Angela Jun1, DNP, FNP-BC, ACHPN, Sue-Kyung Sohn2*, PhD, RN, & Jung-Ah Lee1, PhD, RN
1Sue & Bill Gross School of Nursing, University of California, Irvine, United States.
2Professor, Department of Nursing Sciences, Kosin University, South Korea.
Corresponding Author Details: Sue-Kyung Sohn, PhD, RN, Professor, Department of Nursing Sciences, Kosin University, 194 Wachi-ro, Dongsam 1(il)-dong, Yeongdo-gu, Busan, South Korea. E-mail: sue@kosin.ac.kr
Received date: 21th June, 2021
Accepted date: 06th August, 2021
Published date: 10th August, 2021
Citation: Jun, A., Sohn, S., & Lee, J.A. (2021). Lived Experience of Korean Immigrant Nurse Practitioners. J Comp Nurs Res Care 6(2):175.
Copyright: ©2021, This is an open-access article distributed under the terms of the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
The impact that nurse practitioners make in the health care system has been increasingly visible. The number of nurse practitioners with ethnic minority backgrounds has been growing. However, while much is known about immigrant nurses, limited research has been conducted about immigrant nurse practitioners (NPs) who immigrated as an RN (registered nurses) and became aNP. The purpose of the study was to explore the lived experience of Korean immigrant nurse practitioners. Eight Korean immigrant nurse practitioners participated in this qualitative study that used the unstructured interview technique to collect data. Data were analyzed using Colaizzi's method of phenomenology. Six main themes are identified: motivation, challenges, support system, transition process, conflict, and satisfaction. All participants experienced challenges around English proficiency and visa status at the beginning of their life in the United States. They went through the transition process and overcame challenges successfully with support from various sources. They are currently very satisfied with how they could make a difference in patients’ life. The finding of this study generated qualitative evidence of ethnic minority immigrant nurse practitioners functioning as vital healthcare providers, which is an encouraging fact for the U.S. health care system, where diverse providers are in need.
Keywords: Phenomenology, qualitative study, immigrants, nurse practitioners, lived experience, Korean Americans, minority
Nurse practitioners (NPs) have become an integral part of the United States (U.S.) healthcare system. The number of NPs has been exponentially increasing for the past few decades [1] including the number of Asian American NPs. According to the U. S. Bureau of Labor Statistics, Asian American NPs increased from 2.3% of the total employed person in 2015 to 4.4% in 2019. This phenomenon is also observed within the Korean American community. Although there is no official statistics about Korean American NPs, the number of Korean American NPs or NP students who are the members of Korean American Nurse Practitioners’ Social Network Service group has increased from less than 20 in 2017 to 127 in 2020. Most NPs in this group completed their undergraduate nursing education in Korea before they immigrated to the United States. They became a NP by completing nurse practitioner graduate programs in the Unites States.
While much is known about immigrant nurses, limited research has been conducted about immigrant NPs who immigrated as a RN (registered nurses) and became an NP. Literature about NPs mostly focused on role development through transition processes or role expansion in the specific specialty area [2-6]. Two other studies [7,8] explored lived experience of nurse practitioners. However, Elliott et al. [7] focused on the nurse practitioners within the transformational advanced professional practice model, similar to Health Maintenance Organization (HMO) practices where a primary care provider functions as a gate keeper for referrals to the specialty medical care. Delacroix [8] studied about life experiences of the nurse practitioners who had medical errors using phenomenological approach.
There was only one research article on immigrant nurses who became nurse practitioners in the United States [9]. The target population was Korean American immigrant nurse practitioners. Authors used the life story research method focusing on professional identity. Findings in this study revealed five themes around Korean American immigrant nurse practitioner identity. Their study is significant because it is the only study about immigrant nurse practitioners found through extensive literature search. It generated important nursing knowledge about immigrant nurse practitioners and their professional identity.
However, paucity of research is present about struggles, challenges, or success of immigrant NPs in the U. S. health care system. Effort to bridge gap in this area may start from studying about one of ethnic minority groups of NPs. The purpose of this study is to explore the Korean immigrant nurse practitioners’ lived experience. This may reveal essential information that is needed in developing a support system to foster minority immigrant NPs to thrive as in the U. S. healthcare workforce and provide for better patient outcomes.
The study used a phenomenology approach to explore lived experience of Korean immigrant NPs.
The interviews were conducted at the first author’s office and participants’ home or their workplaces. Eight participants were recruited with the assistance of the Korean American Nurses Association of Southern California. Inclusion criteria included the participant being a Korean immigrant and having worked at least one year as an NP in the United States. Six participants completed their undergraduate nursing education in Korea and graduate nursing training in the United States. Two participants completed both undergraduate and graduate nursing education in the United States. One participant immigrated into the United States when she was in high school. The rest were in their 20’s and 30’s at the time of immigration.
The Institutional Review Board approval on the study protocol was obtained from a university. Data was collected through unstructured, informal, conversational interviews. Two researchers (A. J. & S. S.) interviewed participants in Korean using the same semi-structure interview guideline. To fully immerse into the experiences of the participants, constant bracketing method was reinforced during the interview, and participants used both English and Korean to articulate their experiences most accurately. Interview was conducted two times for each participant and each interview took about hour. The interviews were recorded using an audio recorder. Observation and researchers' note were utilized to collect data.
Data analysis was done as data collection occurred until data was saturated. The recorded interviews were transcribed verbatim in Korean and then translated to English for coding. Translated narratives in English were compared to the original recorded interviews for the accuracy of the transcript.
Data was analyzed using Colaizzi's method of phenomenology [10,11]. Each transcript was read separately by both authors (A.J & S. S.). During this process, bracketing technique was utilized to obtain the true meaning of what the participants experienced. After each author extracted the significant statements, both authors compared their work and discussed similarities and differences to increase credibility of coding. When there was a discrepancy in the coding, both authors went back to the transcripts to understand the participants’ experiences in depth before sharing and settling what our understanding of the statement was. The difference in extracted significant statements between the two authors was less than 5 %.
A total of 47 significant statements were extracted from 8 transcripts. Through further discussion, the authors were able to formulate 93 meaning units. An intentional effort was made to use direct descriptions from the participants. Ninety-three formulated meaning units were grouped into 15 clustered themes. Following this, the authors extracted a distinctive construct of emergent themes and checked the accuracy of the themes to reflect the participants' true experience. A total of six themes emerged. The first author wrote an exhaustive description of all emergent themes. This exhaustive description was confirmed with the second author. To validate the study findings, the member checking technique was used. All participants were satisfied with these results that reflected their experiences and feelings.
Kitto, Chesters, and Grbich’s framework was employed to ensure rigor [12]. For procedural rigor, we tried to maintain transparency of how this research was conducted. The details are documented in the methodology section of this paper. For interpretive rigor, the member checking was completed with all participants to compare and confirm the interview statements and findings. There were multiple debriefing sessions for data analysis. For reflexivity and evaluative rigor, both authors discussed and reflected on how their own personal beliefs and value systems could influence data collection/analysis. As an additional step, the participants confirmed the final findings and gave approval.
A total of six themes emerged from the data analysis. These themes were motivation, challenges, support system, transition process, conflict, and a difference-maker.
All participants pointed out that their specific life experiences or internal desires were their motivation for going back to school to be an NP.
“When my son was seen by a NP for cellulitis, the NP was not only caring, but also provided a good patient education about handwashing and how to use a soap for handwashing. I really like that experience. I think that was when I started thinking about becoming an NP.” (Participants 1)
“My life was simple. It was revolving around work, church, and my family. I wanted to do something new and different. …just working through all my life felt empty. I had been thinking about doing something worthwhile for some time. At that time, going back to school was the easiest choice to me.” (Participant 3)
Non-proficient English and unstable visa status were two major challenges during their early lives in the United States.
Although all participants denied difficulty reading or understanding written English, they reported stress when trying to articulate certain situations and/or underlying connotations while working as registered nurses. Participants 6 chose to work at night due to fear of interacting with patients and physicians in English. Another participant experienced false accusations due to her lack of English proficiency. Two participants experienced different types of difficulties related to English. One participant who had some exposure to spoken English when she was young stated that she felt her English was not at advanced level compared to her classmates, so she initially did not talk much while she was in a graduate school. Another participant had to speak English at work to the certain extent when she was in Korea. She denied struggling with English, but she pointed out difficulty related to the pronunciation of Spanish names of patients.
Three participants recalled elevated level of stress related to securing permanent residency status.
“Even though I was pretty good at conversational English, I intentionally did not speak much at school because I felt my English speaking and vocabulary skills were at the elementary school level compared to how fluent my classmates were when they spoke.” (Participant 7)
“It took a long time to get my green card interview, and I had to have the interview in Canada. It was nerve-wracking.” (Participant 2)
“Just thinking about going back to Korea when I couldn’t find a job that supported my legal status was dreadful. I was not equipped properly to work in Korea because I came to the United States when I was young, but at the same time, job opportunities were limited in the United States because of my legal status. I felt trapped between two countries. I felt like I did not belong to either the United States or Korea.” (Participant 4)
All except for one participant appreciated their support, particularly during the period of their educational training to become an NP. Some found support from the members of the religious organizations they attended regularly. Also, their relationship with a higher being was a source of peace and strength during difficult situations. Family members and coworkers were most frequently mentioned as a support system.
“Once I realized it was not what I did or what I did not that resulted in the death of patients and that their lives were up to God, I was able to cope and deal with patients in hospice without being depressed. (Participant 4)
“My husband initially was not happy about me going back to school, but once I became busy working as an NP, he became supportive. Now he takes care of our kids more actively.” (Participant 8)
The participants went through a transition period from feeling stressed to feeling comfortable. All participants felt fearful of making a medical diagnosis and ordering medications without physicians’ help at the beginning of working as an NP. During the first couple of years, psychological stress skyrocketed because they worried about the possibility of patients’ negative outcomes and subsequent litigation. They constantly worried about the difficult cases after work or even while on their vacation. The constant anxieties and worries improved with time. One participant put extra hours of studying about her patients after work to overcome her fear and worries about them. One stated that it took about 2 years until she became more comfortable telling patients about uncertainty of the diagnosis she made.
There were two other sources of stress at the beginning of their careers. Three participants expressed stress from patients’ preference of physicians over NPs. They experienced situations when patients who made appointments with them even showed their dislike of NPs during the office visit. With more years of practice, participants learned to accept patients’ preferences from the patient’s perspectives and became more comfortable with those kinds of patients. Two participants expressed frustration due to their family members’ or their close friends’ ignorance about NPs. As they gained more experience, it did not bother them anymore. In the wake of this, one participant started a blog with her NP friends to increase awareness about NPs.
All participants reminisced first two years as the challenging years, but in the end, they are all comfortable and enjoy practicing as an NP with more autonomy.
“I had constant worries over medication prescriptions that I wrote in the beginning…ability to make decisions independently was one of the attractive aspects of being a NP.... the desire to practice with more autonomy for patients led me to open my own clinic.” (Participant 1)
“I treated patients only for diabetic-related conditions in the beginning because I was afraid of writing prescriptions for conditions that I was not familiar with. So, I often referred the patients back to their primary care providers for conditions other than diabetes. Years of experience made me more knowledgeable and lessened anxiety over treating patients with conditions other than diabetes.” (Participant 5)
All participants talked about the conflict they experienced. The first major source of conflict was different workplace culture. All participants used to complete their tasks as soon as possible while they worked in Korea. However, in the Unites States, they noticed that completing the tasks quickly brought on more work to do or put pressure on coworkers who followed the given deadlines, which caused unnecessary conflict. All participants agreed that it took some time to get used to the slower speed of the workplace in the United States.
Another source of conflict was how they were treated by their RN coworkers or the organizations they worked for. Six participants felt that their coworkers did not respect them as a medical provider initially. After one participant experienced the RN coworkers did not take care of her stat orders in timely manner in multiple occasions, she had to take the issue to upper management because she felt it could affect patients’ health outcomes negatively. Another participant studied and prepared the patient care thoroughly, and she was able to gain the RN coworkers’ trust as a competent medical provider. Two participants stated they witnessed NPs’ mistakes resulting in harsher consequences by the organizations compared to one of physicians who made the same mistakes.
“LVNs and RNs intentionally did not take priority of my orders regardless how urgent it was. They did not take my orders seriously. I had to create the proper process to solve this problem by getting upper management involved. I had to deal with this seriously to protect patients and myself.” (Participant 4)
“When a mistake happens or patients’ complaints get reported, NPs are treated more harshly than physicians for same issues.” (Participant 5)
The participants pointed out satisfaction they felt as an NP. Their satisfaction came from the sense of achievement, making a difference in people’s lives, and financial security. Graduation from their NP program was the highest moment of feeling the sense of achievement. Gratitude from patients and their families made them feel they were making a positive difference in patients’ life. A deeper and holistic understanding of patients’ situations helped them go the extra mile for their patients.
“I stopped by one of my patient’s home after my regular work hours because her daughter called me her mother was having severe pain from her final stage of cancer. After the patient died, her daughter called me to tell me that her mom died in peace and how grateful she was when I stopped by her mom's house after my regular work hours. Those kinds of the moments are when I feel so good about being an NP.” (Participant 7)
“I am grateful that I can offer more meaningful service to patients as an NP. I became more mature and humbler. Now I am capable of reflecting on all different situations that occur in our lives with humility.” (Participant 6)
“Caring for patients became my vocation. Taking care of patients is not only about the physical diseases. Patients get better through a consistent relationship with me as a provider. I follow through with the patients who do not have insurance coverage and connect them to get appropriate services. It is a lengthy process but when it works out well, I feel a sense of accomplishment.” (Participant 1)
Nurse practitioners (NPs) are a vital part of the United States health care system. The number of NPs has been increasing rapidly for the last decade. There is a handful number of research articles about NPs. Most research focused on role development of NPs or expansion of NP role in the specialty area [2,13]. However, immigrant NPs within current health care system have not been recognized at all. There is a considerable research paucity about how immigrant NPs function as a medical provider.
This study was conducted to explore lived experience of Korean immigrant NPs using a phenomenological approach. A total of 6 themes appeared as I discussed in the result section. This study is significant because, to the authors’ knowledge, this study is the first study that explored the lived experience of immigrant NPs. It added new knowledge of how immigrant NPs have been adjusting to the U.S. health care system.
Our qualitative study explored and provided a descriptive explanation of the lived experience of Korean immigrant NPs. The results echoed similar themes found in the other studies about NPs. For example, Angelow [14] reported that novice nurse practitioners' initial intense stress and nervousness gradually diminished through the transition period. Our study participants also experienced stress and nervousness, which improved over 1 or 2 years in practice. Anxiety and stress of the participants in our study came from thinking about the possibility of litigation related to establishing a medical diagnosis and ordering medications. Davis-Kennedy [15] revealed a lack of specific skills such as suturing and advanced injection techniques as the root of stress during the transition period. Two participants in our study mentioned that NPs need to be prepared better with specific skills while at school as a prerequisite for a better transition.
The difficulty related to spoken English was one of the most common challenges all participants faced. One participant shared her story about how she was wrongly accused of and treated unfairly due to her difficulty with English when she worked as an RN. She expressed occasional difficulty as an NP in educating patients about diagnostic test results. This result is consistent with many studies about immigrant nurses [16-18]. Moyce et al., in their systematic review[16] , reported that language and communication were the common difficulties among foreign-educated nurse (FENs). They reported FENs had a tough time finding employment because they were being perceived as slow. Language and communication barriers lead FENs to isolation and loneliness. Mini [17] also mentioned language related challenges among internationally educated nurses (IENs), particularly need for understanding of cultural differences in communication. Although difficulty finding a job was not mentioned during the interview in our study, one participant intentionally pursued nighttime employment due to fear of language difficulty. Another participant did not talk much during the class, which lead to less engagement with her classmates. Metasynthesis by Xu [18] showed unfamiliarity with accents as one of the reasons for difficulty communicating in English. One of our participants talked about her difficulty understanding the Spanish names of the patients. In Xu’s study, marginalization, discrimination, and exploitation appeared as one of themes in the 14 studies included in the analysis. Interestingly, one participant who experienced wrong accusation said that while she went through a difficult situation due to the wrong accusations, a few of her coworkers brought out discrimination issue over her situation. However, she did not think that wrong accusation was discrimination against her. Another participant expressed a feeling of being marginalized but she thought she had her responsibility to a certain extent not being able to mingle with the group.
Seo and Kim [9] conducted a study about the professional identity of Korean immigrant NPs. Despite their study focused on the professional identity of Korean immigrant NPs, overlapping themes with our study were noted. Our theme “Satisfaction” encompasses their two themes, “dedicated life and feelings of achievement.” Participants in both studies put patients first and went above and beyond their duties. They felt a sense of achievement from feelings of reward with patients’ improvement or comments. “Diligence” from Seo and Kim’s study was noted in our study. However, the participants in our study related diligence as one reason for their conflict with coworkers and more workload. The main characteristics of diligence in Seo and Kim’s study were advanced preparation, conscientiousness, and rule observance. Seo and Kim’s study did not reveal difficulty related to spoken English. Their study focused more on professional identity as an NP than lived experience as an immigrant NP, which might have contributed to the shift of conversation from talking about earlier adaptation in the United States, which might have included difficulty with English. This assumption was possible based on our study finding that all our participants considered their difficulty with English was the problem only at the beginning of their life in the United States. No one except one participant who experiences intermittent difficulty with explaining diagnostic test results, mentioned about the difficulty related to spoken English as a current problem.
This study has several limitations. First, the participant of this study wase limited to immigrant Koreans who became an NP to understand their life experience in the United States. Due to difficulty finding male Korean immigrant NPs, only female NPs were recruited. Three participants used to work at the same health care organization. This study used an unstructured interview method to explore participants’ authentic narratives about their life as an immigrant NP, the details of their struggles and transition process from RN to NP were not fully explored.
This study used a phenomenological approach to explore the lived experience of Korean immigrant NPs and provided insightful perspectives of Korean immigrant NPs. They faced various challenges while adjusting to life in the United States. However, they overcame challenges with their determination and support, and successfully transitioned to competent NPs. Furthermore, they are satisfied and proud that they could make a difference in patients' life. This is significant because our health care system is in dire need of clinicians with diverse backgrounds to improve the quality of care among ethnic minority populations with limited English proficiency. Further research may need to explore how Korean immigrant NPs impact the care process, patient satisfaction, and patient health outcomes. Also, generating collective knowledge about immigrant NPs from other cultural backgrounds may be needed to understand how immigrant NPs play a role in the health care systems and possibly create necessary support for their success as a competent NP.
The authors declare no conflict of interest.
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