Integration strategies and models to support transition and adaptation of culturally and linguistically diverse nursing staff into healthcare environments- an umbrella review

Aims: The aim of this umbrella review was to establish recent evidence on integration strategies and models to support transition and adaptation of culturally and linguistically diverse nursing staff into healthcare environments. Design: Umbrella review conducted according to joanna briggs institute guidelines. Data sources: Data were collected from CINAHL, PubMed, Medic, ProQuest and Scopus electronic databases in 2021. Review Methods: Two researchers simultaneously screened studies’ eligibility by title, abstract and full text. Quality appraisal for the selected studies was assessed according to joanna briggs institute critical appraisal. Data were synthesized by conducting content analysis. Results: Twenty-seven reviews were included in the final synthesis. Strategies and models for supporting the transition and adaptation of culturally and linguistically diverse nursing staff into healthcare environments were structured as intra-organizational, sociocultural, and professional development. Intra-organizational strategies and models were unique to a particular organization and included policies and support, diversity, collegial and peer support, employee treatment and workplace environment. Sociocultural strategies and models addressed social, cultural and group dynamics using cultural training, learning and support, social support and friendships, language and communication, and personal skills development. Professional development enhanced nursing competence, ability to practice and workplace professional development. This was supported through licensure and orientation to work, career and competence development, and workplace mentorship and preceptorship. Conclusion: There is a need to understand culturally and linguistically diverse nurses’ needs and motivation to integrate, which is essential towards developing efficient integrational strategies and models. Strategies and models also need to support cultural and personal competence development of native nurses to aid efficient integration of culturally and linguistically diverse colleagues. Future studies can evaluate nursing workforce shortages and their implications on integration process.


INTRODUCTION
The global nursing workforce deficit in 2020 was estimated as 5.9 million, and statistics show that one out of six nurses is projected to retire by the year 2030 (World Health Organization, 2020). This high retirement rate will exacerbate nurse workforce shortages (Drennan & Ross, 2019). A myriad of factors have been related to global nurse shortages, e.g., failure to attract males into the profession, lower renumeration of nurses compared to national average wages, mass nurse retirements, ageing populations and increased demand for care (Drennan & Ross, 2019;World Health Organization, 2020).
Various measures have been adopted to increase the number of nurses within national healthcare systems, such as attracting more males to nursing, increments in the number of local and international nursing students, restructuring of nursing education and intensified recruitment of overseas, internationally educated nurses (Buttigieg et al., 2018;Nortvedt et al., 2020) The global nursing workforce deficit has increased movement of nurses across international borders (Sherwood & Shaffer, 2014). The transnational movement of nurses is not a new phenomenon and has helped to relieve nursing workforce deficits in many nations (Sherwood & Shaffer, 2014;Gea-Caballero et al., 2019). Migration motivating factors for nurses include economic factors, career development, higher employability, family and friends, and favorable social conditions (Nagórska et al., 2017;Gea-Caballero et al., 2019;Nortvedt et al., 2020).
Despite the positive effects migrant nurses bring to the host nation's healthcare system, they face many sociocultural and professional related challenges (Gea-Caballero et al., 2019). These challenges include linguistic, communication, professional differences, unfair treatment and discrimination, that have been found to be rooted in the diversity of culture, beliefs and values within a multicultural workforce (Xu, 2008;Choi et al., 2019).
The objective of this umbrella review was to identify the current knowledge gap on existent strategies and models used to integrate culturally and linguistically diverse nurses,in healthcare organizations and facilitate their transition and adaptation. The aim was to examine the most recent evidence on integration strategies and models to support the transition and adaptation of these nursing staff into healthcare environments.

Background
Nurses with a migrant background have been defined as culturally and linguistically diverse, owing to their different country of birth and language (Pham et al., 2021). Existing research has shown that migrant nurses face many challenges within healthcare settings, e.g., racial and ethnic problems, bullying, discrimination, limited career mobility, and cultural and linguistic hurdles (Likupe, 2015).
These challenges have been shown to affect their effective integration in healthcare organizations, delivery of care and wellbeing (Ramji et al., 2019). For instance, Covell et al. (2018) found that in some instances, culturally and linguistically diverse nurses faced diminished employment opportunities due to linguistic and professional obstacles, and failure to acquire licensure. Previous research has also established that when culturally and linguistically diverse nurses' linguistic competence was not at the expected level, they were either employed as lower cadre nurses or worked in non-nursing jobs (Nortvedt et al., 2020) Limited understanding of migrant nurses regarding the healthcare system, organization and planning of care in the country of practice has been found to affect their delivery of quality and safe care (Sherwood and Shaffer, 2014). Negative experiences with patients and colleagues, and social challenges have been shown to have an adverse effect on their work wellbeing (Nortvedt et al., 2020). Culturally and linguistically diverse nurses' fear of otherness in the host country and inability to integrate has been shown to impact on their work satisfaction and retention (Gea-Caballero et al., 2019). Owing to the diversity of migrant nurses and their differing experiences in host countries, there is a need for both universal and individualized interventions that enable an efficient organizational integration process (Likupe, 2015).
Adaptation has been defined as the process by which a newcomer becomes acquainted with an organization, its goals, expectations, culture, and structure. It also includes learning roles, work expectations and familiarization with colleagues (Gajda, 2019). It has been established that culturally and linguistically diverse nurses adaptation has two aspects: a short-term transition period, within which basic skills required in employment are gained, and a long-term integration period, within which the nurses acquire linguistic, cultural, and professional competences, and are able to gain independence within their work roles and environment (Xu, 2008). Integration is a twodimensional process undertaken by both culturally and linguistically diverse nurses and the J o u r n a l P r e -p r o o f Journal Pre-proof organization and entails respect for diversity, divergence, inclusivity, and equity, and requires interaction between culturally and linguistically diverse and host nurses for practice adaptation (Ramji et al. 2019;Xiao et al., 2014). Through the process of integration nurses develop a sense of belonging, become part of the workforce and organization, and can effectively practice nursing.
This process is dependent on the organization and culturally and linguistically diverse nurse (Covell & Rolle Sands ,2021).
The process of integration of migrant nurses has been found to be time and resource demanding and influences their physical and mental wellbeing (Nortvedt et al., 2020). Integration involves culturally and linguistically diverse nurses, local colleagues, their managers, and the entire organization, and requires support toward organizational, cultural, and social integration (Gea-Caballero et al., 2019;Buttigieg et al., 2018;Sherwood & Shaffer, 2014). The concepts of adaptation and integration are similar to, organizational socialization, which has been defined as the entire process and actions undertaken by an organization and individual to enable a smooth adaptation to the organization (Van Maanen and Schein, 1977).
Organizational socialization theory is based on the assumption that socialization happens collectively for a group and individually towards meeting a newcomer's particular needs and orientation to complex tasks. Formal and informal approaches are applied, where organizations tailor activities and spontaneous socially driven processes. In instances where a newcomer is expected to attain certain professional aspects, a more structured socialization process is adopted because a lack of structure may make the process random and unclear. Newcomers are also subjected to a timed process with a stipulated period where particular events occur, such as promotion to new roles. The timed socialization process allows the newcomer to have clear expectations and acknowledging when certain events may occur (Van Maanen and Schein, 1977).
Within the organization, members who are more experienced are involved in the process of socializing newcomers and act as role models. On the contrary, socialization can also happen without the involvement of experienced members. In these instances, the newcomer may experience challenges and a lack of role modelling. During the socialisation process, newcomers may face a situation where the organization aims to enhance the existing skills; hence, they may not be expected to shed off the skills and experiences they already have. On the contrary, in instances where the organization may desire that a newcomer creates a new professional image of themselves, a change in the individual thinking and self-image is expected (Van Maanen and Schein, 1977).

Journal Pre-proof
The concepts of organizational socialization, adaptation and integration of culturally and linguistically diverse nurses are used interchangeably in our review.

Aims
The aim of this umbrella review was to establish recent evidence on integration strategies and models to support the transition and adaptation of culturally and linguistically diverse nursing staff into healthcare environments.
The main research question guiding this study was as follows: what kind of integrational strategies and models have been developed to support the transition and adaptation of culturally and linguistically diverse nursing staff into healthcare environments?

Design
An umbrella review was conducted to establish evidence from a wide range of existing systematic reviews (Aromataris et al., 2015) related to integration strategies and models that support transition and adaptation of culturally and linguistically diverse nurses into healthcare organizations.
Guidelines published by the joanna briggs institute guided this review (Aromataris & Munn, 2020).
Reporting of the umbrella review was performed against preferred reporting items for systematic reviews and meta-analyses (Page et al., 2020).

Search methods
Electronic databases CINAHL, PubMed, Medic, ProQuest and Scopus were searched in March 2021. P -participants, C -concept, C -context was used in formulating the research question (Aromataris et al., 2015). Inclusion and exclusion criteria were formulated to limit the scope of the research question within participants, concept and context. Studies that met the following criteria were included: 1) P = participants as nurses, nurse managers and nurse teachers; C = concept as integrational strategies and models of culturally and linguistically diverse nurses into healthcare organizations; C = context as healthcare organizations, including primary, secondary and community care. Published systematic or integrative reviews and peer-reviewed articles published in English or Finnish from the year 2000 onwards were included. A library information specialist J o u r n a l P r e -p r o o f Journal Pre-proof was consulted to enhance the search strategy for each database. The search was aligned according to the inclusion criteria and combined with Boolean operators AND, OR and NOT (see Supplementary file 1).

Search outcomes
A total of 13,752 publications were retrieved from the database searches (see Figure 1). In total, six researchers were involved in the screening process. Initially, n=5301 duplicate studies were eliminated, leaving a total of 8451 studies to be screened. The next phase entailed screening based on titles and abstracts, during which 7694 studies were eliminated. Next, full text screening of n=757 studies was conducted, where 507 papers that did not meet the initial inclusion criteria were eliminated. From the screened (n=250) studies, studies that were neither systematic nor integrative reviews were eliminated. During the entire screening process, research articles were eliminated if they were not peer reviewed or full text, or had wrong outcomes, time limit, language, population, and setting. Each study underwent a double screening process and conflicts were resolved by a third reviewer. A total of (n=27) articles met the inclusion criteria and were subjected to quality appraisal.

Quality appraisal
Quality appraisal for the chosen articles was performed by two researchers separately and later agreed together using the joanna briggs institute critical appraisal tool for systematic reviews and research syntheses (Aromataris et al., 2015). This appraisal tool examines a research article for trustworthiness, quality and findings using eleven distinct aspects. The eleven aspects were analyzed using "yes", "no", "unclear" and "not applicable" criteria. One point was awarded to each criterion that was rated "yes". Initially, both reviewers separately analyzed and scored all the 27 studies. Disagreements were discussed and agreed together. Studies were included in the review if they met at least six out of the eleven requirements. All the articles chosen for the review were found to be of good quality the highest scored the maximum of eleven points and the lowest seven points (see Supplementary file 2).

Data extraction
Data that were relevant to the review question were extracted, hence minimizing the risk of bias (Aromataris & Munn, 2020). Data extracted included authors, year, country, study title, study type, J o u r n a l P r e -p r o o f Journal Pre-proof description of participants, concept, context, methodology and key findings related to integration interventions and models (Table 1).

Synthesis
Inductive content analysis was used to synthesize data in the umbrella review. A three-step process of data reduction, grouping and formation of concepts related to the research question was adopted (Kyngäs et al. 2019). As a result of the analysis, 165 codes, 111 subcategories, 10 categories and 3 main categories were defined that answered the research question. The analysis process is presented in Figure 2.
Integrational strategies and models that supported transition and adaptation of culturally and linguistically diverse nurses were categorized into three domains, i.e., intra-organizational, sociocultural, and professional development. The first domain represented intra-organizational strategies and models that were tailored specifically to a particular organization's characteristics and needs. These were in the form of organization and management support and policies, workplace environment, diversity, employee treatment, and collegial and peer support. The second domain presented sociocultural strategies and models used to meet the social and cultural aspects of culturally and linguistically diverse nurses and enhance both group and individual relations.

Intra-organizational strategies and models
This domain was present in 22 reviews. Organization and management support and policies included fair recruitment policies that alleviated downward professional mobility (Montayre et al., 2018) and facilitated recruitment of more culturally and linguistically diverse nurses and promoted diversity in the workforce (Moyce et al., 2016). To protect the nurses against racism and discrimination within the workforce, healthcare organizations employed antiracism and antidiscrimination policies. Existence of these policies also allowed for managerial action in the defense of culturally and linguistically diverse nurses (Chun Tie et al., 2018). It was also noted that management support alleviated negative integration experiences and promoted efficient integration through adopting strategies and models that promoted professional and linguistic competence development (Covell et al., 2014).
Competence development through managers' support also increased job satisfaction amongst culturally and linguistically diverse nurses (Hyvärinen et al., 2017) and managers' ability to efficiently manage employee cultural diversity was found to advance equality within the nursing workforce (Nichols & Campbell, 2010). Organization supported managers through the provision of resources (Chuntie et al., 2018), support for conducive working environment (Schilgen et al., 2017) and the development of a diverse workforce (Javanmard et al., 2017). Where organizations' support was deemed sufficient, there was a noted reduction in deskilling and helped improve integration and retention in the workforce and organization (Davda et al., 2018).
Workplace environment, diversity and employee treatment were supported through acceptance of workplace cultural diversity and intergroup support (Chuntie et al., 2018, Javanmard et al., 2017. Conducive working terms, conditions, modalities, arrangements and conducive workplace atmosphere and environment improved workplace equality and fair treatment (Wellard & Stockhausen, 2010;Zhong et al., 2017;Hyvärinen et al., 2017;Pung & Goh, 2017;Javanmard et al., 2017;Viken et al., 2018;Ng Chok et al., 2018b;Lin et al., 2018). Healthcare environments with sufficient workforce and existent workplace support were experienced to positively affect culturally and linguistically diverse nursescompetence development and delivery of safe and quality care; this J o u r n a l P r e -p r o o f further affected nurses work wellbeing (Viken et al., 2018;Ng Chok et al., 2018a)

Sociocultural integration strategies and models
This domain was present in 23 reviews. Cultural training, learning and support involved cultural enhancement programs, training and education, and improved cultural competency (Schilgen et al., 2017;Ghazal et al., 2020;Ng Chok et al., 2018b). Sociocultural training (Abuliezi et al., 2021)

Professional development strategies and models
This domain was present in 26 reviews. Licensure and orientation to work for culturally and J o u r n a l P r e -p r o o f linguistically diverse nurses, focused on gaining rights of practice which was supported through organizational support for licensure, certification, and competence recognition (Kawi & Xu, 2009;Covell et al., 2016). Culturally and linguistically diverse nurses were provided with important certification and licensure information (Abuliezi et al., 2021;Ho & Chiang, 2015;Covell et al., 2014) beyond the provision of information, nurses were also allowed extra time for certification and licensure exams (Abuliezi et al., 2021). At the workplace, culturally and linguistically diverse nurses' efficient orientation to work occurred through personalized transition and orientation (Chun  (Konno, 2006;Davda et al., 2018;Primeau et al., 2014), and support for professional integration (Covell et al., 2016).
Organized orientation to work and scope of practice, and organizational supported and prolonged orientation helped culturally and linguistically diverse nurses attain cultural, professional, and linguistic competences. These strategies and models also allowed for the nurses to become self- Career and competence development were supported through recognition of prior competence (Davda et al., 2018;Primeau et al., 2014;Cruz et al., 2017;Covell et al., 2016;Ng Chok et al., 2018a;Ng Chok et al., 2018b;Covell et al., 2014;Nichols & Campbell, 2010;Wellard & Stockhausen, 2010). Culturally and linguistically diverse nurses were also supported towards the acquisition of competence and development of existing competence; this helped them integrate to the workforce and healthcare system (Ng Chok et al., 2018b). Healthcare organizations supported competence acquisition through competence training (Ho & Chiang, 2015), learning support (Zhong et al., 2017) and by offering opportunities for career development (Cruz et al., 2017). Labor and professional organizations also supported culturally and linguistically diverse nurse career development and integration, this strategy allowed for work satisfaction and helped alleviate attrition (Covell et al., 2016;Moyce et al., 2016).
Workplace mentorship and preceptorship, in the form of mentorship to work, helped culturally and linguistically diverse nurses adapt to the host country and organization, utilize their skills, gain professional and linguistic competences, and derive satisfaction from their work (Chun Tie et al., J o u r n a l P r e -p r o o f Primeau et al., 2014;Pung and Goh, 2017;Zizzo & Xu, 2009;Javanmard et al., 2017;Covell et al., 2014;Lin et al., 2018;Xu, 2007). Mentorship from colleagues with similar backgrounds was found to improve nurses' feeling of acceptance (Ghazal et al., 2020). When colleagues efficiently mentored and interacted with culturally and linguistically diverse nurses, there was a positive impact on adaptation and facilitated rapid integration into the organization (Kawi and Xu, 2009).

DISCUSSION
Successful organizational socialization of a newcomer relies on support from the organization, management, colleagues, and the individual (Sluss & Ashforth, 2007;Tomietto et al., 2015). Our results show that integration strategies and models of culturally and linguistically diverse nurses in healthcare organizations are structured within three dimensions: 1) intra-organizational, 2) sociocultural, and 3) professional development. We established that the strategies and models conform to the theory of organizational socialization by Van Maanen and Schein (1977). First, we found that the nature of nursing practice involves some level of risk to nurses, patients, and the organization. Thus, the three domains of strategies and models established in this study contain aspects of both formal and informal tactics aimed at competence development and risk mitigation.
For instance, structured language and communication learning as well as professional competence development for culturally and linguistically diverse nurses comprise a formal approach, whereas informal aspects may include, e.g., their socialization through unstructured peer and colleague support. Organizational socialization relies on collegial support and relationships (Sluss & Ashforth, 2007).
Our study highlights the crucial role that both native and peer colleagues play toward culturally and linguistically diverse nurseintegration through their formal and informal support. Formal collegial mentorship and preceptorship have been found to have a positive effect on nurse competence development. These findings corelate with two dimensions of organizational socialization reported by Taormina (2009), namely training and co-worker support, whereby skills and abilities to perform roles are acquired, social relations are established and acceptance by colleagues at the workplace is achieved. These aspects enable efficient integration. Establishing and supporting friendships both inside and outside of work promote a positive work environment and work wellbeing (Sluss & Ashforth, 2007). This was supported by the findings of this review, which showed that friendships both formal and informal have been used toward culturally and linguistically diverse nursesocialization, cultural interaction,andprofessional development.
Culturally and linguistically diverse nurses come from various cultural and linguistic backgrounds.
Their diversity and that of their native colleagues contribute to a multicultural workforce and organization. Cultural diversity has been found to have positive outcomes on an organization (Dols J o u r n a l P r e -p r o o f et al., 2019). In the established integrational strategies and models identified in our research, there was an expressed need for culturally and linguistically diverse nurses to behave or adjust in some way toward acculturating to the host culture, learning the language, gaining professional competence, and acquiring certain self-skills. Our findings also revealed interventions directed at host colleagues, albeit minimally and only concentrated on their cultural competence development (Javanmard et al., 2017) and building an open and welcoming attitude toward culturally and linguistically diverse nurses (Hyvärinen et al., 2017). However, it is still a crucial finding since cultural adjustment and integration is a two-way and organizational wide process (Taormina, 2009;Dols et al., 2019). Hence, ensuring native colleagues' cultural competence and attitude is essential for efficient nurse integration.
Culturally and linguistically diverse nurses' welfare is important towards their eventual integration into an organization (Primeau et al., 2021). This study established that provision of social amenities as an intervention enabled integration in an organization. Previous research has shown that organization provision of amenities, such as subsidized housing, helps nurses settle well into an organization and influences attrition (Alreshidi et al., 2021).
Organizational socialization theory by Taormina (2009) has shown that work satisfaction and retention in an organization is influenced by relationships between employees, knowledge of duties and prospects for career development. This study identified various interventions that have been used to support culturally and linguistically diverse competence development and career growth.
culturally and linguistically diverse nurses may have experience from other settings (Likupe, 2015) as well as special competences and qualities (Choi et al., 2019). Support for these experiences and competencies has been found to improve nurses' development, work satisfaction, feeling of being valued and eventual retention in an organization (Primeau et al., 2021).
Ensuring nurses' work satisfaction and wellbeing contributes to equal labor practices within an organization (Rahman et al., 2020). It has been documented that some culturally and linguistically diverse nurses experience unfair contractual terms, cadre and even conferred duties at work (Nortvedt et al., 2020). Beyond the organization, our results established that labor and professional organizations are important in supporting culturally and linguistically diverse nurses in their professional growth and eventual integration.
According to Taormina (2009), organizational socialization programs are efficient when they J o u r n a l P r e -p r o o f include four components, i.e., training, understanding of formal and informal rules of the context, co-worker support and future prospects. Our findings show that the first three components have been mostly used, i.e., culturally and linguistically diverse nurse training toward gaining certain competences, understanding of the organization and healthcare system of the host country, and collegial and peer support. Future prospects entail motivating aspects such as remuneration, bonuses, professional development and career advancement (Taormina, 2009). In the analyzed reviews, there were few findings indicating the popularity of future prospects as an integrational approach. This may relate to findings by Tomietto et al. (2015), who studied organizational socialization factors within the first two years of employment in relation to turnover intentions.
Training and formal understanding of policies and protocols within the organization were found to be more effective than informal understanding. The priorities of newcomer nurses also differ with time: initially there is a need to master the required competencies via training and later a need to access professional development opportunities within the organization.

Van Maanen and Schein's (1977) model of organizational socialization established that institutional
strategies are more effective than individualized strategies. This might relate to our finding that clear induction programs, mentorship, preceptorship, and cultural and language competence support strategies at the institutional level are beneficial towards culturally and linguistically diverse nurses' integration. However, we find that future prospects seem not to be given priority in the initial stages of integration even though we establish that this factor is likely to be important considering that renumeration in nursing is low compared to other professions and culturally and linguistically diverse nurses might face low career mobility and even low wages (Drennan & Ross, 2019) and some nurses experience unfair labor terms (Likupe, 2015) and downward career mobility (Nortvedt et al., 2020). Planning clear career paths and professional development opportunities at the institutional level may further motivate culturally and linguistically diverse nurses, support their career growth, satisfaction, and retention in the profession and organization.

Limitations and strengths
To the best of our knowledge, this is the first umbrella review conducted to establish the integration strategies and models used toward supporting transition and adaptation of culturally and linguistically diverse nurses into healthcare organizations. Joanna briggs institute guidelines for J o u r n a l P r e -p r o o f conducting reviews were adhered to, minimizing any probable bias, and the preferred reporting items for systematic reviews and meta-analyses checklist was used to ensure transparency of the report. The database search was limited to nurses and did not include other healthcare professionals with culturally and linguistically diverse background, which might have limited the results of this study. Even though there might be similar culturally and linguistically diverse healthcare workforce integrational experiences, each type of healthcare professional might have norms and interprofessional characteristics that are unique to their group and affect their integration differently. Another limitation is that we were not able to conduct a meta-analysis due to the narrative research reports in previous studies.

Efficient organization integration of culturally and linguistically diverse nurses is an essential
process that enables their onboarding and efficient practice within a host healthcare system. This study has established important strategies and models for creating and implementing integrational interventions. However, we find that most interventions have focus on addressing cultural diversity, linguistic challenges, and differences in the scope of practice. Further inquiry might be needed towards evaluating and understanding nurses' personal needs, goals, and future prospects and how this might strengthen the outcomes of the integration process. For instance, meeting some of the social needs of culturally and linguistically diverse nurses and competitive remuneration might help them settle in well at work and motivate them to integrate.
This study impacts the healthcare organizations towards allocating more material and human resources in support of the integration of culturally and linguistically diverse nurses. The nurse manager's role is pivotal towards ensuring a ward-level conducive work atmosphere, collegial relations, and competence development. At the workforce level, collegial and peer relations, support and cultural understanding are important aspects of integration. However, further research is needed to understand the effect of the current global nursing workforce shortage and its impact on culturally and linguistically diverse nurse integration process within various healthcare systems.
Finally, we suggest that reverse integration may be a useful approach to evaluate native nurses' competences and effects toward culturally and linguistically diverse integration so that interventions to support positive native nurse competences might enhance co-worker support even further. Interaction with local colleagues increases acceptance and adoption of the host culture, language and communication development, and intercultural understanding. It also positively affects the wellbeing of IQM&Ns and overall care outcomes. Cultural pluralism promotes a multicultural healthcare system Bridging and orientation J o u r n a l P r e -p r o o f programs targeted at IQM&Ns.

J o u r n a l P r e -p r o o f
Training the host workforce regarding multicultural working. Organizational sponsored social events help avert clashes of cultures and potential misunderstandings within culturally diverse workforces. Mentorship helps in skill development and reduces deskiling and marginalisation, hence promoting confidence and wellbeing of IQM&Ns. A friendly atmosphere and orientation to culture and practice promote the feeling of being treated well and avert dissapointments. Social justice and equality help IQM&Ns overcome marginalization, discrimination, racism and bullying, and promote fair access to opportunities and career development.
J o u r n a l P r e -p r o o f Peer support and social groups (support systems and informal networks) help in minimizing culture shock and stress. Transition programs help INs overcome language difficulties, cultural conflicts and practice differences. They also help toward offering support and orientation. Mentoring (buddy system) supports early adjustment and provides professional and emotional support. Assertiveness training helps INs maintain patient safety and advocacy. Logistical and emotional support (meet and greet, lodging and social amenities) enables INs to immediately access basic amenities in the host country. Registration and licencing assistance J o u r n a l P r e -p r o o f Xu, 2007 J o u r n a l P r e -p r o o f