. Nienhaus), mmoesko@uke.de (M. Mösko).

https://doi.org/10.1016/j.apnr.2019.02.008
Received 17 December 2018; Received in revised form 7 February 2019; Accepted 10 February 2019
0897-1897/ © 2019 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
B. Schilgen, et al. Applied Nursing Research 46 (2019) 57–66

• Migrant
stress.
healthcare workers experience additional stressors like discrimination practices as well acculturative

What this paper adds:

• Migrant and Autochthonous nurses share similar coping strategies to master occupational burdens
• Differences in language is a main stressor, which impedes a functioning team collaboration as well as a
working nurse-client relationship. More autochthonous than migrant and minority nurses report these dif-
ferences as stressful.
• Migrant nurses of different origin perceive their status as migrants as a sense of community by sharing the
same destiny – this appears as an important resource for migrant and minority nurses.

1. Introduction dominant employer of migrant and minority nurses, while the body of
research in countries like New Zealand, Switzerland, Australia and
The concomitant increase of the elderly population and the decline Luxembourg as other major markets for migrant nurses within the
in the birthrate are challenges to the global demography (GBD 2016 OECD is limited. There is evidence that Canadian nurses feel distress
Disease and Injury Incidence and Prevalence Collaborators, 2017; Lutz, due to demands of loss, novelty, and not feeling at home in the re-
Sanderson, & Scherbov, 2008; Mathers, Stevens, Boerma, White, & ceiving country, whereas Philippine nurses reported higher distress due
Tobias, 2015). The global life expectancy at birth rose by 6.2 years from to language accommodation (Beechinor & Fitzpatrick, 2008). Migrant
65.3 in 1990 to 71.5 years in 2013 (Murray et al., 2015), while the nurses, especially those of ethnic and racial minorities, encounter dis-
population in Europe aged by 12.5 years since 1960 and now amounts crimination, racism and bullying at work on a daily basis (Hogh,
to 82 years in average (OECD, 2017b). Carneiro, Giver, & Rugulies, 2011). This happens in the form of unequal
The healthcare workforce is not only aging but also declining and so career advancement options, unequal pay, insufficient orientation,
healthcare services are additionally confronted with a declining work- overlooking of their skills by colleagues and supervisors (Likupe &
force supply (OECD, 2017a; Simoens, Villeneuve, & Hurst, 2005). Archibong, 2013; Pittman, Davis, Shaffer, Herrera, & Bennett, 2014).
Several strategies like large-scale nursing training campaigns Studies showed that the level of acculturation has an influence on the
(Janiszewski Goodin, 2003), monetary incentives to increase retention individual's social behavior – e.g. the lower the level is, the higher is the
rates (Buykx, Humphreys, Wakerman, & Pashen, 2010), the academi- risk for stress in a relationship or conflicts with family members and
sation of the nursing profession (Fealy & McNamara, 2007; Heitlinger, work colleagues or friends (Renzaho, 2009). Nonetheless, findings also
1999) or even the implementation of socially assistive robots revealed that an initial depression in the first month after arrival goes
(Bemelmans, Gelderblom, Jonker, & de Witte, 2012) are discussed and into remission over time among migrant nurses (Hener, Weller, & Shor,
already partly applied to face the challenge of a long-standing rise in 1997). Measures of mental and organizational support turned out to
demand for care. facilitate the process of acculturation for migrant nurses (Hayne,
Beside these strategies, healthcare workers from abroad are in- Gerhardt, & Davis, 2009).
creasingly hired (Li, Nie, & Li, 2014). The number of migrant nurses and In light of limited empirical evidence on the working situation of
doctors has grown by 60% within the Organization for Economic Co- migrant and minority homecare nurses, this qualitative study's purpose
operation and Development (OECD) since 2004 (ILO, 2015). New is to explore their psychosocial strains and stressors, resources and
Zealand, Switzerland, Australia and Luxembourg register the highest coping strategies.
proportion of foreign-born nurses within the OECD with more than
30%. In the United States and in Germany 14% of nurses are not native. 2. Methods
Among the OECD European countries, Germany and the United
Kingdom account for the largest number of emigrating nurses. (ILO, The research questions underlying the qualitative study were
2015; OECD, 2016). With reference to foreign-born nurses within the
OECD, the Philippines and India accounted for the highest shares (ILO, 1. “Which psychosocial stressors do migrant and autochthonous
2015; OECD, 2016). homecare nurses experience at work?”
Working as nurse comes along with various occupational strains in 2. “Which resources and coping strategies do they employ to face
general. Next to physical strains like acquiring hand dermatitis by using psychosocial stressors?”
gloves, experiencing musculoskeletal pain by lifting and moving pa- 3. “In what way do migrant and autochthonous homecare nurses differ
tients or sleep disorder due to shift work, there are several specific in their experiences in general and in the intercultural context?”
psychosocial strains like impaired mental health by facing low social
support or effort-reward imbalance (Bernal et al., 2015; Ribeiro, 2.1. Study design
Martins, Marziale, & Robazzi, 2012). Homecare nurses are additionally
challenged by musculoskeletal stressors like moving and handling Qualitative research allows to collect data in a natural setting that is
household objects to gain access to the patient in his homely environ- sensitive to the people under study (Creswell, 2007). The interpretation
ment (Szeto, Wong, Law, & Lee, 2013). They also experience verbal and and explanation of behavior in the context of interacting individuals of
sexual abuse and violence, problems with workload planning due to different cultural backgrounds is prone to cultural bias (Aneas &
time pressure and so feel rushed (Hignett, Edmunds Otter, & Keen, Sandín, 2009), so migrant nurses as well as native nurses were inter-
2016; Hittle, Agbonifo, Suarez, Davis, & Ballard, 2016) with negative viewed in equal shares. The scientific theoretical basis of this study is
effects on their psychosocial health. formed by the phenomenological research approach, which describes
While there is a substantial body of research evidence about the the significance of the lived experiences by the individual. The phe-
psychosocial health of nurses in general, the present knowledge about nomenological approach focuses on the description of what the parti-
the health of migrant and minority nurses is scarce as a recent sys- cipants under study recognize together in experiencing a phenomenon
tematic review shows (Schilgen, Nienhaus, Handtke, Schulz, & Mösko, (Creswell, 2007).
2017). Just 14 empirical studies explicitly focused on migrant and The qualitative study was conducted in accordance with the
minority nurses' health in the international research literature. Those “Consolidated criteria for reporting qualitative research” (COREQ)
studies were mainly conducted in the United States, who are the guidelines (Tong, Sainsbury, & Craig, 2007).

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B. Schilgen, et al. Applied Nursing Research 46 (2019) 57–66

2.2. Selection and recruitment of participants Table 1

Set of interview questions.
The research was undertaken in the federal state of Hamburg. The Work in general
homecare system in Hamburg is organized either by non-commercial or • Please describe a typical working day!
private-commercial providers (Statistisches-Bundesamt, 2017b). As- • What do you like about your work as a nurse?
suming that the intent to realize a profit within the private commercial • What is stressful about your work as a nurse?

services may have an effect on nurses reporting of stressors (Slotala, • How do you cope with it?
Collaboration with colleagues
2011), such as time pressure (Hielscher, Nock, Kirchen-Peters, & Blass,
• How do you interact with your colleagues?
2013) led to a subdivision of participants in two strata. Nursing care • What do you like about working with your colleagues?
providers who additionally focus their services on migrant and minority • What is stressful about working with your colleagues?
clients may differ from those services that care for clients regardless of • What helps to deal better with the burdens you have just reported?
Collaboration with direct supervisor
their origin (Campinha-Bacote, 2002). This led to a further stratifica-
• How do you interact with your supervisor?
tion of the sample: The above-mentioned two strata were subdivided • What do you like about working with your supervisor?
into those focusing on the care for migrant clients and those who not. • What do you experience as stressful about working with your supervisor?
Finally, two nursing services per stratum were randomly chosen. The • How do you cope with the burdens you have just reported?
Contact with clients
choice for a random stratified sample originated on the one hand from
• How do you experience being in contact with your clients?
the cross-cultural context of the study (Buil, de Chernatony, & Martínez,
• What do you like when you are in contact with your clients?
2012; Robinson, 2014). On the other hand, it was the study team's aim • What, from your point of view, is stressful in contact with your clients?
to have a heterogeneous sample of nurses from different cultural • How do you cope with the burdens you have just reported?
Intercultural context – colleagues and supervisors
•
backgrounds and to compare both without predetermining potential
Do you also work with colleagues or supervisors who come from other countries
“typical” cultural traits to any of them. Firstly, the service's manage- or have a different cultural background than yourself?
ment was contacted. A brief glimpse was given into the study and to get If so,
to know whether migrant as well as natives are employed. Studies
about data saturation in qualitative research recommend six to twelve • what do you like?
• what do you experience as stressful?
interviews per stratum (Guest, Bunce, & Johnson, 2006). Thus, per
service six migrant and six natives nurses were recruited for an inter- • how do you cope with the burdens?
Intercultural context – clients
view (Fig. 1). • Ifdifferent
you ever think about your clients who come from other countries or have a
cultural background than yourself, how do you experience the contact to
Eligible to participate were (i) registered nurses and nursing assis-
these people?
• What
tants with German certificate or whose certificates are in a validation
do you like?
process, since they received their training and certificate abroad; (ii)
• What do you experience as stressful?
who were born in Germany or born abroad and migrated to Germany;
(iii) had been practising in homecare for at least one year; (iv) being
• How do you cope with the burdens?
employed on a full-time or part-time basis for at least one year in
homecare or for six month in the case of having had changed the em- The study team agreed on a top-down recruitment approach to ar-
ployer within the last year (this was needed to ensure a certain famil- range each of the 48 interviews. In case of a positive feedback of the
iarity with the recent employer) and (v) who were at least 18 years old. management board, each service's nursing manager was contacted and
Not being able to speak German was not an exclusion criteria, since invited for participation in this study.
the intention of the study was to include every nurse in the recruiting Out of 404 eligible nursing providers in Hamburg, 62 were stepwise
process regardless of her or his command of language following the randomly contacted. Of those, fifteen agreed to participate and assured
principle ‘language is no barrier’ (Lee, Sulaiman-Hill, & Thompson, to ask their nurses whether those want to be interviewed. The services'
2014; Squires, 2009). In those cases, a professional interpreter would nursing managers received information material mainly via email. In
have assisted the interviews. order to increase credibility, the study was presented during the

Non-commercial
Private-commercial
(charitable)
Services
Services
n = 273
n = 131

Services without Services with ad- Services without

Services with addi- Random
additional focus ditional focus on additional focus
tional focus on care stratified
on care for Mi- care for Migrant on care for Mi-
for Migrant clients sampling
grant clients clients grant clients
n=2
n=2 n=2 n=2

Migrant Native Migrant Native Migrant Native Migrant Native Recruited by each
nurses nurses nurses nurses nurses nurses nurses nurses services‘ nursing
n=6 n=6 n=6 n=6 n=6 n=6 n=6 n=6 manager

Fig. 1. Recruiting process.

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B. Schilgen, et al. Applied Nursing Research 46 (2019) 57–66

employers' meeting in the premises of the services. A positive feedback Table 2

was finally given by ten providers who provided 60 possible interviews Characteristics of the study sample.
with their nurses. The final study sample was formed by 48 nurses from Migrant nurse Autochthonous nurse
eight providers. (n = 24) (n = 24)

Gender
2.3. Data collection
Female 21 (87.5%) 20 (83.3%)
Male 3 (12.5%) 4 (16.7%)
A semi-structured interview guide (Table 1) was developed based on
Age (yrs)
relevant literature findings about work-related strains and stressors. Mean (SD) 42.92 (11.98) 45.17 (9.78)
The team of authors first discussed the draft of the guide and adapted it Range 23–68 30–62
correspondingly. The modified version was then sent to five experts in
Country of birth
the field of migration and health and respectively adapted. Finally, the Afghanistan, Ghana 4 (each 2)
interview guide was pilot tested among four nurses, slightly modified (16.6% (8.3%))
and considered appropriate for application. Africa, Bosnia, Brazil, 12 (each 1) (50%
Colombia, Croatia, (4.2%))
Key areas in the interview guide were strains/stressors, resources
Ecuador, Finland,
and coping strategies in the collaboration/contact with colleagues, su- Indonesia, Latvia, Russia,
periors and clients. In this context, the collaboration within a linguis- Uganda, Yugoslavia
tically and culturally diverse team and with clients was also examined. Iran 3 (12.5%)
Each nurse was asked whether she or he works with colleagues or has Turkey 5 (20.8%)
Germany 24 (100%)
direct supervisors or cares for clients who each come from other
countries or have a different cultural background than themselves. Occupational background
Registered General Nurse 4 (16.7%) 12 (50%)
All but one participant agreed that the interview would be digitally
Nursing assistant 3 (12.5%) 2 (8.3%)
recorded, so one interview was recorded by paper and pencil. The in- Geriatric nurse 8 (33.3%) 8 (33.3%)
terviewer's thoughts and reflections on all interviews were registered as Geriatric nursing auxiliary 9 (37.5%) 2 (8.3%)
field notes during as well as after each interview. Highest level of education
The main author conducted all interviews between February and Certificate of secondary 6 (25%) 3 (12.5%)
July 2017; those lasted between 35 and 60 min and were taken after or education
before the nurses' work shift. The interviews took place in the offices of General certificate of education 10 (41.7%) 11 (45.8%)
ordinary level
the nursing services or in the nurses' private homes while total privacy
Vocational diploma 0 3 (12.5%)
was assured. General certificate of education 4 (16.7%) 5 (20.8%)
advanced level
2.4. Data analysis University degree 4 (16.7%) 2 (8.3%)

Length of time working as nurse in general (yrs)

For the purpose of this study, data were analysed by the conven- Mean (SD) 12.04 (11.11) 19.65 (9.27)
tional approach to qualitative content analysis described by Hsieh and Range 1–45 5–35

Shannon (Hsieh & Shannon, 2005). The audiotapes were transcribed Length of time working at current employer (yrs)
verbatim. The main author developed an initial coding framework. Mean (SD) 6.34 (7.20) 8.71 (8.66)
Range 0.5–26 0.5–30
In the context of quality assurance, two further members of the
research group independently derived categories and its corresponding
definitions and prototypical text passages from four randomly chosen
nurse.
transcripts. Their findings were then mapped with the initial coding
framework. Differences as well as congruencies were discussed. The
final category system was presented and reflected in a workshop within 3.1. Sample characteristics
the research group. Afterwards, the suggestions were applied to the
entire data set. Therefore, the category system was revised within the The sample consisted of 48 nurses. According to the initial criteria,
process of analysis. MAXQDA version 10 was utilised to manage the half of them were born abroad. Migrant nurses are those study parti-
coding process (VERBI-Software, 2017). cipants who were born abroad - in other words – not in Germany.
Autochthonous nurses are those participants in the study, who were
2.5. Ethical considerations born in Germany and whose parents were both born in Germany. The
typical gender distribution in favor for female nurses (Eurostat, 2017)
Ethical approval was obtained from the ethics commission of the proves true in this study as in both cohorts (migrants nurses & auto-
Hamburg medical council (application “Antrag PV5440”) prior to data chthonous nurses) less than 20% of the nurses are male (Table 2).
collection phase. At the beginning of each interview, written consent Native nurses in this sample are older on average.
was obtained and each participant was reminded that a withdrawal at The migrant nurses' sample represents 16 countries on four con-
any time of the interview is possible without any negative consequences tinents and more likely employed as geriatric nurse or geriatric nursing
for her or him. Each participant received an allowance in terms of a 15 auxiliary than their native counterparts are. The participants in this
Euro cash pay-out subsequent to the interview. study are: 1. Registered general nurses (Gesundheits- und
KrankenpflegerIn) who mainly work in hospitals, at specialist medical
3. Results practices but also in the homecare sector. They assist in medical ex-
aminations and treatment and document patient data. Registered gen-
The study findings are presented as follows: first, the sample char- eral nurses have to complete a three-year vocational training. 2.
acteristics are described. Then the category system that emerged from Geriatric nurses (AltenpflegerIn) mainly work in geriatric and ger-
the qualitative content analysis is illustrated. The categories are high- opsychiatric settings and provide nursing care for the elderly. They also
lighted including verbatim quotes from the interviews. Each quote has a have to successfully pass a three-year vocational training. 3. Nursing
corresponding identifier number for respondents, with captions of “I” Assistants (Gesundheits- und Pflegeassistent/in) completed a two-year
for interview and “M” for migrant nurse or “A” for autochthonous vocational training and assist registered general nurses and geriatric

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nurses in terms body care (washing the patients'/clients' body) or food same job.
intake. 4. Geriatric Nursing Auxiliaries (AltenpflegehelferIn) underwent Caring for clients at their home is associated with physical strains.
a one-year training and support nurses in their daily care of the elderly. Migrant nurses reported that they struggle to handle those clients
As the training last from one to three years, there are salary differentials whose furnishing at home does not comply with the requirements of
between the different levels of profession (Bundesagentur-für-Arbeit, professional care: “And you also have some heavy bedridden patients and
2019). Native nurses in this study have worked on average more than customers. You have such coercive positions. It's all physically stressful.”
seven years longer in the nursing sector than their migrant colleagues (I33-M). Among migrant nurses, the topic ‘Handling of heavy clients’
and two years longer with their current employer. turned out to be very prominent. 15 out of 24 nurses voiced out that
they feel burdened from transferring a heavy client from e.g. the
3.2. Category system wheelchair to the toilet.
Nurses often work under very physical and psychological stressful
The three leading subjects of the study were “barriers”, “resources” conditions. An autochthonous nurse explained that she feels stressed by
and “coping strategies”. These three subjects were then embedded in being unable to distance herself from work. She stated her thoughts
four contexts, namely “work in general”, “colleagues”, “direct super- about her demanding job are ever-present and so she could not unwind.
visor” and “clients”. Within the contexts colleagues and clients, a fur- Time pressure was perceived as a leading structural stressor with
ther subdivision into “intercultural” and “general” allowed the distinct negative effects on nurse's physical and mental health as it was ex-
description of cultural influences on the work of the nurses under study. pressed in both strata. “What's very stressful for me is that I'm under time
Thus, one subject and its specific context formed a cluster (Hsieh & pressure. It's terrible that it has to be so accurate to the minute. And that's
Shannon, 2005). The following grid illustrates the entire category psychological stress for me, too.”(I33-M).
system for the migrant and the autochthonous stratum respectively that Approached on the subject ‘resources’ nurses told that they receive
was finally derived from the interviews (Table 3). vouchers for fitness studios, massages or even special gymnastic ex-
ercises taking place in their nursing station. Other nurses added uti-
lizing technical aids if present at client's household.
3.2.1. Work in general
Being in contact with own friends and pursuing one's hobby sup-
Working as a nurse in the host country is connected with the ex-
ported nurses to cope with daily stressors. “If something is bothering me at
pectation of better working and living conditions. However, migrant
work now, I'm not going straight to my supervisor. First of all, I talk to my
nurses explain that they feel a sense of competitiveness among their
mother or my family about it.” (I3-M).
colleagues in a way that ‘other’ migrant nurses are competing for the

Table 3
category system for the qualitative content analysis.
Migrant nurses Autochthonous nurses

1. Work in general barriers Personal: Personal:

Competitiveness Non-distancing oneself from others and work
Structural: Structural:
Time pressure Time pressure
Handling heavy clients Mobilization of clients
Lack of/absence of resources Lack of/absence of resources
resources Professional:
Technical aids, Offers from employer (e. g. training courses)
Personal/Private:
Social contacts
Freelance activities
coping strategy Endowment of the profession
Human interaction
2. Collaboration with colleagues barriers Intercultural Divergent understanding of behavioral patterns
Differences in language
Divergent understanding of nursing care
In general Talking about each other Prioritizing one's own well-being
instead of one with other
resources Addressing a problem directly to colleagues
coping strategy Intercultural No ethnicization or culturalization No ethnicization or culturalization
Sharing commonalities Mutual support as language/cultural interpreter
In general Supporting mutually
Experiencing friendliness/respect
Working on one's own
3. Collaboration with direct barriers Lack of appreciation
supervisor Unequal treatment
resources Seeking clarifying discussions
Appreciation of the individual by superiors
coping strategy Voicing out own opinion Willingness to talk
Meeting at eye level Meeting at eye level
4. Contact with clients barriers Intercultural Claims/expectations of clients Malfunctioning verbal communication Claims/expectations of
Prejudices against migrants clients
In general Client's personal fate Client's personal fate
Harassment (e.g. verbal, sexual)
resources Exchanging with colleagues Exchanging with colleagues
Discussing problems directly
with clients
coping strategy Conversing with clients
Perceiving gratitude/appreciation
Keeping one's distance

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B. Schilgen, et al. Applied Nursing Research 46 (2019) 57–66

The sensemaking of the profession ‘nurse’, the human interaction, everyone is the same, the most important thing is [that they are] people.”
helping elderly dependent people who in turn are shining with grati- (I40-M).
tude were vented a number of times as coping strategies “because nur- Autochthonous registered general nurses reported that they ap-
sing it's something meaningful, the gratitude that comes back.” (I32-A). preciate the support of their migrant colleagues as language or cultural
interpreter: “I have my apprentice with me and she translates everything
3.2.2. Collaboration with colleagues wonderfully. Sometimes she also has a different feeling, because she is just a
A divergent understanding of behavioral patterns challenges the little bit closer to the culture. She can give me information that I might not
collaboration of migrant nurses and autochthonous nurses. In this in- have right now.” (I6-A).
tercultural context, an autochthonous registered general nurse ex- Four-fifths of all nurses in both strata explicitly appreciated the
pressed about her migrant colleague: “it is this mentality; she arrives at mutual support among their colleagues. They support each other by
work 45 minutes late. That is their laxly mentality. Of course, some of them either picking up the slack for someone who calls in sick or switching
come from another cultural background, where it's all handled a bit more shifts due to private reasons. Mutual respect and friendliness were also
laxly.” (I17-A). German colleagues are perceived as strict in their way of frequently mentioned factors having positive influence on nurses' col-
working as this migrant registered general nurse noted: “Foreigners are laboration: “I especially like the way we deal with each other. I find the
more flexible. I feel that the Germans are a bit strict but on the other hand, respect for each other very very important, because there are a lot of dif-
they are trying to do the job properly, so correct.” (I24-M). ferent people who work together and of course a lot of characters.” (I8-A).
A leading stressor that hindered the collaboration of colleagues from Migrant nurses felt in various situations at work more comfortable
different origins were differences in language. Experiencing commu- with other migrant nurses, since they are sharing commonalities:
nication difficulties with their migrant colleagues is burdensome as this “Somehow I feel better with these people, they're so close to me. For example,
negatively affects their way of working: “filling out forms and explaining people from Poland - we have a lot of similarities with them.” (I24-M, mi-
to them why, where, what has to be filled out is very difficult, because it goes grant registered general nurse). “I experience the cooperation with for-
back to almost baby language. It takes a lot of time.” (I35-A). Beyond, a eigners better. I feel better because we are sharing the same destiny. With
migrant nursing assistant expressed: “The hard time was my language, Germans, well, I don't feel bad, of course. But somehow, we are foreigners
because I could not speak German so well and my colleagues sometimes did together.” (I30-M, migrant nursing assistant).
not understand me.” (I18-M). Working on one's own and not pursuing further the solution of a
Prioritizing one's own well-being affected the collaboration within a problem with a colleague helped this autochthonous geriatric nurse:
team as these nurses were missing common effort from their colleagues “actually one cannot change the world and cannot change people and then I
to balance unexpected events: “Yeah, but I find that disrespectful if say I prefer to do it alone instead of facing these conflicts. Firstly, I am more
someone just does what he or she wants. Don't think what others want.” time-saving and secondly, the many years of work experience show me that
(I18-M). Another registered general nurse complained: “If it's always the the individual person does not want to change, or the structures cannot be
same people who pick up the slack. Those who always say: ‘No, I can't.’ changed.” (I10-A).
Everyone can be in that situation - but not always.” (I7-A). Another re-
gistered general nurse said: “Sick leave is an issue here; they are always the 3.2.3. Collaboration with direct supervisor
same four or five calling sick, but secondly there are always - and I count Nurses felt burdened by supervisors who demand complete com-
myself among them - the same four or five who, strangely enough, are almost mitment from their employees, but do not value their effort:
never ill and have to absorb what the sick colleagues cause.” (I10-A). “Sometimes, I would wish she had that look that she has on herself on us,
Nurses reported that they feel stressed by colleagues who talk about too. The praise here is very, very sparse.” (I12-A).
each other instead of one with other. This migrant registered general Migrant nurses reported to be treated unequal in terms of wishing
nurse reported: “there were colleagues backbiting me. And I don't like that. for off days or holidays as this migrant nursing assistant explained: “I
You should rather say it directly to me, but don't blaspheme over others. I find that burdensome sometimes. I have no children. I always have to go on
expect them not to hide anything from me. I want us to work together.” (I40- holiday earlier, although I would also like to go in midsummer.” (I31-M).
M). She wondered, whether the higher qualification of her colleagues,
Even though homecare nursing is regulated by quality standards, namely registered general nurses is prejudicial to her.
the understanding of what is client oriented nursing care of high quality In case of misunderstandings or problems with her supervisors, this
differs among nurses. This autochthonous nursing assistant pointed out migrant registered general nurse explained: “I try to find a conversation
that quality in nursing care means more than “sated and tidy” and she with the supervisors asking whether I made a mistake, or how could it get
missed the lacking “German efficiency” (I36-A) among her migrant better? So it's important to me that I can get rid of that.” (I33-M).
colleagues. This migrant nursing assistant was missing an under- Appreciative supervisors are perceived as those who support and mo-
standing of holistic care and explained that care also has an emotional tivate nurses to show commitment in challenging times of high demand
element: “You can't prepare breakfast or lunch and leave the kitchen dirty or important structural changes. “Well, I think it's good that they give me
afterwards, since the client is no longer able to clean the kitchen. There are all the opportunities to further my education.” (I41-M). “She has an ear for
colleagues who are just, what's it called, sloppy. They leave everything there everything. So it's nice when I come to the office at noon after a longer tour
or not really pay attention to cleanliness. But I've learned that we are not and someone is sitting there listening to you and smiling or sometimes takes
equal and you can't change your colleagues.” (I18-M). you in his arms.” (I6-A).
The direct verbal exchange with colleagues as the leading resource Voicing out your own opinion is a coping strategy among migrant
among the nurses under study enables them to cope with and possibly nurses to enable a functioning collaboration with their supervisor. This
resolve barriers and strains. This migrant geriatric nurse expressed: “If I migrant registered general nurse explains: “Of course it is necessary to
have had difficult situations at work, I try to converse with my colleagues maintain distance; but here [Germany] it is not the same as in [home
here.” (I33-M). Her migrant colleague explained: “Afterwards you also sit country], where as a subordinate you are not allowed to say anything. Here
together and put the situation, the mistakes from both sides on the table and you are asked for your opinion.” (I47-M). This migrant registered general
find a solution.” (I34-M). nurse confirmed: “we always meet at eye level here. It is not that we always
Migrant and autochthonous nurses commented positive on a diverse get orders from above, but that we work together.” (I33-M). Autochthonous
workforce: “Well, I mean, we all see ourselves as normal, as human beings. nurses appreciated having a supervisor who is ready and willing for
And we don't say ‘Oh, look, they're from Turkey or they're from Poland’. I talks but who also volunteers addressing issues: “you get answers to your
think we are steering more and more towards becoming multicultural.” (I15- questions and he [the supervisor] is always solution-focused, will never tell
A). “Turkey or Russia, Poland, Hungary. I work with all of them. To me, you ‘do it alone or google it’.” (I14-A). This registered general nurse was

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glad: “He [the supervisor] is really great. A great, a fair boss. Even if it's can I do?’. I don't leave my client's home being nasty and slamming the
something unpleasant. He is here and goes off to the side with the people and door.” (I28-M).
does it all discreetly.” (I17-A). The personal exchange with clients and colleagues helps nurses to
cope with burdening client-related situations: “And I still like the con-
3.2.4. Contact with clients versations with the people, talking about what kind of life they had or what
Participants from the German cohort reported that they feel bur- kind of person they are.” (I12-A).
dened by a malfunctioning verbal communication with those clients, Feeling appreciated or receiving signs of gratitude motivate nurses
with whom they cannot communicate in their first language: “it's really to persevere in challenging times: “There are nice moments or people who
stressful that in this case, you can't make yourself understood because you are just happy when you arrive. If you haven't been there for a while and
don't share the same language.” (I15-A). “I find that incriminating when you they welcome you, saying ‘Aaah, it's nice to have you back’. That balances
don't know what they want.” (I44-A). Another registered general nurse the stress, else I probably wouldn't have persevered for 25 years in nursing.”
confirmed that forming a relationship to a client is difficult: “you just (I17-A). These nurses experienced forms of gratitude from their clients:
don't have that kind of bond, because you can't really converse with them “Well, there are very special clients where I really like to go because they are
properly about something.” (I6-A). very warmhearted, very cordial. That's what I think is the price of care that
The intercultural exchange with clients was affected by the clients' you get something back.” (I14-A).
expectations or claims of how to be cared for in the health care system Keeping one's distance from clients, with whom the relationship is
and that hinder the nurse's work: “When I go to a client who's praying, he affected, helped nurses to master those challenging situations. A kind of
expects me to wait. Sit, stay calm, even though I'm under time pressure be- professional distance was reported by this nurse: “And if I don't like
cause my other clients are waiting. And this is mentally a burden for body someone, I'll keep a distance. Just ignore it. That's what I learned. But I'm
and soul. We work with completely different models, with completely dif- still going there and do my job. And afterwards I leave the place.” (I18-M).
ferent behaviors.” (I45-M). Another registered general nurse felt that her This migrant registered general nurse coped by keeping a local distance:
ideas and those of her migrant clients about how nursing in Germany “I then go to my supervisors and ask if I might be allowed to work somewhere
works, strongly differ: “They think that, just because they pay five Euro else for a few days. So that I will be relieved a little bit psychologically.”
prescription fee which is indeed very, very much for them, they have a right (I47-M).
to tell us when to come and how long to stay there.” (I27-A). Taken together nurses share similar barriers at work regardless of
A migrant geriatric nurse reported that she experienced clients who their ethnic or cultural background. However, more Migrant nurses
feel uncomfortable to be taken care by a foreign nurse: “there are also indicated that they feel physically burdened by handling heavy pa-
people who have problems with foreigners and show that.” (I11-M). This tients. Time pressure is a further prominent stressor that is causing
migrant female registered general nurse reported an articulate form of mental and physical stress among nurses. Communication problems due
racial discrimination: “When I was with a client, she was always so scared to language barriers turned out to be a leading stressor for the auto-
of me. And I asked her why. She replied ‘because you're black’.” (I28-M). chthonous nurses in collaboration with their migrant colleagues. The
This male migrant geriatric nurse experienced ethnical discrimination: teamwork within a diverse workforce is also affected by different work-
“Some clients don't like foreigners. And that's something you have to respect related mentalities. On the one hand, migrant nurses perceive their
when they don't want you to come in, while other colleagues are allowed to autochthonous colleagues as sometimes strict, while their auto-
come in. You know what I mean?” (I21-M). A Muslim registered general chthonous colleagues on the other hand report that they feel burdened
nurse reported that her German client did not allow her enter the flat as by migrant nurses with a laxly mentality. Migrant and German nurses
long as she was still wearing her scarf (I49-M). feel stressed by colleagues who exclusively focus on their own well-
The very close relationship with clients can be very stressful by being instead of the whole team. A supervisor who treats her or his
experiencing her or his living circumstances in detail. This nurse par- employees unfairly or does not appreciate their effort causes burden in
ticularized: “He has no pants, no clean laundry, no bed linen. Sometimes I nurses. This study also showed that communication barriers impede a
feel like I have to take my salary to him. It burdens you because you see this functioning relationship with clients leading to a stressful feeling of not
every day.” (I11-M). Another registered general nurse stated: “They are being able to reach the client. The very close relationship with clients
seriously ill people. If you take this closer to yourself, it's very stressful.” on the other hand makes nurses also feeling burdened by their client's
(I48-A). personal fate.
Three out of 21 female nurses in the migrant cohort experienced Foreign nurses reported forms of discrimination proceeding from
forms of sexual harassment from male clients. A migrant nursing as- clients. The close nurse client relationship in the homecare setting in-
sistant remembered: “I don't like that. When a man tries to touch me. And volves the danger of being sexually harassed as this was reported in the
too many men do, but not all.” (I18-M). A migrant registered general migrant cohort.
nurse reported: “Men, older men. They think, a woman is meant to be For autochthonous as well as migrant nurses the endowment of the
touched and not only for care. And that's disgusting. And to some people I profession as a nurse, the mutual support among colleagues, the direct
don't like to go and I try to ignore what they want. Some people think, verbal exchange with the supervisor at eye level and the perception of
foreigners are like this.” (I24-M). A further migrant nursing assistant gratitude/appreciation are coping strategies that helps them to suc-
explained that she has never talked to someone about her experiences cessfully master barriers occurring at their workplace.
of having been a victim of sexual harassment.
Nurses report that they converse with their colleagues about pro- 4. Discussion
blems or issues that burden them. This exchange of views helps them to
reflect the situation and to find a way to solve it or to accept the si- This study provides a comparative insight into work-related stres-
tuation as it is: “I discuss this with my colleagues, or I can also talk about it sors, resources and coping strategies of migrant and autochthonous
with my supervisor. Then I reflect about it again.” (I47-M). Another par- nurses. By interviewing migrant and minority nurses as well as auto-
ticipant perceived the verbal exchange with her colleague as a resource chthonous nurses, a detailed insight into factors that influence the to-
to cope with client-related burdening situations: “I will talk to my col- getherness of human beings of different origins and culture was pos-
leagues about it. Well, I'm actually a person who addresses it directly.” (I43- sible.
A). In contrast, this migrant registered general nurse discusses issues Typical work-related stressors of nurses like lifting heavy patients,
directly with the client: “But I try to solve the problem myself instead of time pressure or prioritizing one's own well-being are perceived bur-
coming to the office and complaining or taking the problem home with me. dening regardless of the nurses' origin or cultural background. Different
I'll take my time and talk to the client and ask ‘What's wrong with you? What patterns exist in the way how nurses perceive stressors which seems to

63
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be related to their cultural background and/or their origin. This study Suominen (2011) confirmed the importance of enabling nurses to ad-
confirms that human beings who are interacting with others of diverse vance their knowledge and allowing them to exchange with colleagues
background tend to mutually attribute ‘typical’ traits (Czopp, Kay, & and supervisors (Toode et al., 2011). Making an organization highly
Cheryan, 2015; Drewniak, Krones, & Wild, 2017; Elbarazi et al., 2017; performing and its workforce effective, Hunt (2007) explains that
FitzGerald & Hurst, 2017; Hammond, Marshall-Lucette, Davies, Ross, & managers and supervisors should value individuals regardless their
Harris, 2017; Hollup, 2014; Ito & Tomelleri, 2017; Ndobo, Faure, ethnic, racial or cultural background. Once again, this promotes the
Boisselier, & Giannaki, 2017; Spencer, Logel, & Davies, 2016). Migrant need to consider diversity as enriching rather than hindering.
and native nurses in this study agreed on time pressure as a leading Within the healthcare sector, nursing care is dominated by women
stressor. Their corresponding explanations diametrically oppose. Mi- who in general are at higher risk to experience sexual harassment than
grant nurses attribute the obligation to arrive on time at one's client's men (Eurofound, 2017). This situation is exacerbated by the circum-
household to the ‘German punctuality’ and the explicit obligation to stance that homecare nursing takes mainly place in the clients' house-
follow rules and guidelines e.g. in terms of completing forms to the hold. Thus, homecare nurses, mainly female are working in a context,
‘German strict way of working’. Both is perceived as burdensome, since where they are at their client's mercy as this could be also shown in this
complying with these obligations takes time, next causes time pressure study (Adrienne Cruz & Klinger, 2011).
that is in turn causing stress. Migrant nurses in this study report ade- Within this study, the nurses' reports of barriers and resources did
quate nursing care requires being flexible in talking and communicating not substantially differ within services operated by either non-com-
with clients rather than complying with obligations like doing paper- mercial or private-commercial providers. The assumption, the intent to
work. On the contrary, German nurses feel burdened by the migrants realize a profit within the private commercial services may have an
‘laxly mentality’ in the context of time management causing time effect on nurses reporting of stressors (Slotala, 2011), such as time
pressure. FitzGerald and Hurst (2017) distinguish between implicit pressure (Hielscher et al., 2013) was not confirmed.
prejudices and implicit stereotypes, since the latter ones can cause
damages even when they are not negative per se (FitzGerald & Hurst, 4.1. Strengths and limitations
2017). The ‘German punctuality’ and the ‘German strict way of
working’ are examples for implicit prejudices that can also be a positive Participant selection in qualitative studies is prone to selection bias.
stereotype (Czopp et al., 2015), since migrant nurses consider that as an Even though, this study employed a stratified random sampling to se-
important trademark for qualitative care in the host country. lect nursing services, the services' nursing managers ultimately pro-
Differences in language are perceived as a barrier affecting nurses' vided the study team with the contact data of the nurses willing to
mutual collaboration as O'Daniel and Rosenstein explain (O'Daniel & participate. Notwithstanding the nursing director had already assured
Rosenstein, 2008). They add that a cultural and ethnic diverse work- the nurse's voluntary participation on call with the main author, each
force challenges intraprofessional communication and collaboration, nurse was asked by the main author at first contact again whether she
since ways of communication and behavior differ across culture and or he volunteers in participating.
ethnicity (O'Daniel & Rosenstein, 2008). A strategy to cope with these In the light of strains and stressors, some participants may not have
barriers is working alone, since the person who is perceived to cause the mentioned some experiences, knowing that the study results would be
barrier or the setting might be unfluctuating. An enormous amount of discussed and published although pseudonymization and con-
time to the detriment of one's clients being necessary justifies the de- fidentiality were assured several times following the ethical rules of the
cision to not further clarify unclear situations or issues. It remains in ethics commission of the Hamburg medical council.
doubt, whether eschewing burdening barriers benefits the health of a Once the interviews were carried out and transcribed, the tran-
nurse. Especially, when the nurse justifies this decision with the ob- scripts were not returned to the participants for comment and/or cor-
ligation for the well-being of the client. Changing the perspective to- rection. At the time of writing this manuscript, the participants have not
wards clients, language barriers can also put the client's safety at risk as provided any feedback on the findings.
van Rosse, de Bruijne, Suurmond, Essink-Bot, and Wagner (2016) ex- This study has also its distinct strengths, since the cohort is re-
plained and named medication errors, erroneous pain or fluid balance presentative to nurses' gender, age and qualification distribution in
management as possible risks. Flores (2005) reviewed the impact of Hamburg (Rothgang, Sünderkamp, & Weiß, 2015; Schleswig-Holstein,
interpreter services on the quality of healthcare. She highlights that 2017; Statistisches-Bundesamt, 2017a, 2017b). The process of dis-
hospital patients with a low English proficiency report better health cussing the data and forming categories with researchers of different
outcomes and “greater levels of comfort” when treated by bilingual educational background in several rounds is a major benefit to provide
practitioners or in the presence of professional interpreters than by ad alternative interpretations of the data (Barbour, 2001).
hoc interpreters (Flores, 2005). The main author's background as a studied nurse as well as the
Similarly, Macdonald et al. (2013) argued that language barriers in diverse expertise of the researchers involved in this study (Health
a team can lead to misunderstandings and misperceptions of each Services Researcher, Psychologists, Epidemiologist) supports the claim
other's views of health and healing to the disfavor of the patients and for ‘thinking conceptually and reflexively’ (Polit & Beck, 2010). The
clients (Macdonald et al., 2013). Communication skills are a leading transferability of the study results is additionally to the sample's re-
competence that nurses must be equipped with to establish an adequate presentativity supported by the thick description of the study data.
nurse-client relationship and an adequate working relationship with the Thus, proximal similarity is clearly given (Polit & Beck, 2010).
nursing colleagues and supervisors (Halcomb, Stephens, Bryce, Foley, &
Ashley, 2016). 5. Conclusion
There is convincing evidence that effective communication leads to
improved information flow, more effective interventions to the favor of This qualitative study as the first survey of its sort in the German
employees and clients, improved safety and enhanced employee morale homecare setting confirms international findings about occupational
(Brunton & Cook, 2018; O'Daniel & Rosenstein, 2008). This study stressors of homecare nurses in general and goes beyond in identifying
confirms that the mutual exchange among colleagues and direct su- stressors, resources and coping strategies by comparing migrant and
pervisors not only serves as a key resource to address the issue of dif- autochthonous nurses (Hittle et al., 2016; Macdonald et al., 2013;
ferences in language but also allow a positive working atmosphere in Schilgen et al., 2017; Young et al., 2017). Migrant and Autochthonous
the context of coping. nurses share similar coping strategies to master occupational burdens.
Feeling appreciated by supervisors supports nurses to cope with Physical stressors like lifting heavy clients turned out to be a common
stress and serves as a motivational factor. Toode, Routasalo, and stressor across both groups. However it was reported by more migrant

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and minority nurses. A good collaboration in the team and a having an Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of
appreciative supervisor are resources that support migrant and minority healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), 181–184.
https://doi.org/10.1177/10459602013003003.
nurses as well as autochthonous nurses to face the stressors and to cope Collaborators, G. D.a. I. I.a. P. (2017). Global, regional, and national incidence, pre-
with those. valence, and years lived with disability for 328 diseases and injuries for 195 coun-
Differences in language is a main stressor which impedes a func- tries, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016.
Lancet, 390(10100), 1211–1259. https://doi.org/10.1016/S0140-6736(17)32154-2.
tioning team collaboration as well as a working nurse-client relation- Creswell, J. W. (2007). Qualitative inquiry and research design: Choosing among five ap-
ship. This stressor is quoted by more autochthonous than migrant proaches. California: Sage Publications, Inc.
nurses. Cruz, A., & Klinger, S. (2011). Gender-based violence in the world of work: Overview and
selected annotated bibliography. International Labour. Retrieved from http://www.ilo.
Sexual and verbal harassment towards nurses is still a threat that org/wcmsp5/groups/public/—dgreports/—gender/documents/publication/wcms_
happens to migrant and minority nurses as this study showed. 155763.pdf.
Migrant nurses of different origin perceive their status as migrants Czopp, A. M., Kay, A. C., & Cheryan, S. (2015). Positive stereotypes are pervasive and
powerful. Perspectives on Psychological Science, 10(4), 451–463. https://doi.org/10.
as a sense of community by sharing the same destiny – this appears as
1177/1745691615588091.
an important resource for migrant and minority nurses. Drewniak, D., Krones, T., & Wild, V. (2017). Do attitudes and behavior of health care
An increasingly diverse nursing workforce benefits an increasingly professionals exacerbate health care disparities among immigrant and ethnic min-
diverse aging society. The political will to strengthen homecare nursing ority groups? An integrative literature review. International Journal of Nursing Studies,
70, 89–98. https://doi.org/10.1016/j.ijnurstu.2017.02.015.
in Europe will by default lead to an increasing demand for those ser- Elbarazi, I., Devlin, N. J., Katsaiti, M. S., Papadimitropoulos, E. A., Shah, K. K., & Blair, I.
vices. The diversity in the nursing workforce should not only be seen as (2017). The effect of religion on the perception of health states among adults in the
an enforced political and societal automatism that nursing is relying on United Arab Emirates: A qualitative study. BMJ Open, 7(10), e016969. https://doi.
org/10.1136/bmjopen-2017-016969.
to face the workforce gap. Migrant and minority nurses enrich the Eurofound (2017). Sixth European working conditions survey – Overview report (2017 up-
provision of care and contribute to its professionalization, since they date). Luxembourg: Publications Office of the European Union.
are experts in understanding the challenges of cultural and ethnic di- Eurostat (2017). Employment by Sex, Age and Detailed Economic Activity (From 2008
Onwards, NACE Rev. 2 Two Digit Level - 1 000).
versity. Thus, policymakers, organizations and those responsible at Fealy, G. M., & McNamara, M. S. (2007). A discourse analysis of debates surrounding the
meso- and micro levels are called upon to advocate for the inherent entry of nursing into higher education in Ireland. International Journal of Nursing
expertise of migrant and minority nurses as ambassadors of culturally Studies, 44(7), 1187–1195. https://doi.org/10.1016/j.ijnurstu.2006.04.006.
FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: A systematic
diverse nursing care. This appreciation of their competence is surely review. BMC Medical Ethics, 18(1), 19. https://doi.org/10.1186/s12910-017-0179-8.
beneficial for their health. This study allows an insight into a diverse Flores, G. (2005). The impact of medical interpreter services on the quality of health care:
nursing workforce and their challenges and capabilities in the context A systematic review. Medical Care Research and Review, 62(3), 255–299. https://doi.
org/10.1177/1077558705275416.
of collaboration and client-centered care. Based on the findings, stra-
Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough?:An ex-
tegies to make a diverse team successful and healthy can be derived. periment with data saturation and variability. Field Methods, 18(1), 59–82. https://
doi.org/10.1177/1525822x05279903.
Role of funding source Halcomb, E., Stephens, M., Bryce, J., Foley, E., & Ashley, C. (2016). Nursing competency
standards in primary health care: An integrative review. Journal of Clinical Nursing,
25(9–10), 1193–1205. https://doi.org/10.1111/jocn.13224.
This work was supported by the Institution for Statutory Accident Hammond, J., Marshall-Lucette, S., Davies, N., Ross, F., & Harris, R. (2017). Spotlight on
Insurance and Prevention in the Health and Welfare services (BGW). equality of employment opportunities: A qualitative study of job seeking experiences
of graduating nurses and physiotherapists from black and minority ethnic back-
Grant recipient is: Dr. Mike Mösko. URL: www.bgw-online.de. The grounds. International Journal of Nursing Studies, 74, 172–180. https://doi.org/10.
funds are provided by a non-profit organization that is part of the social 1016/j.ijnurstu.2017.07.019.
security system in Germany. The funder had no role in study design, Hayne, A. N., Gerhardt, C., & Davis, J. (2009). Filipino nurses in the United States:
Recruitment, retention, occupational stress, and job satisfaction. Journal of
data collection and analysis, decision to publish, or preparation of the Transcultural Nursing, 20(3), 313–322. https://doi.org/10.1177/1043659609334927.
manuscript. Heitlinger, A. (1999). Nurses and nursing: A comparative perspective. Journal of
Interprofessional Care, 13(2), 165–174. https://doi.org/10.3109/
13561829909025548.
References
Hener, T., Weller, A., & Shor, R. (1997). Stages of acculturation as reflected by depression
reduction in immigrant nursing students. The International Journal of Social Psychiatry,
Aneas, M. A., & Sandín, M. P. (2009). Intercultural and cross-cultural communication 43(4), 247–256. https://doi.org/10.1177/002076409704300402.
research: Some reflections about culture and qualitative methods. Forum, Qualitative Hielscher, V., Nock, L., Kirchen-Peters, S., & Blass, K. (2013). Zwischen Kosten, Zeit und
Social Research/Forum, Qualitative Sozialforschung, 10(1), 51. Anspruch. Das alltägliche Dilemma sozialer Dienstleistungsarbeit. Wiesbaden: Springer
Barbour, R. S. (2001). Checklists for improving rigour in qualitative research: A case of Fachmedien Wiesbaden.
the tail wagging the dog? BMJ, 322(7294), 1115–1117. https://doi.org/10.1136/ Hignett, S., Edmunds Otter, M., & Keen, C. (2016). Safety risks associated with physical
bmj.322.7294.1115. interactions between patients and caregivers during treatment and care delivery in
Beechinor, L. A., & Fitzpatrick, J. J. (2008). Demands of immigration among nurses from Home Care settings: A systematic review. International Journal of Nursing Studies, 59,
Canada and the Philippines. International Journal of Nursing Practice, 14(2), 178–187. 1–14. https://doi.org/10.1016/j.ijnurstu.2016.02.011.
https://doi.org/10.1111/j.1440-172X.2008.00680.x. Hittle, B., Agbonifo, N., Suarez, R., Davis, K. G., & Ballard, T. (2016). Complexity of
Bemelmans, R., Gelderblom, G. J., Jonker, P., & de Witte, L. (2012). Socially assistive occupational exposures for home health-care workers: Nurses vs. home health aides.
robots in elderly care: A systematic review into effects and effectiveness. Journal of Journal of Nursing Management, 24(8), 1071–1079. https://doi.org/10.1111/jonm.
the American Medical Directors Association, 13(2), 114–120.e111. https://doi.org/10. 12408.
1016/j.jamda.2010.10.002. Hogh, A., Carneiro, I. G., Giver, H., & Rugulies, R. (2011). Are immigrants in the nursing
Bernal, D., Campos-Serna, J., Tobias, A., Vargas-Prada, S., Benavides, F. G., & Serra, C. industry at increased risk of bullying at work? A one-year follow-up study.
(2015). Work-related psychosocial risk factors and musculoskeletal disorders in Scandinavian Journal of Psychology, 52(1), 49–56. https://doi.org/10.1111/j.1467-
hospital nurses and nursing aides: A systematic review and meta-analysis. 9450.2010.00840.x.
International Journal of Nursing Studies, 52(2), 635–648. https://doi.org/10.1016/j. Hollup, O. (2014). The impact of gender, culture, and sexuality on Mauritian nursing:
ijnurstu.2014.11.003. Nursing as a non-gendered occupational identity or masculine field? Qualitative
Brunton, M., & Cook, C. (2018). Dis/integrating cultural difference in practice and study. International Journal of Nursing Studies, 51(5), 752–760. https://doi.org/10.
communication: A qualitative study of host and migrant registered nurse perspectives 1016/j.ijnurstu.2013.09.013.
from New Zealand. International Journal of Nursing Studies, 83, 18–24. https://doi. Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis.
org/10.1016/j.ijnurstu.2018.04.005. Qualitative Health Research, 15(9), 1277–1288. https://doi.org/10.1177/
Buil, I., de Chernatony, L., & Martínez, E. (2012). Methodological issues in cross-cultural 1049732305276687.
research: An overview and recommendations. Journal of Targeting, Measurement and Hunt, B. (2007). Managing equality and cultural diversity in the health workforce. Journal
Analysis for Marketing, 20(3), 223–234. https://doi.org/10.1057/jt.2012.18. of Clinical Nursing, 16, 2252–2259. https://doi.org/10.1111/j.1365-2702.2007.
Bundesagentur-für-Arbeit (2019). Berufenet. Retrieved from https://berufenet. 02157.x.
arbeitsagentur.de/berufenet/faces/index?path=null. ILO (2015). International Labour Office - Global estimates of migrant workers and migrant
Buykx, P., Humphreys, J., Wakerman, J., & Pashen, D. (2010). Systematic review of ef- domestic workers: Results and methodology: Special focus on migrant domestic workers.
fective retention incentives for health workers in rural and remote areas: Towards ILO.
evidence-based policy. The Australian Journal of Rural Health, 18(3), 102–109. Ito, T. A., & Tomelleri, S. (2017). Seeing is not stereotyping: The functional independence
https://doi.org/10.1111/j.1440-1584.2010.01139.x. of categorization and stereotype activation. Social Cognitive and Affective Neuroscience,

65
B. Schilgen, et al. Applied Nursing Research 46 (2019) 57–66

12(5), 758–764. https://doi.org/10.1093/scan/nsx009. related illness in nursing: an integrative review. Revista Da Escola De Enfermagem Da U
Janiszewski Goodin, H. (2003). The nursing shortage in the United States of America: an S P, 46(2), 495–504. https://doi.org/10.1590/S0080-62342012000200031.
integrative review of the literature. Journal of Advanced Nursing, 43(4), 335–343. Robinson, O. C. (2014). Sampling in interview-based qualitative research: A theoretical
https://doi.org/10.1046/j.1365-2648.2003.02722_1.x. and practical guide. Qualitative Research in Psychology, 11(1), 25–41. https://doi.org/
Lee, S. K., Sulaiman-Hill, C. R., & Thompson, S. C. (2014). Overcoming language barriers 10.1080/14780887.2013.801543.
in community-based research with refugee and migrant populations: Options for Rothgang, P. D. H., Sünderkamp, S., & Weiß, C. (2015). Die Rolle der privaten Anbieter in
using bilingual workers. BMC International Health and Human Rights, 14, 11. https:// der Pflegeversorgung in Deutschland. Expertise für den bpa – Bundesverband privater
doi.org/10.1186/1472-698X-14-11. Anbieter sozialer Dienste e.V. Berlin Bundesverband privater Anbieter sozialer Dienste
Li, H., Nie, W., & Li, J. (2014). The benefits and caveats of international nurse migration. e.V. (bpa). bpa Arbeitgeberverband.
International Journal of Nursing Sciences, 1(3), 314–317. https://doi.org/10.1016/j. Schilgen, B., Nienhaus, A., Handtke, O., Schulz, H., & Mösko, M. (2017). Health situation
ijnss.2014.07.006. of migrant and minority nurses: A systematic review. PLoS One, 12(6), e0179183.
Likupe, G., & Archibong, U. (2013). Black African nurses' experiences of equality, racism, https://doi.org/10.1371/journal.pone.0179183.
and discrimination in the National Health Service. Journal of Psychological Issues in Schleswig-Holstein, S. A. F. H. U. (2017). Gesundheitspersonal in Hamburg 2015.
Organizational Culture, 3(S1), 227–246. https://doi.org/10.1002/jpoc.21071. Beschäftigtenzuwachs über dem Bundesdurchschnitt.
Lutz, W., Sanderson, W., & Scherbov, S. (2008). The coming acceleration of global po- Simoens, S., Villeneuve, M., & Hurst, J. (2005). Tackling nurse shortages in OECD countries.
pulation ageing. Nature, 451, 716. https://doi.org/10.1038/nature06516https:// OECD health working papers, no. 19OECD Publishinghttps://doi.org/10.1787/
www.nature.com/articles/nature06516#supplementary-information. 172102620474.
Macdonald, M. T., Lang, A., Storch, J., Stevenson, L., Barber, T., Iaboni, K., & Donaldson, Slotala, L. (2011). Ökonomisierung der ambulanten Pflege. Eine Analyse der wirtschaftlichen
S. (2013). Examining markers of safety in homecare using the international classifi- Bedingungen und deren Folgen für die Versorgungspraxis ambulanter Pflegedienste.
cation for patient safety. BMC Health Services Research, 13(1), 191. https://doi.org/ Wiesbaden: VS Verlag für Sozialwissenschaften|Springer Fachmedien Wiesbaden
10.1186/1472-6963-13-191. GmbH.
Mathers, C. D., Stevens, G. A., Boerma, T., White, R. A., & Tobias, M. I. (2015). Causes of Spencer, S. J., Logel, C., & Davies, P. G. (2016). Stereotype threat. Annual Review of
international increases in older age life expectancy. The Lancet, 385(9967), 540–548. Psychology, 67, 415–437. https://doi.org/10.1146/annurev-psych-073115-103235.
https://doi.org/10.1016/S0140-6736(14)60569-9. Squires, A. (2009). Methodological challenges in cross-language qualitative research: A
Murray, C. J. L., Barber, R. M., Foreman, K. J., Ozgoren, A. A., Abd-Allah, F., Abera, S. F., research review. International Journal of Nursing Studies, 46(2), 277–287. https://doi.
... Vos, T. (2015). Global, regional, and national disability-adjusted life years (DALYs) org/10.1016/j.ijnurstu.2008.08.006.
for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, Statistisches-Bundesamt (2017a). Gesundheitspersonalrechnung. Gesundheitspersonal nach
1990–2013: Quantifying the epidemiological transition. The Lancet, 386(10009), Alter, Beschäftigungsart und Beruf.
2145–2191. https://doi.org/10.1016/S0140-6736(15)61340-X. Statistisches-Bundesamt (2017b). Pflegestatistik 2015. Pflege im Rahmen der
Ndobo, A., Faure, A., Boisselier, J., & Giannaki, S. (2017). The ethno-racial segmentation Pflegeversicherung. Ländervergleich – Ambulante Pflegedienste.
jobs: The impacts of the occupational stereotypes on hiring decisions. The Journal of Szeto, G. P. Y., Wong, K. T., Law, K. Y., & Lee, E. W. C. (2013). A study of spinal kine-
Social Psychology, 1–17. https://doi.org/10.1080/00224545.2017.1389685. matics in community nurses performing nursing tasks. International Journal of
O'Daniel, M., & Rosenstein, A. H. (2008). Professional communication and team colla- Industrial Ergonomics, 43(3), 203–209. https://doi.org/10.1016/j.ergon.2013.02.003.
boration. In R. G. Hughes (Ed.). Patient safety and quality: An evidence-based handbook Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative
for nurses. Rockville (MD): Agency for Healthcare Research and Quality. research (COREQ): A 32-item checklist for interviews and focus groups. International
OECD (2016). Health workforce migration (2015 ed.). . Retrieved from http://www.oecd- Journal for Quality in Health Care, 19(6), 349–357. https://doi.org/10.1093/intqhc/
ilibrary.org/social-issues-migration-health/data/oecd-health-statistics/health- mzm042.
workforce-migration-edition-2015_87fde0a0-en. Toode, K., Routasalo, P., & Suominen, T. (2011). Work motivation of nurses: A literature
OECD (2017a). International migration outlook 2017. OECD Publishing. review. International Journal of Nursing Studies, 48(2), 246–257. https://doi.org/10.
OECD (2017b). Life expectancy at birth (indicator). https://doi.org/10.1787/27e0fc9d-en. 1016/j.ijnurstu.2010.09.013.
Pittman, P., Davis, C., Shaffer, F., Herrera, C. N., & Bennett, C. (2014). Perceptions of van Rosse, F., de Bruijne, M., Suurmond, J., Essink-Bot, M. L., & Wagner, C. (2016).
employment-based discrimination among newly arrived foreign-educated nurses. The Language barriers and patient safety risks in hospital care. A mixed methods study.
American Journal of Nursing, 114(1), 26–35. https://doi.org/10.1097/01.naj. International Journal of Nursing Studies, 54, 45–53. https://doi.org/10.1016/j.ijnurstu.
0000441792.93279.29. 2015.03.012.
Polit, D. F., & Beck, C. T. (2010). Generalization in quantitative and qualitative research: VERBI-Software (2017). MAXQDA. The art of data analysis. Software for qualitative,
Myths and strategies. International Journal of Nursing Studies, 47(11), 1451–1458. quantitative and mixed methods research. Retrieved from http://www.maxqda.com.
https://doi.org/10.1016/j.ijnurstu.2010.06.004. Young, C., Hall, A. M., Goncalves-Bradley, D. C., Quinn, T. J., Hooft, L., van Munster, B.
Renzaho, A. M. (2009). Immigration and social exclusion: Examining health inequalities C., & Stott, D. J. (2017). Home or foster home care versus institutional long-term care
of immigrants through acculturation lenses. Theorising social exclusion (pp. 117–126). for functionally dependent older people. Cochrane Database of Systematic Reviews,
Oxon: Routledge. 4(Cd009844), https://doi.org/10.1002/14651858.CD009844.pub2.
Ribeiro, R. P., Martins, J. T., Marziale, M. H. P., & Robazzi, M. L. D. C. C. (2012). Work-

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