Research Article| Volume 26, ISSUE 4, P470-476, August 2019

Playing the game: A grounded theory of the integration of international nurses

Published:December 18, 2018DOI:



      Migration trends to Australia have seen an increase in international nurses, with twenty-nine percent of current registered nurses having received their first nursing qualification outside of Australia. The process international and local nurses navigate to enable successful integration into the Australian healthcare system is unclear.


      To explore how international nurses and Australian nurses adapt to work together in the Australian healthcare system and to develop a theory that explains this process.


      Grounded theory methodology was used. Concurrent data collection/generation and analysis of online-survey data (n = 186) and in-depth interviews (n = 15) was undertaken. Storyline was used as a technique of analysis to develop, construct and present the theory. Focus groups (n = 9 + 7) were conducted to confirm the relevance of the theory.


      Nurses work together to enable successful integration of international nurses. Four phases underpin this adaptation to the cultural norms of the workplace: (i) Joining the game; (ii) Learning the game, (iii) Playing by the rules, and (iv) The end game. These phases comprise the grounded theory Playing the game: Integration of internationally qualified registered nurses in the Australian healthcare system.


      Additional orientation programs and collegiate support for international nurses were significant factors influencing successful adaption to the cultural context of the work environment. Defining the role and scope of practice of the registered nurse in the Australian context provided challenges.


      Supportive colleagues were critical to successful integration and retention of experienced nurses irrespective of where nurses obtain their nursing qualification. Additional orientation programs for international nurses could improve the experience of nurses migrating to work in Australia.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Collegian
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Birks M.
        • Mills J.
        Grounded theory: A practical guide.
        SAGE, London, England2011
        • Birks M.
        • Mills J.
        Grounded theory: A practical guide.
        2nd ed. SAGE, London, England2015
        • Birks M.
        • Davis J.
        • Smithson J.
        • Cant R.
        Registered nurse scope of practice in Australia: An integrative review of the literature.
        Contemporary Nurse. 2016;
        • Braithwaite J.
        • Herkes J.
        • Ludlow K.
        • Lamprell G.
        • Testa L.
        Association between organisational and workplace cultures, and patient outcomes: Systematic review.
        BMJ Open. 2017; 6
        • Bryant A.
        • Charmaz K.
        Grounded theory in historical perspective: An epistemological account.
        in: Bryant A. Charmaz K. The SAGE handbook of grounded theory. SAGE, Thousand Oaks, CA2007: 31-57
        • Charmaz K.
        Constructing grounded theory.
        2nd ed. SAGE., London, England2014
        • Chun Tie Y.
        • Birks M.
        • Mills J.
        The experiences of internationally qualified registered nurses working in the Australian healthcare system: An integrative literature review.
        Journal of Transcultural Nursing. 2018; 29: 274-284
        • Department of Health
        Nurses and midwives NHWDS 2016 fact sheet.
        (Retrieved from Canberra)2017
        • Fouché C.B.L.
        • Bartley A.
        • Brenton N.
        Strengths and struggles: Overseas qualified social workers’ experiences in Aotearoa New Zealand.
        Australian Social Work. 2014; 67: 551-566
        • Hawthorne L.
        Health workforce migration to Australia: Policy trends and outcomes 2004-2010.
        (Retrieved from)2012
        • Hawthorne L.
        WHO four-country study: Health workforce migration in Australia.
        World Health Organization, Geneva, Switzerland2014
        • Healee D.
        • Inada K.
        Working with difference: Thematic concepts of Japanese nurses working in New Zealand.
        Nursing & Health Sciences. 2016; 18: 91-96
        • Ho K.H.M.
        • Chiang V.C.L.
        A meta‐ethnography of the acculturation and socialization experiences of migrant care workers.
        Journal of Advanced Nursing. 2015; 71: 237-254
        • Holmes T.
        • Grech C.
        CaLD nurses transition to Australian tertiary hospital practice: Exposing the reality: A mixed methods study.
        Collegian. 2014; : 1-10
        • McGrath B.P.
        Integration of overseas-trained doctors into the Australian medical workforce.
        The Medical Journal of Australia. 2004; 181: 640-642
        • Moradi Y.
        • Mollazadeh F.
        • Jamshidi H.
        • Tayefeh T.
        • Zaker M.R.
        • Karbasi F.
        Outcomes of professional socialization in nursing: A systematic review.
        Journal of Pharmaceutical Sciences and Research. 2017; 9: 2468-2472
        • Murray S.F.
        • Bisht R.
        • Baru R.
        • Pitchforth E.
        Understanding health systems, health economies and globalization: The need for social science perspectives.
        Globalization and Health. 2012; 8: 30
        • Nursing and Midwifery Board of Australia
        Internationally qualified nurses and midwives: Meeting the registration requirements.
        (Retrieved from)2016
      1. Nursing and Midwifery Board of Australia. 2018, NMBA English langauge skills registration standard (2019). Retrieved from

        • Ong-Flaherty C.
        Critical cultural awareness and diversity in nursing: A minority perspective.
        Nurse Leader. 2015; : 58-62
        • Organisation for Economic Co-operation and Development
        Health at a glance: Asia/pacific 2016: Measuring progress towards universal health coverage.
        OECD Publishing, Paris2016
        • Philip S.M.
        • Elizabeth
        • Woodward-Kron R.
        Nursing educator perspectives of overseas qualified nurses’ intercultural clinical communication: barriers, enablers and engagement strategies.
        Journal of Clinical Nursing. 2015; 24 (2610p): 2628-2637
      2. Queensland Government. (2012), Queensland Health Strategic Plan for Multicultural Health 2007–2012. Retrieved from Brisbane, Australia:

        • Silverman D.
        Interpreting qualitative data: A guide to the principles of qualitative research.
        4th ed. 2011 (Los Angeles, CA)
        • Stanhope-Goodman S.H.
        • Brenda
        • Nordstrom P.
        Completing substantially equivalent competency assessment: Barriers and facilitators for internationally educated nurses.
        Journal of Nursing Regulation. 2014; 5: 35-39
        • Stankiewicz G.
        • O’Connor A.M.
        Overseas qualified nurses in Australia: Reflecting on the issue.
        The Australian Journal of Advanced Nursing : A Quarterly Publication of the Royal Australian Nursing Federation. 2014; 31: 32-38
        • Timmermans S.
        • Tavory I.
        Theory construction in qualitative research: From grounded theory to abductive analysis.
        Sociological Theory. 2012; 30: 167-186
        • Xiao L.D.
        • Willis E.
        • Jeffers L.
        Factors affecting the integration of immigrant nurses into the nursing workforce: A double hermeneutic study.
        International Journal of Nursing Studies. 2014; 51 (2014): 640-653
        • Yu N.
        Contemporary theory of metaphor: A perspective from Chinese. Vol. 1. John Benjamins Publishing Company, Poole, Philadelphia1998