1. "I want to see a real nurse!": Indian Immigrant Nurses in U.S. Urban Safety-net Hospitals & Implications for Health Disparities Sheba George, PhD Department of Community Health Sciences, Fielding School of Public Health, UCLA & Center for Biomedical Informatics, Charles R. Drew University of Medicine and Science, Los Angeles.

2. Outline Background of my work Background of my work International health care providers in the U.S International health care providers in the U.S Racial/Ethnic Health Disparities and Social Sciences Racial/Ethnic Health Disparities and Social Sciences Results Results Discussion Discussion Implications for Quality of Care and Health Disparities Implications for Quality of Care and Health Disparities

3. Background Of Work When Women Come First: Gender and Class in Transnational Migration, When Women Come First: Gender and Class in Transnational Migration, Immigration of Indian nurse providers to the U.S., and nursing shortage Immigration of Indian nurse providers to the U.S., and nursing shortage Ethnographic study- participant observation, In- depth and Focus group interviews- 2yrs- U.S./India Ethnographic study- participant observation, In- depth and Focus group interviews- 2yrs- U.S./India

5. IMGs/FENs in the U.S. 1. Ongoing shortage of healthcare workers, continuing recruitment of International Medical Graduates (IMGs) and Foreign Educated Nurses (FENs) 2. 1/4th of U.S. medical work force are IMGs 3. Of new U.S. nurses, 6% in 2000 and 12% in 2011 were FENs 4. 2/3rds of IMGs/FENs are estimated to serve in hospitals that provide care for the poor

6. R/E Health Disparities Definition of R/E health disparities by the Institute of Medicine Definition of R/E health disparities by the Institute of Medicine Racial or Ethnic differences in the quality of healthcare that are not due to access-related factors (e.g.insurance, income) or patient level factors (e.g. preferences, need).

7. R/E Health Disparities Difference Quality of Health Care Non - Minority Minority Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems and Legal and Regulatory Climate Discrimination: Biases, Stereotyping, and Uncertainty Disparity Differences, disparities, and discrimination: Populations with equal access to healthcare. (Source: Smedley, Stith, and Nelson 2003 via Gomes and McGuire 2001)

8. The Role of Social Sciences The Whitehead/Dahlgren model of health determinants (Source: Bartley, Blane, Smith 1998 via Dahlgren and Whitehead 1991)

9. International Healthcare providers and Health Disparities 1. IOM study focuses on provider-patient interaction as a key to improving quality of care 2. My work points to broader social and cultural factors  importance of the social organization of work shaped by gender and racialization  differences in ethnic/ professional culture & training of health professionals

10. Outline Background of my work Background of my work International health care providers in the U.S International health care providers in the U.S Racial/Ethnic Health Disparities and Social Sciences Racial/Ethnic Health Disparities and Social Sciences Results Results Discussion Discussion Implications for Quality of Care and Health Disparities Implications for Quality of Care and Health Disparities

11. Results Interactional ChallengesInteractional Challenges Differences in Professional CulturesDifferences in Professional Cultures Indian Nurses ’ responses to work challenges: “ Real nursing work ” vs. “ charting and sweet talking ”Indian Nurses ’ responses to work challenges: “ Real nursing work ” vs. “ charting and sweet talking ”

12. Interactional Challenges Tremendous but expected challenges with immigration Tremendous but expected challenges with immigration Unexpected challenges –the types of barriers to their incorporation and career mobility in the workplaces. Unexpected challenges –the types of barriers to their incorporation and career mobility in the workplaces. On the ward floor, immigrant nurses reported facing discrimination from patients, doctors and hospital administration as well as from their peers. On the ward floor, immigrant nurses reported facing discrimination from patients, doctors and hospital administration as well as from their peers.

13. Interactional Challenges: Patients “ Some patients don't like us- our color. When that happens, we tell the patient that in all the other hospitals, in the 3(p.m.) to 11(p.m.) and the 11(p.m.) to 7(a.m.) shifts, it is only foreign nurses who work. There won't be any American nurses. And some patients will insist, ‘ I don't want you. I want a white nurse. ’ Then we tell them, ‘ If you want to find a white nurse, go ahead and look for one. ’“ Mrs. George

14. Interactional Challenges: I want a real nurse “ So he (the patient) said, ' I want to see a nurse.' We both had uniforms on. We both had our identification badges. So I said 'We are nurses. My name is Susie and this is Nanny. We are both registered nurses.' He said 'I want to see a real nurse. ’ So I said, 'We have our registration. We are registered nurses. So I think we are real nurses. ’” Mrs. Eapen

15. Interactional Challenges: Co-workers Language fluency and accents Language fluency and accents Competency questioned Competency questioned Surveiled by doctors & Management Surveiled by doctors & Management

16. Differences in Professional Culture: Not knowing patients vs. total patient care Not knowing patients vs. total patient care Physical and emotional distance vs. closeness to patients Physical and emotional distance vs. closeness to patients Doctor ’ s orders vs. nurses ’ roles and responsibilities Doctor ’ s orders vs. nurses ’ roles and responsibilities

17. Differences in Professional Culture: Total Patient Care As Mrs. Thomas explained, “... Here nursing is about total patient care, the total well being of the patient- Mental and physical care of the patient as well as the patient ’ s family. Back home you give medicines, that is all. ” As Mrs. Thomas explained, “... Here nursing is about total patient care, the total well being of the patient- Mental and physical care of the patient as well as the patient ’ s family. Back home you give medicines, that is all. ”

18. Differences in Professional Culture : Closeness to Patients Mrs.Philip noted, “ Here you have to be very polite to them and take care of them as a close friend. ” Mrs.Philip noted, “ Here you have to be very polite to them and take care of them as a close friend. ” Mrs.Thambi reflected on her work experiences in India, “ I didn ’ t know the patients ’ names. I didn ’ t know who they are. ” Mrs.Thambi reflected on her work experiences in India, “ I didn ’ t know the patients ’ names. I didn ’ t know who they are. ”

19. Differences in Professional Culture : Roles and Responsibilities “ Patient care managers. ” “ Patient care managers. ” Teachers Teachers Consultants Consultants

20. FEN Response: Real Nursing Work The distinction goes as follows: The distinction goes as follows: Indian nurses are better at doing the “ actual ” work of nursing ” – the practical work of bandaging patients, checking IVs and inserting catheters- whereas American nurses are good at “ charting, writing and sweet talking. ” Indian nurses are better at doing the “ actual ” work of nursing ” – the practical work of bandaging patients, checking IVs and inserting catheters- whereas American nurses are good at “ charting, writing and sweet talking. ”

21. “ I see-like a couple of nurses, not everybody- just a couple of nurses- they come and they sit and they talk, talk, and talk. But you hardly see them moving around and working- I mean, the real nursing job.... ” “ Are these immigrant nurses? ” “ Are these immigrant nurses? ” “ No, these are white Americans. They will flirt around with white doctors- Bah, bah, bah- I mean, we don't go for all these things. We come, do our job, take care of our patients, say ‘ Hi, I am so and so ’ and we do our job. The Americans have a way of saying- ‘ Hi honey, Hi sweetheart. ’ I mean, I have even seen nurses kissing the patients. We don't go for all that. And the patient likes that- the patient thinks 'Oh, the nurse - so wonderful she is.' You know what I mean? Those nurses can act a lot. They get better feedback from patients. At the same time, we may be working hard and we may not be getting that much appreciation. ”

22. FEN Response: Real Nursing Work “ I don't like ambulatory nursing because it's not really nursing- it's like more of a office nurse type. Lot of paperwork- I really don't like doing paperwork much. I like to do real nursing.... Ambulatory (nursing) could be boring sometimes. Sometimes it could be so busy that it could make you confused if you are not used to it. All the patients come and so many people you have to send together to the O.R. (Operating Room). You have to check everybody. You have to be careful- anything you didn't do and they will call you. So originally the nurses were all white- in ambulatory, they are all white. ”

23. Indian Immigrant Nurses ’ Experiences: A Summary Difficult but expected challenges Difficult but expected challenges Interactional difficulties on the ward floor Interactional difficulties on the ward floor Differences of professional culture and differing expectations for quality care Differences of professional culture and differing expectations for quality care FENS ’ characterization of their work - the irony of un- “ real ” nurses doing “ real nursing work ” FENS ’ characterization of their work - the irony of un- “ real ” nurses doing “ real nursing work ”

24. Outline Background of my work Background of my work International health care providers in the U.S International health care providers in the U.S Racial/Ethnic Health Disparities and Social Sciences Racial/Ethnic Health Disparities and Social Sciences Results Results Discussion Discussion Implications for Quality of Care and Health Disparities Implications for Quality of Care and Health Disparities

25. Discussion A Racialized Hierarchy A Racialized Hierarchy a. Racially stratified division of labor b. A distinct professional hierarchy in nursing

26. Three Factors that Contribute to a Racialized Hierarchy Gendered and Racialized Expectations of Emotional Labor in Nursing Gendered and Racialized Expectations of Emotional Labor in Nursing Impact of professional and ethnic cultures from India Impact of professional and ethnic cultures from India Racialization and Distrust of Foreigners Racialization and Distrust of Foreigners

27. Gendered and Racialized Expectations of Emotional Labor in Nursing 1. Emotional Labor 2. Racialized Occupational Segregation and Emotional Labor 3. Nursing – Archetypal Profession

28. Differences in professional and ethnic cultures from India 1. Nursing professional skills and values from specific structural and cultural context a. Nurse patient ratio/Family presence b. Broader Indian cultural norms about PDA c. Gender based stigmas about nursing 2. Norms of emotional labor for US nursing and Indian nurses ’ reticence to meet these standards

29. Racialization and Distrust of Foreigners 1. Racialization and FENs in urban safety net work settings – left to sink or swim! 2. Distrust of foreigners leads to questioning of their professional competency

30. Outline Background of my work Background of my work International health care providers in the U.S International health care providers in the U.S Racial/Ethnic Health Disparities and Social Sciences Racial/Ethnic Health Disparities and Social Sciences Results Results Discussion Discussion Implications for Quality of Care and Health Disparities Implications for Quality of Care and Health Disparities

31. Implications for Quality of Care and Health Disparities: Impact Patient perceptions of quality of care and the impact on health disparities Patient perceptions of quality of care and the impact on health disparities Multidisciplinary teams and health disparities Multidisciplinary teams and health disparities Strengths of FENS could have positive impact on health disparities Strengths of FENS could have positive impact on health disparities

32. Implications for Quality of Care and Health Disparities: Intervention 1.US trained staff (co-workers, administrators)/ patients of the immigrant nurses need to be better informed about competencies and qualifications of FENs. 2.FENs need tailored orientation programs for better integration into workplaces 3.Leverage the strengths of FENs vis-à-vis their work experiences and ethnic, professional cultural backgrounds 4.Need for more research at the point of care

33. Thank you shebageorge@ucla.edu