Culture Shock in Nursing: A Concept Analysis

: 1) Background: Culture shock is a common experience by internationally educated nurses (IENs) working in foreign countries, characterized by disorientation and discomfort due to distinct norms, values, and rituals. 2) Aim: this study explores culture shock in IENs and explores mitigation techniques to enhance understanding of challenges faced in foreign cultural contexts. 3) Method: Using Concept Analysis by Walker and Avant (2019). 4) Results: A total of 20 articles were reviewed. Four major attributes were identified: psychological and emotional impact, communication barriers, acculturation and quality of life, and organizational challenges . 5) Conclusion: This paper explores the challenges faced by nurses from foreign countries due to cultural adjustment and proposes solutions to minimize its effects. It is beneficial for nurses, healthcare organizations, and policymakers, aiming to improve patient care and health outcomes. 6) Implication for Practice: Addressing culture shock can promote a smooth transition, enhance nurses' experience, and improve their cultural competence. Providing tailored orientation and mentorship programs can help IENs feel supported and empowered, leading to increased job satisfaction, retention rates, and better patient outcomes.


Introduction
In our contemporary era, with extensive transportation accessibility, people have the freedom to travel at their convenience, whether for leisure, migration, work, or education.Various methods exist for categorizing these travelers, including the duration of their journeys such as migrants, sojourners, and tourists, the distance they cover, whether is it near or far, the familiarity, their reason for moving is education, trade, expansion, and the dynamics of stranger-host relations (friendly vs. antagonistic), among others [1] "Nursing is a profession that requires not only medical knowledge and skills but also cultural competency and adaptability.Internationally educated nurses (IENs) who work in bedside nursing often face culture shock, which can significantly impact their adaptation and professional experiences.Immigrant nurses may face a more significant challenge than non-immigrants as they contend with additional stressors like adaptation difficulties, language barriers, and discrimination [2,3].Challenges in communication, instances of racism even within the same racial group, discrimination based on immigrant status, and licensing barriers arising from disparities in their nursing education backgrounds [4].
The difficulties arising from culture shock may compound the existing challenges faced by individuals in their current work environment.Apart from the stress from cultural unfamiliarity, healthcare providers undergo work-related stress that can profoundly affect their overall well-being, and this stress may result in adverse clinical outcomes, including medical errors, compassion fatigue, and unprofessional behavior [5].In an intercultural setting, differing interpretations of behavioral norms, variations in understanding nursing care, and ineffective communication hinder collaboration within a diverse nursing workforce while migrant and minority nurses encounter biases, and verbal and sexual harassment originating from their clients [6].Despite this situation, internationally educated nurses remain optimistic and demonstrate the ability to cope with the challenges that arise from the culture shock experienced in bedside care.Although language differences serve as a primary stressor that hinders effective teamwork and a positive nurse-client relationship, both migrant and native nurses employ similar coping strategies to navigate occupational challenges, and establishing strong teamwork and having a supportive supervisor are valuable resources that aid migrant and minority nurses, as well as native nurses, in addressing stressors and managing them effectively [6].Mental stress sickness is linked to the social adaptation that happens during migration, which is impacted by the host community's acceptance of the new sociocultural norms as well as the new work environment, successful adaptive adjustments can help prevent stress, but if the adaptation is maladaptive, it may lead to stress while residing in Japan, potentially diminishing the overall benefits of migration [7,8,9].
Nurses classify culture into primary (family-based) and secondary (professional) categories, and their personal and professional adaptation is shaped by a combination of these cultural influences; various factors, including language barriers, differences in nurse training protocols, and challenges in support systems, housing, and life outside work, contribute to culture shock for individuals from different nations, including Filipino nationals [10].Despite the plentiful differences in hospital practices between the Philippines and the United States, especially when it comes to technology, nurses are still satisfied with their jobs [11].Factors like getting higher wages, and benefits and appreciating the people they work with have an impact on job satisfaction [2].All these aforementioned studies suggest that orientation and induction programs can help to acculturate the IENs.
According to Merriam-Webster, culture shock is a sensation of unease, uncertainty, and occasionally fear that can strike someone who is unprepared and exposed to a foreign culture or environment [12].Understanding the definition of culture shock may also be aided by synonyms like disorientation, dislocation, alienation, and confusion.In the context of this particular study, culture shock is defined as a sense of uncertainty or anxiety experienced by individuals immersed in a culture that is unfamiliar or [13].It is also a common experience for internationally educated nurses (IENs) who migrated to a new country for work [14].
The experience of internationally educated nurses experiencing culture shock at the bedside will be the main focus of this study.The purpose of this concept analysis is to provide guidance on how to spot and mitigate culture shock prior to deployment for nurses who would like to pursue opportunities overseas.This concept analysis instead of delving into specific issues and challenges unique to each country, focused on addressing them in a more general sense.Through the study, the realities of the experiences of the nurses who are now employed in such areas will be brought to light, improving our understanding of workforce dynamics and the specific elements that lead to culture shock as well as useful coping strategies in such circumstances.

Design
This study is based on the Walker & Avant Method (2019) [15].This particular method stands on the premise that concepts are static and context-free and steps are utilized to come up with cases, thereby forming well-defined boundaries that give meaning to the concept itself.Table 1 shows the 8 steps of the concept analysis.

STEPS PROCESS
Step 1 Selecting the concept to be used Step 2 Establishing the purpose of the analysis Step 3 Distinguishing all possible applications of the concept Step 4 The formation of defining attributes Step 5 Pointing out the model case Step 6 Pointing out borderline, related, and contrary cases Step 7 Recognizing antecedents and consequences Step 8 Defining empirical referents

Data Collection
Researchers began an initial search approach on December 2023 for the review, locating pertinent databases and sources from PubMed, Google Scholar, ScienceDirect, Elsevier, CINAHL/EBSCO.Following several conversations, papers including keywords like culture shock, acculturation, migration, internationally educated nurses (IENs), mentorship programs, and culture shock were the primary focus for data collection.The search process is guided using PRISMA diagram as shown in Figure 1.The next step was sorting through 450 similar papers based on keywords and titles to find possible studies from the period of 2005 to 2023.To ascertain the studies' pertinence to the study question and inclusion criteria, the titles and abstracts of the discovered papers are screened.The eligibility assessment phase involves a thorough evaluation of the full-text articles to determine whether they meet all the predefined criteria (peer-reviewed academic journals, English or translated into English articles and publications, nurses who migrated to foreign countries, and nurses who experienced culture shock) for inclusion in the review.In this case, articles are narrowed down specifically to the ones that mainly focus on the Culture Shock of International Educated Nurses (IENs).During the eligibility assessment phase, any duplicate studies identified during the initial search process are removed to ensure that unique studies are considered.This rigorous process helps to ensure that the review includes all relevant studies while excluding studies that do not meet the predefined criteria.Out of the 155 articles reviewed, there are only 44 articles that fit the inclusion criteria, and from those articles, the next steps will be data extraction and analysis.After clearly defining the exclusion criteria, only 20 articles are included in the final analysis.

Inclusion and Exclusion Criteria
For this particular study which looks into the Culture Shock experienced by Internationally Educated Nurses (IENs), nurses who experienced culture shock in any foreign country were included, studies that were written in full-text English and/or translated into full-text English were also an inclusion criteria as well as peer-reviewed Non-peer-reviewed articles, journals, publications such as blogs and websites; and non-nursing professionals including students as well as nurses who did not immigrate to any country were all excluded from the study.

Data Evaluation and Quality Appraisal
An extensive matrix table was used to classify data that have been selected using the Sparbel and Anderson (2000) [16] tool with the following information: author, year of publication, country of publication, design, method, aims, findings, level of evidence, and the findings of the studies .Researchers independently assessed the methodological quality employed in this investigation.The inclusion and exclusion criteria should be fulfilled by all articles.To further assess the quality of the studies in the articles above, the Level of Evidence by Melnyk & Fineout-Overhold (2015) [17].The researchers held several meetings wherein all decisions, agreements, and disagreements were made through consensus.Expert colleagues in nursing research were invited to validate studies and provide insights to further enhance the study.

Defining attributes
The main goal of concept analysis is to identify an idea's defining characteristics.The set of qualities known as defining traits or defining characteristics serves a similar purpose to the standards used in medicine to make differential diagnoses [15].
Based on the 20 articles from the literature table, the following are the identified key defining attributes of Culture Shock: 1) Psychological and Emotional effect on IENs, barriers to communication or language barriers, the availability of resources and support, and acculturation.

Model case
A model case is an instance of applying the concept that showcases all its distinctive characteristics [15].In other words, the model case ought to be a perfect example of the idea, a typical example, or an ideal example.The study's model case is illustrated in the example below.
MJ, a 37-year-old Filipina, recently relocated to Springfield, Missouri with her husband and 7-year-old son.They arrived in July 2021 after their visa was granted, despite it only being valid for a few months.MJ had always dreamed of living and working in the United States, so she jumped at the opportunity.However, she is feeling nervous about her new job as a nurse, especially since she is using modern medical equipment that is too advanced for what she is used to in the Philippines.She is also worried about communicating with her patients and coworkers due to her accent and fear of not being able to understand them.Despite these concerns, MJ's employer provides significant benefits to help her adapt to American culture, including a free apartment for a month and transportation to and from work.During her 30-month contract, she will attend orientation sessions that cover US culture, medical procedures, and hospital protocols.These sessions are specifically designed for international nurses, which will help her feel more comfortable and confident in her new role.MJ has also made friends with some of her colleagues, including other Filipino nurses, who have offered to help her with transportation and other tasks.With time, MJ has been able to get used to her new workplace and even serve on committees within her department.She has also received a Daisy Award nomination for her dedication to her patients, and her family is settling in nicely to their new home.
In this model case, MJ is well aware of the different issues that she and her family will face prior to accepting the offer from her employer.She knows that she will do a lot of adjustments once they transfer to the US.However, she was able to adjust because of her employer who is very supportive to their newly hired employees specifically to the IENs.This case highlights the four attributes of culture shock: impact on psychological, emotional, and physical well-being, the importance of effective communication, availability of resources and support, and overcoming culture shock with time and effort.The case of MJ, a professional moving to a new country, demonstrates the challenges of adapting to a new environment with a different culture, language barriers, and limited social support.However, MJ's ability to adapt her communication style, access to support from her employer and colleagues, and resilience in the face of cultural challenges allowed her to overcome culture shock and thrive in her new environment.The study emphasizes the importance of perseverance and determination in overcoming cultural obstacles and recovering confidence.A model case is an example of the use of the concept that demonstrates all the defining attributes of the concept [15].

Related Case
George is a 27-year-old, registered nurse in the United States.He was in high school when he realized how choosing the right career can improve someone's quality of life.He has witnessed his relatives' families sending two of their kids to nursing school and eventually moving to the United States.The joy, pride, and financial implications of their children both having successful careers in the US and being able to help their families back in the Philippines have inspired him to take up nursing as well.He began researching American culture in addition to studying hard to pass the board exams for the US and the Philippines.He did this by reading about American history and way of life, watching American films, and playing American sports like baseball, hockey, basketball, and American football.Having all these efforts gave him a boost in his confidence with the language and in how he can immerse himself in the American community.He began studying the history, way of life, and tourist attractions of the location he would soon be visiting after passing the NCLEX exam and the hospital to which he was being deployed.He listened to podcasts that discussed the professional behaviors and attitudes in the American healthcare industry.He also searched for local Filipino communities on different social media platforms so he could still have some kind of connection to his roots.These efforts paid off, as when he arrived in the US, he knew he was prepared, at least, to deal with and cope with the culture shock that he was expecting.He was thrilled that he was able to join conversations with his American colleagues when they discussed sports, their history, or just anything random.This played a big role in building his selfconfidence and, in a way, eased his anxieties about isolation and the feeling of homesickness.He easily found a set of friends and felt a sense of belongingness in just a short time.Following several months of practice, he gained a wealth of knowledge about American work practices, and he thought the Philippines would have improved by now if these practices had been implemented there.Simple things like observance of time, transparency in the recruitment process (hiring because of merits and not because of connections and politics), treating colleagues as equal and not being looked down on because someone has lower educational qualifications, and obviously, just less corruption.
George did not seem to encounter most of the culture shock challenges encountered by IENs when moving as he tried his best to smartly prepare prior to his deployment.He didn't struggle immersing himself in the American community as he managed to familiarize himself with their way of life, work ethics and language.Though he just brushed off most of the usual predicaments of a new IEN in a foreign turf, he still felt quite overwhelmed experiencing the differences, not just in the nursing practice but in the professional world in the United States.This scenario fits the criteria for a related case wherein they do not include all the attributes but can be similar to the model case but are not them [15].

Borderline Case
Cindy, a 32-year-old nursing staff member, moved from the Philippines to Germany.She has been hired for 3 years in a tertiary hospital in the said country.Like most expatriate nurses, she initially felt disoriented and stressed due to the new environment and culture shock.However, unlike many others, she continues to struggle with aspects of the new culture, finding it challenging to connect with the natives and adjust to her work due to extensive differences between the healthcare settings where she previously worked.Despite an extended period, she still experiences a persistent sense of discomfort.Her variation in coping is prolonged, indicating a difficulty in cultural adjustment.
Before arriving in Germany, Cindy underwent thorough training with their language acquiring significant proficiency.She demonstrated competence in the language, experiencing no challenges in effectively communicating with the German people.This situation meets the conditions for borderline cases, which refer to examples or instances that encompass the majority of the defining attributes of the concept under scrutiny but not necessarily all of them.Borderline may contain most or even all of the defining characteristics but differ substantially in one of them, such as length of time or intensity of occurrence [15].

Contrary Case
Joyce has worked as a registered nurse in the intensive care unit (ICU) in the Philippines for ten years.Following her 2013 nursing degree graduation and passing her licensure examination, she decided to pursue training in the hospital where she completed her affiliation training when she was a student nurse.She did not need to complete the first adaptation training and first few orientation modules because she was already quite familiar with the hospital and the unit she was hired for.Instead, she received training for an advanced skill set in the intensive care unit.Joyce is a nurse who also assists in the family's food and catering business.She comes from a close-knit family.She has no intention of moving abroad to pursue her career because she is the family's eldest and has greater experience managing the company.She had her family run business in addition to nursing, so she did not feel the need to travel abroad.
Joyce is a nurse who is only registered in the Philippines.She did not migrate abroad, she did not encounter any language barrier, and it is clear that she has not experienced culture shock in her current workplace, especially since she has not undergone orientation or initial training after being introduced to the hospital and unit for which she has been hired for.This scenario possesses characteristics that disqualify them from meeting the study's inclusion requirements.Contrary cases are clear instances of "not the concept" [15].None of the defining attributes can be seen in a contrary case as depicted in the above scenario.

Antecedents
Antecedents are defined as incidents, events or attributes that must arise or occur prior to the occurrence of the concept [15].For an individual to experience culture shock, an individual must first have lived in another country or area, speak another language and practiced their own way of life and religion and then move to another area where the way of life, language, and even religion is completely different, thus, the feeling of anxiety or disorientation which can affect certain behaviors or attitudes.For IENs, culture shock is a common occurrence.A number of antecedents have been extracted from the literature gathered.
Individual related antecedents identified include: IENs having been educated abroad, their first language is not English but have English as the medium of instruction in their nursing curriculum, have partially or completely different cultural practices, including religion, social and family interactions and work ethics, and lastly, the wages from back home are way lower.In addition to this, the IEN's perceive moving to a more prosperous and financially and politically stable country will improve not just their individual quality of life but their whole nuclear to their extended family in general.Low remuneration, high supply of nurses with low demand in the job market, poor professional development and sub par living conditions contribute to the migration of nurses to wealthier countries [22].Regardless of the impressions of homesickness and struggles experienced by other foreign workers, they are more inspired by the fact that if they move abroad, they will be compensated well and this outweighs their hardships and still have a better quality of life [3].Once the IEN's get through the initial phases of the culture shock and their roles as nurses expand, their motivation to work and learn will increase, and they eventually achieve their given tasks [7].A study in New Zealand had a theme about sacrifice wherein the IENs get through the tedious and rigorous process of passing the English exam and borrowing money just to fund their application abroad, and start a new life [20].The IENs may also have possessed and acquired certain skills or even achieved certain senior levels in their home countries but end up having a junior role in a new country.This value incongruence can eventually lead to the IENs dissatisfaction with his job and end up feeling fragmented and devalued [10].

Consequences
The effects of culture shock vary from person to person.This case study has gathered both favorable and unfavorable outcomes documented in existing literature.One positive consequence is having a supportive supervisor, expressing appreciation, and fostering effective teamwork, which are valuable resources aiding migrant, minority, and native nurses in handling stressors.Interestingly, the study also observed that language differences pose a challenge, making it difficult for teams and nurses to collaborate successfully.Notably, native nurses experienced this challenge more frequently than their migrant counterparts..An immigrant nurse not fully immersed in the multicultural nursing environment may misinterpret nonverbal cues from patients, such as smiling, eye contact, or smirking.This misunderstanding can lead to unnecessary tension between the nurse and the patient [23].Hiring nurses from other countries led to positive results such as sharing the knowledge.Nevertheless, the data also points to several adverse and unfavorable consequences, including issues related to language barriers and discrimination [29].
Additional education to the new nursing program, comprehensive language proficiency includes comprehensive nursing skills and medical system, but the research discovered that IENs encountered language barriers and experienced a decline in their confidence as nurses [7].In qualitative research conducted in Saudi Arabia, while six nurses (30%) pointed out that their nurse managers did not provide sufficient support, creating a significant issue for them, the majority still felt supported by their line managers.It was discovered that participants encountered significant work-related pressures and experienced challenges in acquiring cultural skills.They also faced difficulties in addressing the cultural and spiritual needs of their patients while maintaining highquality nursing care [19].Facilitating mutual learning within multicultural teams and fostering positive interactions among diverse groups play crucial roles in advancing intercultural understanding.These factors act as catalysts, enhancing the adaptation and integration of immigrant nurses into the workforce.The research unveils that insufficient regulations and resources employed in the recruitment, categorization, and utilization of immigrant nurses at both national and healthcare organizational levels can serve as structural impediments to their successful adaptation to professional nursing practice and integration into the workforce in a host country [25].

Empirical Referents
Empirical referents are concrete, observable phenomena that serve as evidence for the existence or occurrence of a particular concept.In other words, they are the tangible things or experiences that help to illustrate or prove the validity of a concept or idea.These referents provide direct evidence for the concept's existence, making it easier to understand and validate its meaning [15].Diagram 1 is the visual representation of this study where Culture shock is the concept and on top of it are the attributes linked to culture shock: Psychological and Emotional Health, Communication Skills Cultural Awareness; and Cultural Adaptation [1,6,7,28] Before relocating to a new environment, International Educated Nurses (IENs) are not exposed to the technology they will be using.Moreover, cultural diversity is already present before they arrive at their new destination [6].Both technology and cultural diversity have been found to be the underlying factors.
The hiring of IENs can have both favorable and unfavorable effects on patients, nurses, and staff.On the bright side, IENs' adaptability and ability to adjust to various situations have resulted in increased teamwork and staff appreciation among colleagues.Supervisors have been supportive and a valuable resource for IENs, making them feel more at ease and confident in their new work environment.However, despite these positive outcomes, there are also negative consequences.Some IENs may not receive adequate preparation from their agency, leading to feelings of disorientation and isolation.Additionally, language barriers can make it challenging for IENs to collaborate effectively with their peers and communicate clearly with patients, resulting in a loss of confidence and potential misunderstandings.Finally, cultural and spiritual differences can create additional obstacles for IENs, who may be more conservative in their cultural and religious practices.

Discussion
Culture shock is a common experience for internationally educated nurses (IENs) who migrate to a new country for work [14].Figure 2 shows the concept representation of the concept analys in culture shock in nursing.The defining attributes of culture shock in internationally educated nurses include: 1) The impact on psychological and emotional health: A variety of strong emotions, including homesickness, perplexity, frustration, anxiety, and a sensation of loneliness, are typical of culture shock.These emotions can significantly impact the mental health and overall well-being of internationally educated nurses.2) Disorientation and confusion: Internationally educated nurses may feel disoriented and confused when they encounter new cultural norms, values, and practices in the healthcare setting.3) Language and communication barriers: Language differences can create significant barriers to effective communication between internationally educated nurses and their colleagues, patients, and other healthcare professionals.4) Differences in healthcare systems: Internationally educated nurses may face challenges in understanding and adapting to the healthcare system of their new country, including different policies and procedures, documentation practices, and roles and responsibilities within the healthcare team.5) The loss of professional identity: Internationally educated nurses may experience a loss of professional identity as they transition from their familiar healthcare system to a new one.6) Challenges in building professional relationships: Culture shock may hinder the ability of internationally educated nurses to establish effective working relationships with their colleagues and supervisors due to cultural differences in communication styles, hierarchy, and professional expectations.7) Adjustment to new workplace norms: Internationally educated nurses may struggle to adapt to the work culture and practices in their new country, including different approaches to patient care, teamwork, and decision-making processes.8) Homesickness and longing for familiar surroundings: Culture shock can evoke a strong feeling of homesickness and a longing for the familiarity of one's home country, family, friends, and support networks Culture shock is a common experience among internationally educated nurses (IENs) who migrate to work in a new country.However, there is a lack of comprehensive research on addressing culture shock specifically in this population [14].This study aims to fill this gap by examining the cultural factors that contribute to culture shock and identifying effective strategies for addressing it among IENs specific cultural factors that contribute to culture shock in this population.Include: 1. Understanding the role of language proficiency in the adaptation process and addressing language barriers 2. Examining the impact of cultural differences in nurse-patient interactions and patient care delivery.3. Exploring the influence of organizational culture on the adaptation and integration of internationally educated nurses.4. Investigating the role of mentorship programs in providing cultural support and facilitating the adaptation process 5. Investigating the effectiveness of cultural orientation programs for internationally educated nurses in addressing culture shock.

Implication for Nursing Practice
Culture shock is a common phenomenon experienced by internationally educated nurses who seek opportunities to work in different countries ([14].It is important to address culture shock in nursing practice as it can significantly impact the well-being and effectiveness of internationally educated nurses (IENs) at the bedside.The experience of culture shock can lead to feelings of isolation, anxiety, and frustration for IENs.By recognizing and addressing culture shock, nurses can help to promote a smooth transition and enhance their overall experience and satisfaction.Providing orientation and mentorship programs specifically tailored to address culture shock can help IENs feel supported and empowered in their new work environment.Improving cultural Religion and racial differences Apprehension competence and understanding among the nursing staff can also help to create a more inclusive and supportive work environment, which will benefit both internationally educated nurses and the overall healthcare team.By addressing culture shock in nursing practice, healthcare organizations can ensure that these nurses feel valued and supported, leading to increased job satisfaction, retention rates, and ultimately better patient outcomes.

Limitations and Recommendations
Limitations: 1.One limitation of this study is the potential for selection bias.Since the study specifically focuses on nurses who have already experienced culture shock, it may not capture the perspectives and experiences of nurses who have successfully adapted to a foreign healthcare system without significant culture shock.2. Another limitation is the potential for recall bias.Since the study relies on participants' recollections of their culture shock experiences, there may be inaccuracies or gaps in their memory and perception of events.
Recommendations: 1.To overcome the limitation of selection bias, future studies can consider a more diverse sample of nurses, including those who have successfully adapted to foreign healthcare systems.This can provide a more comprehensive understanding of the factors that contribute to culture shock and identify additional coping mechanisms.2.To address the limitation of recall bias, future studies can employ more objective measures, such as direct observations or structured assessments of culture shock experiences.3. To ensure the relevance and applicability of study findings, it would be beneficial to involve local healthcare professionals in the research process.This would provide insights from the perspective of the host country and help to identify specific cultural challenges that nurses may face, as well as potential solutions or support strategies that can be implemented.

Conclusions
This study aims to offer valuable perspectives on the difficulties experienced by nurses educated in other countries because of cultural adjustment, as well as provide solutions to minimize its effects.The findings will be useful for nurses who are considering or currently working in a foreign country, as well as for healthcare organizations and policymakers involved in the recruitment and support of internationally educated nurses.In a way, it will also help mitigate the negative effects of culture shock on patient care and overall healthcare outcomes.This study encourages to explore and address the challenges faced by internationally educated nurses related to culture shock, with the ultimate goal of improving their experiences and promoting cultural competence within healthcare systems.Level VI

Figure 1 .
Figure 1.PRISMA Flow Diagram of Culture Shock in Nursing Inclusion: articles written in full textEnglish language, Peer reviewed, Nurses who experienced culture shock in any country Exclusion: Non-peer reviewed journals, Nurses who did not migrate to another country, Non-

Table 2
Inclusion and Exclusion Criteria.