Introduction
A critical shortage of nurses in developed countries contributed to the active recruitment of nurses from other, particularly developing, countries such as Indonesia (Efendi, Chen, Nursalam, Indarwati, & Ulfiana, 2016; Efendi, Mackey, Huang, & Chen, 2017). Using migrant nurses is used by receiving countries as a quick remedy to meet the growing needs of aging populations and to achieve adequate staffing levels (Buchan, 2006). Indonesia is a major provider of care workers to meet the global demand (Efendi, Nursalam, Kurniati, & Gunawan, 2018; National Board for the Placement and Protection of Indonesian Overseas Workers [NBPPIOW], 2014). In the last decade, Indonesia has encouraged nurse migration based on economic benefit (Efendi, Nursalam, Dang, & Arief, 2015).
Responding to the international recruitment of health personnel, the World Health Organization (WHO) began regulating this movement by issuing the WHO Global Code of Practice (WHO, 2010). This code emphasizes and promotes the ethical recruitment of health personnel to minimize brain drain and brain waste, specifically from developing countries. This code is intended as a guide for receiving countries to promote and respect fair labor practices for all health personnel (WHO, 2010, 2011).
Recent data show that Taiwan is the most common destination for migrant nurses from Indonesia, with a total placement of 597 nurses as of the end of 2013 (NBPPIOW, 2014). It is surprising to know that Taiwan is the top destination for Indonesian nurses, as 75% (178,205) of the migrant workers in Taiwan are employed in the informal employment sectors (Economic and Trade Office of Indonesia, 2015). However, little is known regarding the level of education, placement channels, type of employment, or background of the Indonesians who work as migrant nurses in Taiwan. Moreover, there are incomplete and inconsistent data on migration in the literature (Clemens & Pettersson, 2008).
Taiwan, as a developed and wealthy country, has attracted foreign workers from many countries, including Indonesia. The Council of Labour Affairs first opened Taiwan to foreign workers in 1989, and migrant care workers were first hired in 1992 to meet the rising care needs of Taiwan's aging population (Kung, 2002). Recently, the number of foreign labor workers in Taiwan has increased significantly, to over 600,000, with most originating from the Philippines, Thailand, Indonesia, Malaysia, Mongolia, and Vietnam (Department of Statistics, Ministry of Interior, 2019). The Economic and Trade Office of Indonesia reported that 245,180 Indonesians worked as registered care workers in Taiwan in 2015. Although this number was slightly less in 2017 (190,587), Indonesia remains the largest source of migrant care workers in Taiwan (Ministry of Labor, Taiwan, ROC, 2017).
Despite the movement of Indonesian nurses to Taiwan, few studies have explored their experiences or examined their motivations in pursuing work as care workers in Taiwan. Foreign care workers have become an important part of care provision in Taiwan's long-term care (LTC) industry despite the paucity of information about their lived experience. This study was designed to explore the lived experiences of Indonesian migrant care workers in Taiwan. The insights gathered from their perspectives may be used to improve future placements and maximize the mutual benefits to both countries.
Methods
Research Design
A qualitative study using a phenomenological approach was used to reveal the nature of being a care worker in Taiwanese LTC institutions. The interpretive phenomenology employed both interpretive and descriptive elements to better understand the nature of the essence of the daily lived experiences of the participants (Van Manen, 1997). To conduct precise analysis and interpretation, participant-friendly settings were prearranged to allow their provision of rich and deep information.
Participants
Indonesian nurses who have worked as care workers in Taiwan's LTC institutions were recruited purposively as participants in this study. The inclusion criteria were that they were Indonesian nurses who (a) have lived and worked as a care workers in Taiwan for a minimum of 6 months and (b) are an enrolled nurse in Indonesia. Although the size of the research participant population was predetermined, once data saturation was reached, no additional interviews were held. The study was advertised to three potential participants, and afterward, further recruitment proceeded using a snowballing technique, which was selected because of the dispersed locations of the nurses and the limited access that researchers had to databases of Indonesian nurses working in Taiwan. The potential participants were contacted by phone and asked to provide verbal consent to participate. Twenty-four care workers from different locations of Taiwan (Taipei, Tainan, and Kaohsiung) were contacted as potential participants.
Data Collection
Data collection was carried out between August and September 2017. The participants were contacted, provided information on the study, and informed that their participation would be voluntary and that they could withdraw at any time. All communications with participants were conducted in their mother tongue, Bahasa Indonesia. The participants were interviewed for 45-90 minutes each using a semistructured questionnaire. The questionnaire was designed to assess (a) the reason for migration, (b) their lived experiences while working as care workers, (c) perceived barriers in addition to cultural differences, (d) unwanted events, (e) experiences that they have lived, and (f) recommendations for nurses who want to come to work in Taiwan. We collected the data using interviews and gathered in-depth information that reflected the perceptions and experiences of the participants. The interviews were audio-recorded and transcribed verbatim. Transcribed data were then cleaned, de-identified, and translated into English, and the transcriptions of both the original version and the English-translated version were reviewed for authenticity. No additional themes emerged after 16 interviews.
Ethical Considerations
Approval to conduct the study was granted by the ethical committee of Universitas Airlangga, Surabaya, Indonesia (513/KEPK). Written consent from the participants was obtained before conducting the interviews. The participants were assured that their data would be kept confidential and used for research purposes only. Access to the data was limited to members of the research study only.
Data Analysis
The data were carefully analyzed after transcription following the six steps of van Manen's (1997) phenomenological approach, which include (a) emphasizing the phenomenon by developing the research question around the experience of becoming a care worker in Taiwan, (b) selecting the participants and undertaking face-to-face interviews to explore the experience, (c) recognizing and reflecting on the important themes, (d) writing and rewriting to describe the phenomenon, (e) preserving the focus through in-depth exploration, and (f) considering both the parts and the whole to balance out the research context. We analyzed both versions of the transcripts using NVivo 11 (QSR International, Burlington, USA). Four themes emerged, which were subsequently used to describe the participants' lived experiences accompanied by one verbatim excerpt each.
Rigor and Trustworthiness
The rigor and trustworthiness of this study were examined in accordance with Lincoln and Guba (1985) to maintain the concepts of credibility, dependability, confirmability, and transferability. Three ways were used to improve the credibility of the data. First, the researchers were trained by an expert investigator in the qualitative method of data collection. Second, the researchers asked for feedback from an experienced researcher in hermeneutic phenomenology regarding the data quality and subsequent interpretations. Third, the participants were invited to provide suggestions and to comment on the data.
A professional transcriber was hired to transcribe the data for each interview session verbatim. The transcribed data were then reviewed by all of the team members in this study and an external expert to address the issue of dependability. The confirmability of this study was maintained by showing the results to the participants. Finally, the transferability of this study was evaluated by providing a thick description of the study that fits with other contexts.
Results
Participants' Description
Sixteen Indonesian nurses who have worked as care workers were enrolled as participants and interviewed individually. The settings for interview were selected by the nurses as places where the participants would feel comfortable to communicate their story. Most of the participants were women (n = 11). Their ages ranged from 22 to 41 years, most were single (n = 11), and most held a diploma in nursing (n = 12) or a BSN (n = 4) as their highest level of education. The nurses were mostly from the province of Jawa Tengah (n = 9) and were currently working and living in Taipei City (n = 8). Most of the participants had lived in Taiwan for more than 2 years (n = 11). The net monthly salary of the participants ranged from 15,000 to 30,000 Taiwan dollars (see Table 1).
Findings
Following the work of van Manen's phenomenology, this study revealed four themes and eight subthemes, including (a) "motives for working abroad: financial motives and seeking different life experiences"; (b) "feelings of being trapped: victimized by fraud, losing professional identity, and losing professional skills"; (c) "difficult journey: communication inadequacy and limited career pathway"; and (d) "feelings of being supported: support from their employer and support from their recruiting agent."
Theme 1: Motives for Working Abroad
Coming from a poor financial background drove most of the participants to seek migrant work in Taiwan, with most expecting to have a better future as a result. Nevertheless, some of the participants stated that gaining the experience of working abroad was their primary reason for seeking migrant work in Taiwan. All of these responses refer to the first theme in this study, which reflects on the meaning behind deciding to move to Taiwan to live and work. Nearly every participant initially believed Taiwan to be a place where they could earn money and gain more experience. Most of the respondents identified financial gain as a motivation to work in Taiwan.
Financial motives
Most of the participants had sought migrant work in Taiwan because of the poor economic situation of their families. They expected that working in Taiwan would improve their financial situation and, thus, support their family needs. As Participant 5 described: "...my family needs my support to live a decent life."
Several participants were attracted by the higher salary offered by the recruiting agents in their home country. As Participants 3 and 5 noted:
"[horizontal ellipsis]Second, was the economic (motive)[horizontal ellipsis]. I know that the salary was low. It was far under my expectations. Here, good-Lord, it is far better than in Indonesia."
"I am here because the salary offered is much higher than in Indonesia. By doing a similar job, I can earn five times more...."
In search of a different life experience
Some of the participants stated that money was secondary for them in taking migrant work in Taiwan. More important, they said, was acquiring experience working outside their country of birth. Participants 11 and 1, respectively, recalled:
"I really want to go abroad to acquire new experience. Working in foreign countries has been a personal challenge. Frankly speaking, I was hoping to go to Japan, but I failed, and, so, came here."
"I was just, like[horizontal ellipsis]I wanted to know better the differences between the medical and nursing instruments used in caring for patients here and in Indonesia...yeah, especially about the instruments they (Taiwanese nurses) use..."
However, still other participants said that the life experience of working abroad had been their priority in seeking overseas employment. Participant 4 shared that:
"...My most important reason (for working abroad) was just wanting to go abroad to look for new life experiences."
Theme 2: Feelings of Being Trapped
The participants revealed that they faced unexpected experiences while working and living in Taiwan. They expressed feeling trapped by the different nursing qualification system in Taiwan, which prevented their working as professional nurses while here.
Victimized by fraud
Some of the participants shared that they did not initially realize that they would be required to do work that is typically done by people holding lower qualifications. They said that they had been persuaded to come to Taiwan by the offer of a higher salary and promises of easy work. Participant 10 recalled:
"I was lulled by the (recruiting agency's) sweet offer[horizontal ellipsis] a high salary and a load (workload) that wouldn't be heavy. Only five days of work per week, eight hours per day. But it didn't work out that way. I have to work 12 hours a day, and the five-day work week was just an empty promise...."
Losing their professional identity
Almost all of the participants soon realized that it would not be possible to transfer their qualifications and work in Taiwan, as the system in Taiwan does not permit foreign nurses to work as professional nurses. Participant 8 stressed that:
"...we felt very sad. Our status is not clear here. We have a high degree in nursing from our country, but here we are nothing. Maybe there is another way to solve this problem."
Participant 10 stated that obtaining work that was in line with their professional background was a promise without truth.
"...To be honest, it was not like what I expected. When I first arrived, I didn't see it (as part of my job)[horizontal ellipsis]. I was given the dirty parts to clean, told to tidy up the mess[horizontal ellipsis]or just (to help) old people do they want to do."
Losing their professional skills
The participants also discussed how they felt losing their skills while working in nursing homes and LTC facilities, where they were not permitted to continue practicing their professional skills. They felt that they were being forced to stop using these skills and saw no future for their career. As Participant 15 stated:
"[horizontal ellipsis]I am not allowed to practice some of the skills that I know I can do. Like suction, for example. As long as you were qualified, you are allowed to do that back home. I think that only Taiwanese nurses are allowed to perform this procedure."
Some of the participants began to perceive the restrictions on what they were allowed to do. As Participant 10 recalled:
"...We don't have the right to give an injection or to do other things that nurses in Indonesia may do in their job...."
Theme 3: Difficult Journey
There was no consensus regarding the challenges that Indonesian nurses experience in Taiwan. However, communicating with older adult care recipients and their local counterparts was generally viewed as another significant hurdle at work. Other participants identified that this situation inhibited their career development.
Communication inadequacy
Failure to understand the local language hindered the participants from fully understanding conversations and instructions. The participants agreed that this contributed to their hardship and significantly exacerbated their stress. As one participant noted:
"Taiwanese speak in a different intonation and so quickly. As you can guess, it causes a lot of stress when I cannot understand anything about my patients."
For the younger participants, the language barrier made them bear others' problems as their own and take on all of the consequences, as they were unable to voice their thoughts and opinions. Participant 9 related:
"...as a first-timer, I didn't fully understand the language. If other care workers made a mistake, all of them were older than me and put the guilt on me. I couldn't speak for myself...so silence was my only option."
Limited career pathway
Their limited career opportunities in Taiwan were another significant issue for the participants. They reported that this significantly impacted their future plans. Participant 11 stated:
"Here, it is impossible to advance my career. It is only about settling myself, and just a matter of moving to another country."
Participant 4 agreed, stating that:
"There is no such a thing as a career. We're not Taiwanese. Otherwise (if we wanted to develop a career in Taiwan), we would have to take another test and attend school again[horizontal ellipsis]."
Finding the situation difficult, the participants even suggested that the younger generation of nurses should think twice before deciding to work as care workers in Taiwan. Participant 1 stressed:
"If they are able to put Taiwan as the last option, they should. If they can, they should think of Japan or the Middle East. Indonesian nurses would have a brighter future in those places...."
Theme 4: Feeling of Being Supported
Nevertheless, the participants felt that their management was supportive at work, although, for others, their agents in Taiwan always offered help whenever the nurses needed help to cope with their current situation.
Support from the employer
The participants agreed that support from their employer and nursing home/LTC institution was critical to creating a supportive workplace environment. Participant 7 suggested:
"My nursing home is doing its best to help me adjust and adapt to the new environment. They are motivating us to learn and study Mandarin in every situation. So far, we seldom have problems with our employer."
Participant 6 added:
"They told me to keep smiling while working...."
Support from the recruiting agent
The participants voiced that the placement agencies played a nurturing role, particularly when dealing with problems in the workplace. Participant 9 said:
"I was prepared because the agency that helped us gave us a few suggestions for when we are dealing with any problems in our life. They will come when I complain about almost anything."
Participant 3 highlighted the support received from her recruiting agent, recalling that:
"[horizontal ellipsis]My agent came to handle just about all of my problems. If I have any problems with my employer, they send someone. They are very helpful."
Discussion
This study explored the lived experiences of migrant nurses working as care workers in Taiwan. This study revealed the motivations for participants choosing to work abroad and their personal experiences while working as care workers, including the situations that they were required to face and their learning from these experiences. The current trends suggest the popularity of working abroad, as informed by the NBPPIOW (2014), which narrows the gap in understanding by unveiling the learned experience from the firsthand perspective of the participants.
The latest data from NBPPIOW (2019) show that Taiwan was the second largest recipient of Indonesians as migrant labor, after Malaysia. The nurses who participated in this study highlighted the desire to improve their poor financial situation as the most important reason for applying to work in Taiwan. This finding echoed previous studies that identified economic motive as a primary factor attracting migrant workers to a destination country (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004; Buchan, 2015). All of the participants agreed that Taiwan was one of the most popular destination countries for Indonesian nurses to live and work in. The participants noted that they were attracted by the ease of access when applying to work as care workers in Taiwan. Furthermore, the opportunity to have a better life was underscored by the nurses, as the currency conversion between the two countries gave them a higher income when compared with working as a nurse in Indonesia. They expected that being a care worker in Taiwan would allow them to help their families improve their economic situation. Nevertheless, other participants asserted that gaining experience working abroad was a factor that encouraged them to seek work in Taiwan (Aiken et al., 2004; Buchan, 2015; Kingma, 2007). However, they ultimately felt neglected in their current position because of their inability to continue performing in the professional capacity they were accustomed to in Indonesia.
The expectation of being employed in an advanced technological and sophisticated health system was emphasized by the participants. However, some revealed dissatisfaction with their identity and their skills going unused abroad. Before coming to Taiwan, the nurses perceived that being a care worker would allow them to hold a role equivalent to their professional nursing role in Indonesia. This misunderstanding was a cause for dissatisfaction. The term "care worker" is widely associated in Indonesia with geriatric nursing. Therefore, many Indonesian migrant nurses expect that they will be able to work as professional nurses in Taiwan. This situation is similar to that of Indonesian nurses working as care workers in Japan under the bilateral scheme (Kurniati, Chen, Efendi, & Ogawa, 2017).
A clear career path for foreign care workers should be addressed as an important component in sustaining the migration cycle within the nursing sector (Buchan, 2015). Nevertheless, the different approach between Taiwan and Indonesia has failed to address this issue. The Government of the Republic of Indonesia recognizes nursing as a profession with a set of responsibilities to be carried out by the certificate holder (Law on Health Workers, 2014). On the other hand, the health system in Taiwan does not allow foreign nurses to work at their certified level of qualification. This finding urges the need for a clear, informed, and well-explained contract for Indonesian nurses interested in working as care workers in Taiwan. The term "care worker" should be clarified, as it confuses nurses who sign up to work in Taiwan's LTC facilities.
Thorsteinsson (2002) reasoned that more effective communication is necessary to encourage nurses to involve feeling, trust, and empathy in care delivery. In addition, the findings of this study highlighted the importance of effective communication at work. The participants argued that it signified the accuracy of the transfer of information among the nurses, care workers, residents, and their manager. They indicated that language difficulties posed a significant challenge in delivering care and coordinating work. Language differences were perceived by the participants as requiring specific sets of skills, techniques, and processes. Therefore, the different languages used in their work became an inevitable barrier against the participants conducting their role as care workers.
The uniqueness of the migration scheme is related to the support of the care facilities and the healthcare agencies of Taiwan. The participants noted that support from Taiwan LTC institutions was critical in their initial adjustment to working and living in Taiwan. Furthermore, they stressed that the private recruitment agencies in Taiwan and in the sending countries should provide services for both employers and foreign care workers. Cooperation with recruiting agencies in the sending countries should help ensure that information on foreign care workers is provided to prospective employers. Once a foreign care worker is selected by an employer, the agency in the sending country will assist the foreign care worker to complete the requisite procedures before entering Taiwan (Chen, 2013). As most of Indonesian nurses do not speak Mandarin fluently, the services of these agencies should be given a greater emphasis in the future.
Limitations
Given the nature of qualitative research, the findings in this study may only be transferred to gain an understanding of the phenomenon within similar contexts and settings. Moreover, the lack of the Indonesian Nurses' Association as a potential source of information in Taiwan may have limited diversity among the participants.
Conclusions
Most nurses who participated in this study were prompted to work in Taiwan by poor financial background and the expectations of a better life. They expected to be able to help improve the economic situation of their families and to upgrade their skills in their destination country. The participants expressed feelings of being stressed, challenged, and disappointed. Their unmet expectations of being employed as nurses increased because of their relegation to relatively menial tasks that did not reflect their professional nursing backgrounds. This situation highlights the need for a clear definition of work responsibilities for those who sign up to work in Taiwan's LTC facilities. Language problems were raised as a barrier for nurses migrating from Indonesia to Taiwan. Fortunately, the participants felt somewhat supported by the LTC management and recruiting agencies. It is hoped that structured policies related to strengthening the support provided by LTCs to Indonesian care workers are standardized in Taiwan.
Implications for Practice
Some findings of this study reveal the challenges encountered by Indonesian nurses working in Taiwan's LTC industry. The results of this study highlight the need for better predeparture preparation and better recruitment processes. Nurses who intend to work abroad must be made aware in their native language of the details of what they are applying for. This study is expected to contribute to the formulation of appropriate future-migration policies based on the contexts that are specific to Taiwan. This study recommends that policies be changed to facilitate professional nursing career development, particularly for overseas nurses who work in Taiwan. Putting the experiences of Indonesian care worker nurses into the context of the global market reveals a cycle of brain gain, brain drain, and brain waste that hinders the career path of Indonesian nurses. Taiwan, as a receiving country, should play a more positive role in promoting and encouraging good practices by recruitment agencies in compliance with the WHO global code.
Acknowledgment
Special thanks to Universitas Airlangga, Surabaya, Indonesia, for funding this study.
Author Contributions
Study conception and design: All authors
Data collection: FE, SH
Data analysis and interpretation: FE, EM, LH, SH
Drafting of the article: All authors
Critical revision of the article: All authors
References