Abstract
The objective of this study was to identify how differences in cultural and professional values between New Zealand-born-and trained doctors and International Medical Graduates (IMG) impact IMGs' journeys to practise effectively and remain in New Zealand.
A mixed-method approach was used to support exploration of quantitative results with qualitative results to identify those values that created challenges and understand them in context. The quantitative phase (Phase 1) included the development of a 42-item questionnaire, the Professional Cultural Values Continuum (PCVC), which was pre-validated and aimed to identify participants' cultural and professional values. Specific cultural values measured were power distance – the degree of acceptance of unequal distribution of power, individualism – the degree of interdependence preferred, and communication context – the amount of context needed to create meaning. Professional values measured reflected the values of the New Zealand health system. The questionnaire was anonymous and sent out electronically. Statistical comparison was by ANOVA, and factor analysis was used to explore the questionnaire structure.
The qualitative phase (Phase 2) used semi-structured face-to-face interviews and aimed to identify cultural challenges faced by IMGs and New Zealand doctors working alongside IMGs. The qualitative data obtained were transcribed, and framework analysis based on cross-cultural theories was used to interpret the data and identify how cross-cultural challenges could explain their experiences.
Phase 1 participants were 373 New Zealand doctors (NZD), 198 IMG, and a group not identified prospectively: 25 doctors born and raised elsewhere but who qualified in New Zealand (MQNZ). Phase 2 participants were 14 IMGs and nine New Zealand doctors.
Overall, the PCVC questionnaire revealed statistically significant differences in power distance, with the MQNZ doctors having the highest power distance, followed by the IMGs, suggesting MQNZ and IMG doctors’ preference for a hierarchical environment – at odds with the New Zealand culture. Further breakdown of the IMG group by amount of challenges faced, years practising in New Zealand, and cultural diversity compared to New Zealand also found statistically significant differences in the power distance and in the high-low context construct and the professional values construct. IMGs who had been practising in New Zealand for less than two years were the most different and faced the most challenges.
Interviews found that cultural communication and hierarchy differences contributed to professional challenges. Many of the findings could be explained through the cross-cultural theories. Cross-cultural code-switching (the act of modifying one’s behaviour in a foreign setting to accommodate differences) was also identified, resulting in IMGs experiencing psychological challenges. The greater the cultural and professional difference of IMGs (compared to New Zealand), the greater the intensity of psychological challenges experienced when switching. Moreover, complaints about IMGs increased when they reverted to default behaviours regarded negatively by New Zealand colleagues or patients.
Furthermore, minimal support during this cultural transition resulted in IMGs experiencing psychological challenges, especially the competence challenge. This lack of support consequently led to frustration and left them feeling vulnerable.
In summary, cultural and professional value differences can impact IMG's ability to practise effectively. While IMGs are open to change, they face a lack of orientation and cultural education opportunities, hindering integration. Using the lens of cross-cultural code-switching to explain and identify cultural differences that cause psychological challenges for IMGs will assist in developing meaningful support and specific and tailored programmes to better support IMGs cultural integration and thus effective practising in New Zealand. Furthermore, cultural training for New Zealand doctors would help them understand the challenges IMGs face and identify collegial support they could offer. Additionally, establishing and allocating cultural mentors for IMGs could assist in addressing their psychological challenges, vulnerability, and isolation. With this support, the journey may prove more manageable and encourage IMGs to remain, strengthening the New Zealand population's access to quality healthcare.