Culturally and linguistically diverse registered nurses' experiences of integration into nursing workforce – A qualitative descriptive study

Title: Culturally and linguistically diverse registered nurses’ experiences of integration into nursing workforce – A qualitative descriptive


Introduction
The global healthcare workforce shortage has been estimated to significantly increase for nurses in the coming years (Calenda et al., 2019).This shortage has been described as critical and more dire than what is expected for other professions.The factors that are contributing to the nursing workforce shortage include an ageing population, increased demand for care, ageing nursing staff, and a high number of qualified nurses who are not working in healthcare (Calenda et al., 2019).
To address this nursing shortage, educational and healthcare systems have promoted the recruitment of both local immigrant and native nurse graduates along with internationally educated nurses (Dumont and Socha-Dietrich, 2021).Due to the changing labor markets and competitiveness for healthcare workers, foreign nurse recruitment to Finland has expanded from the Nordic region to further international destinations such as the Philippines (Näre and Cleland Silva, 2021).This phenomenon, along with a growing number of locally educated culturally and linguistically diverse (CALD) graduates (Mikkonen et al., 2016), has increased the cultural and linguistic diversity within the Finnish nursing workforce (Calenda et al., 2019).
This study focuses on CALD nurses in Finland, with cultural and linguistic diversity referring to an individual who has a country of birth, language, ethnicity, and/or cultural background that differs from the dominant group in society (Pham et al., 2021).Although CALD nurses help the current workforce meet societal demands and healthcare, extensive evidence has shown that these nurses undergo various challenges while integrating into work life (Buttigieg et al., 2018).These challenges have been found to impact their confidence, social life, and work satisfaction (Brunton et al., 2019), as well as impede their smooth integration into the workforce (Zanjani et al., 2021).In previous studies, organizational integration has been defined as the process through which CALD nurses overcome intra-organizational challenges and socialize to an organization (Ramji and Etowa, 2018).
Organizational socialization theories such as the institutional versus the individualized integration tactics by Van Maanen and Schein (1977), Feldman (1976) anticipatory socialization model and Buchanan (1974) three-stage early career model, define the process through which a newcomer assumes a new role, learns, adapts, and integrates to the organization (Aderiye, 2022).Organizational socialization defines integration as a long-term process; however initial stages of integration have been found to exert significant importance towards newcomers' sense of belonging, integration, and long-term intention to stay in an organization (Aderiye, 2022;Kamau et al., 2022).
This study defines CALD nurse integration as a process which includes competence recognition and support, positive cultural relationships in the workplace, organizational support, acceptance of diversity, and the promotion of work wellbeing.Good organizational integration has been shown to positively impact CALD nurse care delivery and work satisfaction, as well as reduce attrition (Khalili et al., 2015).
Due to cultural and linguistic diversity within the nursing workforce, management of diversity is a two-way process that affects both employees and the organization (Ramji and Etowa, 2018;Buttigieg et al., 2018).Processes related to cultural belonging, communication, and practical adaptation (Covell and Rolle Sands, 2021) can improve the relationships between nurses, healthcare organizations, and society to positively affect the social and work life of CALD nurses (Calenda et al., 2019), as well the work environment for the entire nursing workforce (Roth et al., 2021).
This study aimed to describe the integrational experiences of CALD nurses working in Finnish primary and tertiary healthcare settings.Previous research has predominantly focused on examining CALD nursing students' experiences of the clinical environment, learning, and mentorship (Mikkonen et al., 2020), whereas more descriptions of how CALD nurses experience their shift to practical work are needed.

Design
The presented research represents a qualitative descriptive study that employed content analysis (Kyngäs et al., 2019).The naturalistic paradigm was utilized to describe participants' experiences and views in their natural environment (Kyngäs et al., 2019).This approach was chosen to better understand CALD nurses' lived experiences of their integration into the Finnish healthcare setting.

Aim and research question
The research aim was to describe CALD registered nurses' experiences of their integration into the Finnish nursing workforce.The research question was: what kind of experiences do CALD registered nurses have of their integration into the Finnish nursing workforce?

Participants
A total of 24 CALD registered nurses participated in the study.The inclusion criteria were: being a registered nurse with a CALD background, and working within the Finnish primary or tertiary healthcare system.Participants were recruited through snowball sampling, i.e., eligible participants were first contacted through email, and those who were successfully recruited suggested further potential participants.Of the participating registered nurses, 17 were female and 7 were male.The participants represented 11 different nationalities, more precisely Kenya (n = 5), Zimbabwe (n = 1), Nigeria (n = 2), Philippines (n = 8), Ghana (n = 1), China (n = 1), Vietnam (n = 1), Hungary (n = 2), Russia (n = 1), Ukraine (n = 1) and Romania (n = 1).The participants had lived in Finland for an average of seven years and their average age was 34, ranging from 24 to 50 years.The average working experience among the participants was seven years, more precisely 1 to 5 years (n = 10), 6 to 10 (n = 11) and 11 to 15 (n = 3).Their self-evaluation of Finnish language level proficiency was at the beginner level (n = 1), intermediate (n = 17), and advanced (n = 6).

Data collection
Data were collected in the spring of 2021 from 24 study participants, who had been recruited from Finnish healthcare organizations located in the North Ostrobothnia, Central, and Metropolitan regions of Finland.The first and second rounds of interviews were used to pilot test the quality of the interview themes and questions.These interview responses were later added to the study data set because no significant weaknesses in the interview themes were found.Online, semi-structured interviews were conducted and recorded as video and audio.The semistructured interviews were built on three general themes found in the umbrella review, including intraorganizational, sociocultural and professional development themes relating to CALD nurses' integration into healthcare settings (Kamau et al., 2022).The interview included open questions by allowing participants to share their experiences relating to those three topics.A total of three interviews were conducted in the Finnish language, with the remaining 21 conducted in English.Collected data were transcribed verbatim.Data saturation was reached after 24 interviews; hence no further participant recruitment was carried out.

Data analysis
Interview data were transcribed verbatim into 369 pages of raw data, which were later analyzed using inductive content analysis (Kyngäs et al., 2019).The philosophical background of critical realism guided this study (Fletcher, 2017).The philosophical belief in critical realism is that individuals' experiences are captured through their senses, emotions, linguistic and cultural aspects (Lauzier-Jobin and Houle, 2021), and everyone has unique experiences (Fletcher, 2017;Lauzier-Jobin and Houle, 2021).Hence, critical realism helped us understand the phenomena through the exploration of multiple CALD nurse experiences.The inductive analysis process started with the researcher reading through the transcribed text; during this process, a total of 596 meaning units in sentence form connected to the research question were established.The meaning units were then arranged through data coding, where 359 codes were identified.Following data abstraction, the codes were analyzed and categorized based on similarities; a total of 21 subcategories were established during categorization; these were labelled according to the research question.The sub-categories were then further arranged into eight categories that described CALD nurse experiences of integration into healthcare (see Table 1).

Ethics
Research permission was granted by the higher education institution conducting the study.A written research invitation letter that contained information regarding the data management plan, research purpose and aims, anonymity, confidentiality, and voluntary participation was sent to participants.Written consent was sought from participants prior to every interview; this ensured voluntary participation and participant autonomy (Stang, 2015).In the consent form, participants were informed of their right to withdraw their consent without any consequences (Declaration of Helsinki, 2013).The study burden (Doody and Noonan, 2016) was minimized by ensuring that the interviews lasted between 30 and 60 min, and that they were held at a time and date that was convenient for each participant.Special codes were used to conceal any data that could be used to identify participants.Prior to and after the interviews, participants had a chance to ask questions related to the research.

Results
The categories relevant to CALD nurses' experiences of integration into the Finnish healthcare system that were identified through content analysis will now be presented in more detail.Othering and belonging describes a process which CALD nurses must undergo before they can become part of the nursing team.This process included experiences of disregard, mistrust, and misperceptions.The CALD nurses used the term disregard when discussing instances in which they felt that Finnish nurses looked down upon them, their competency was judged, or they had to prove themselves.When there were challenges with the Finnish language, the CALD nurses noted a palpable feeling of disregard which had a negative effect on teamwork and relationships.

"Because you have a language barrier. Communication is very important. So, if you don't really communicate well they will always look down upon you"
(Participant 003) Mistrust in CALD nurses' competence, qualifications and/or skills limited their work as they were perceived to not have adequate knowledge for successfully completing nursing tasks.The participants also noted that native nurses questioned their clinical competence in the case that a CALD nurse's Finnish language skills were not polished.Due to this mistrust, CALD nurses felt that their efforts and achievements went unnoticed even if they made positive contributions at work.The nurses felt as though they had to prove their honesty, sincerity, and competency.

"It's very hard in the beginning, but when you gain trust, and they know that you are honest in what you do and you are sincere in what you want, then a relationship can be built"
(Participant 018) The CALD nurses reported being perceived in various ways by their colleagues; for example, they were sometimes perceived as hard workers who were willing to learn.The CALD nurses felt that initial misperceptions were based on stereotypes.There were instances in which the CALD nurses felt that they came second to natives; these perceptions of hierarchy at the healthcare organizations were described as negative reception and treatment at the workplace.
"Many of them have actually told me 'do you know I thought so and so about foreigners or even about people from Africa'.But when they get to know you in person, most of the time the perception changes and most of the time it changes from a negative to a rather positive perception just because they know you personally and you have interacted" (Participant 007) Language challenges and skill development presented as Finnish language challenges, language courses, and language learning.Finnish language competence was related to smooth communication and the satisfactory completion of tasks.Low Finnish language competence contributed to diminished wellbeing, isolation, negative social experiences, and feelings of incompetence.Insufficient Finnish language proficiency limited access to opportunities, diverted the focus from positive personal and professional qualities, led to discrimination and retaliation from native colleagues, limited career development, and increased nurses' intentions to leave.

"I don't think I have plans to continue being a nurse in this country because of these challenges because I don't feel challenged enough as a nurse because I feel like I have really strong capabilities, I am able to really do much, but the language will always limit me"
(Participant 012) The CALD nurses felt that the best place for learning the Finnish language was at the workplace and in a pair in which the other member's Finnish language proficiency was better.The use of slow and easy to understand spoken language was also reported to help with comprehension and learning.Moreover, interactions with relatives and patients facilitated language learning.The participants reported that it was common that no language courses were offered; furthermore, when Finnish courses were provided, they did not include much content, were poorly scheduled, inconsiderate of CALD nurses' work-life balance, and were not available during working hours.
"They didn't even arrange a Finnish for foreigner's language course for us, it was our own conscious effort that 'hey we need to go to attend summer classes for Finnish language' to develop our language skills" (Participant 020) Work orientation included CALD nurses' experiences of their induction into work, mentorship, and feelings of abandonment and selfreliance.Induction into work was experienced to be a process through which CALD nurses familiarized themselves with their duties and the work community, as well as gained confidence for operating efficiently within the clinical context.In many cases, the induction period was perceived as short, while certain nurses were given roles that they had not held prior to the induction period.A longer induction period was positively associated with work orientation, competence, confidence, and ability to adapt.A slow, gradual induction, when coupled with collegial support, promoted a smooth integration to work and reduced work-related errors.
"I do not instantly know everything when I start working, you know, for example, when I came to work of course I do not know how to admit patients, and these types of tasks were hard for me, along with releasing patients from the hospital" (Participant 013) Mentorship describes the process through which native colleagues and peers support a smooth and efficient integration to work and the organization, development of competences, and work learning.The participants felt that mentorship was efficient when it included a peer mentor who was able to communicate clearly, guide the CALD nurses sufficiently well in comprehensive Finnish, and were overall sociable colleagues.The mentorship period was longer than the normal induction and tailored to individual needs.
"You need the mentoring phase, and I think that the mentoring phase could be longer depending on the individual needs of specific people, because some people learn fast and for some it takes some time" (Participant 002) Abandonment and self-reliance were observed in instances when the induction period and/or mentorship were short or non-existent; during these instances, the CALD nurses experienced that they were left to learn and develop their skills on their own.Aspects attributed to CALD nurses' personal biases, prejudices, and perceptions towards colleagues and work led to experiences of abandonment.CALD nurses felt that selfreliance required them to put more effort into their work, stay openminded, adopt a positive attitude, be courageous, and initiate collegial relationships.The CALD nurses who had faced abandonment felt that they had to prove themselves by putting in more work hours, showing that they had certain qualities that native nurses lacked, and leave a positive impression at the workplace.
"Yeah, two weeks of induction into the workplace and that is about it, everybody else also gets that.So, it's up to you to develop your skills and learn more from the environment" (Participant 005) Relationships covered both collegial relationships and interactions with patients and their family members.Collegial relations described nurse-nurse relationships at the workplace and were significant to CALD nurses' integration.A mutual relationship between nurses led to candid conversations, trust in the CALD nurse's competence, acceptance, and recognition.Friendly collegial interactions were important to the creation of workplace friendships, alleviation of isolation, and gaining of respect.Moreover, collegial relationships at the workplace promoted efficient communication, the perception of fair treatment, strong teamwork, efficient problem-solving, integration, as well as the feeling of being welcome, appreciated, and understood.Some CALD nurses felt that their presence within the workforce was seen as opportunistic behavior; in these cases, native nurses lacked open-mindedness during interactions.
"Only if nurses here were a bit welcoming, a bit open minded, and you know, just not looking as every international nurse, I would say, who comes here as an opportunist" (Participant 017) Concerning relationships with patients and their family members, the CALD nurses felt that in some instances the patients were receptive, friendly, and thankful in other cases, the patients mimicked how the CALD nurse spoke, asked not to be provided with care and preferred to receive care from a native nurse.According to the participants, family members' preference for native nurses was related to mistrust in the CALD nurses' professional and language competences coupled with racial and cultural background differences.A patient's open-mindedness allowed nurses to efficiently carry out their duties and enabled more interactive communication.Positive patient feedback encouraged CALD nurses and increased their confidence.Moreover, some older patients felt that the presence of a CALD nurse provided a positive foreign experience.
"I feel that some patients, older people, maybe haven't had any experience with foreigners, although these residents are already old, they are open minded" (Participant 018) "Most of the patients here, they are interested in foreigners.So even some of them would be willing to talk in English" (Participant 012) Racial/ethnic experiences presented as discrimination, racism, and cultural insensitivity.In cases of discrimination, the CALD nurses felt as though they were ignored by native nurses and received unequal workplace treatment in terms of work allocation and terms of service.The CALD nurses also reported discrimination from patients, i.e., the patients were not highly social with the CALD nurses.Inaction by managers when discrimination was reported was also experienced to be managerial discrimination.This form of discrimination affected multiple aspects of work life and interaction within the work environment.The CALD nurses felt that enhanced interactions between the nurses and patients, along with acceptance and equality at the workplace, were vital to alleviating discrimination.

"The biggest challenge for example, in my workplace is discrimination and the problem is that the discrimination is coming from the manager"
(Participant 009) The CALD nurses reported experiencing racism from colleagues, patients, family, and other staff.In many cases it was explicit, as the racial sentiments were directly voiced and directed at the CALD nurses.The racial and ethnic sentiments concerned the CALD nurses' food preferences, skin color and linguistic competence.Nurses often experienced that they had to remain firm and report the incident of racism.However, the inaction of management towards racism was perceived as a challenge to changing the prejudice among native nurses.Racism was experienced to negatively affect the work environment and lead to discrimination at the workplace.

"I mean I'm a dark-skinned person, I'm a black person, so working mostly with my colleagues who probably have white skin you always hear one or two things being said behind your back. Of course, they probably just dismiss you and call you the N-word so to speak"
(Participant 011) Diversity among the nursing workforce and a multicultural workplace supported two-way mutual cultural learning, teamwork and prevented racial experiences.Furthermore, the CALD nurses reported that they had more knowledge of Finnish culture than of the Finnish language, but there was noticeable variety in the responses.Collegial cultural interactions helped build collegial cultural support, as well as respect for cultural values, cultural interest, cultural openness, and cultural acceptance.Workplace diversity helped CALD nurses settle in at the workplace, benefit from peer support, and feel that the organization appreciated multiculturalism.Organizational cultural support was experienced when there were multicultural teams and workplace employee pairing.Cultural accommodation, multicultural educational training, and cultural orientation were reported to potentially help both interpersonal and professional cultural learning, respect, and tolerance for other cultures, the alleviation of prejudiced cultural perceptions, and cultural accessibility.
"Finns describe their experiences in a direct way, so you do that also.Maybe I don't know much about different cultures, but this is different to the culture Asians grow up in" (Participant 001) Intra-organizational support presented as nurse manager support and organizational support.The nurse manager role and support from nurse managers were important to building connections between CALD and native nurses, conflict resolution, competence development and continuous education.Nurse managers were also an important part of mentorship and clinical learning, with their support, guidance, patience, and understanding perceived as critical to enhancing professional development.Changes in management culture, diversity, a supportive attitude, low managerial discrimination, and feedback made managers more responsive to personal and professional needs.Organizational support was viewed as important to integration and competence development.In some instances, the CALD nurses perceived a lack of organizational support for social support activities, acceptance of CALD nurses, provision of special support, and the retention of employees.The CALD nurses reported experiencing the same organizational expectations as native nurses.However, as CALD nurses were at a different starting point, these expectations were perceived as a burden that made it difficult to integrate and increased their intentions to leave the healthcare profession.
"If I can talk about the organization, the managers have a large, a very large, role to play" (Participant 007) Professional competence development involved deskilling, career development, and workplace competence development.According to the CALD nurses' responses, deskilling assumed two forms, i.e., nurses were either given practical nurse roles orin extreme caseswere employed as nurse assistants.Hence, their expertise and competence was undervalued, and some reported even being hired and perceived as low cadre nursing professionals.Professional competence development occurred through courses organized at the workplace and work life seminars, which improved competence through the teaching of work skills.Nevertheless, the CALD nurses reported that the healthcare organizations needed to provide better access to organized teaching and strongly support continuous education.
"It undervalues our nursing skills to work as just a nursing assistant in a nursing home or any healthcare system" (Participant 020) When discussing the work environment, CALD nurses presented experiences of workplace bullying and a conducive work environment.Bullying involved various instances of negative behavior towards the CALD nurses by the native nurses.Some native colleagues reported instances of bullying to the management as a means of collegial defense.Moreover, the CALD nurses reported that there was sometimes a clear lack of action to eliminate bullying when it was reported.

"It gives the native nurses an upper hand to bully the foreign nurses because they see that nothing is being done no matter how many times somebody goes to complain"
(Participant 009) A conducive work environment was defined as an environment in which nurses felt welcomed, respected, and appreciated.A positive work atmosphere was essential to building a welcoming workplace, which was described as conducive for both the nurses and patients.
"A good workplace atmosphere is number one key to having a good integration because you will be feeling comfortable" (Participant 024) The participants felt that organizing social gatherings outside of work, teamwork at the workplace, and a high degree of receptiveness from the native nurses promoted a positive work atmosphere, with these factors also reported to build confidence, improve the work environment, and facilitate integration into the workforce.

Discussion
The presented research aimed to describe CALD registered nurses' experiences of their integration into the Finnish nursing workforce.The findings revealed instances of racism and bullying even in an era where there have been global efforts to eradicate such practices.Racial ethnic and linguistic prejudices within the workforce contribute to CALD nurse segregation and lead to perceptions of their incompetence, which subsequently lower CALD nurses' confidence, self-belief, work satisfaction, and ability to deliver quality care (Mapedzahama et al., 2012).
The perception that CALD nurses are hardworking and willing to learn established in this study agrees with what was reported by Mapedzahama et al. (2012), i.e., CALD nurses do not accept racial labels, perceptions, and prejudices, but will rather try to prove that they possess the expected qualities and abilities.Javanmard et al. (2017) established that racism towards CALD nurses commonly manifested as bullying or the rejection of care by a patient, both of which led to humiliation, discrimination, isolation, and decreased professional identity.These findings can be compared with what the CALD nurses in this study experienced within the Finnish context, i.e., native nurses had the upper hand to bully, inaction by the management against racism, and patients' preference for native nurses.Some of the CALD nurses participating in this study also felt that their racial and/or ethnic backgrounds resulted in the denial of certain opportunities.Kawi and Xu (2009) established that in most cases racial/ethnic aspects are a catalyst for lowered professional mobility among CALD nurses, receiving undesired tasks, unfair shift management, and unequal pay.
The results presented in this paper establish the need for two-way mutual cultural learning across Finnish healthcare organizations as the participating CALD nurses felt that they were expected to adapt to the dominant culture.Kawi and Xu (2009) stated that a mutual understanding of cultures between CALD and native nurses can help alleviate conflicts, perceptions, stereotypes, and the feeling of cultural displacement.Organizational support for multiculturalism and cultural understanding was previously cited as an effective way to promote cultural sensitivity and knowledge (Javanmard et al., 2017).
A CALD nurse's foreign language proficiency has been found to make it challenging for them to communicate with colleagues, patients, and families (Mikkonen et al., 2016).The participating CALD nurses reported experiencing Finnish language challenges yet did not receive sufficient support for learning the language through the organization in which they were employed.Previous research by Balante et al. (2021) reported that CALD professionals experience both cultural and linguistic communication challenges, as well as that the expression of culture in communication is a causative factor for intercultural communication conflicts.For instance, the interviews analyzed in this study revealed that CALD nurses experience low levels of interaction with some of their Finnish colleagues or patients; these interactions were, at times, perceived negatively, but might well have only represented an innocent cultural communication difference.Lum et al. (2016) established that the low clinical linguistic proficiency of CALD nurses could potentially compromise the quality of delivered care.Our findings, demonstrate that CALD nurses are aware and cautious about patient safety and quality care and feel that language proficiency would improve the delivery of care.However, CALD nurses should interact with native colleagues to gain the cultural competence necessary to grasping other important aspects of language such as slang, accents, and expressions (Javanmard et al., 2017).Although the participating CALD nurses experienced problems with the Finnish language, they were multicultural and multilingual, which could positively S. Kamau et al. influence the healthcare system.Covell et al. (2016) established that patient care and the healthcare system can benefit from the diverse cultural backgrounds and languages of CALD nurses if they appreciate this multiculturalism and convey it to the patients.
The presented results established that the healthcare organization and nurse managers have a crucial role in CALD nurses' integration, retention, career development, and access to opportunities.Organizational support and equity are helpful towards raising CALD nurses to a similar level as native nurses, while nurse managers facilitate the career development and competence of CALD employees (Ramji and Etowa, 2018;Kamau et al., 2022) In this study, most of the CALD participants did not perceive organizational equity; for instance, each employee had the same orientation period irrespective of their background, mentorship was not provided, language learning was not particularly supported, organizational policies (such as anti-racism) were lacking, and some specific cultural needs of CALD employees were unmet.
This study also provided evidence of deskilling at the workplace, i.e., CALD nurses were made nurse assistants or given practical nurse roles even when they were already registered nurses.Salami et al. (2018) stated that the phenomenon of downward occupational mobility not only leads to non-recognition of CALD skills, but also to loss of the skills over time.When asked about their intentions to leave the profession, the CALD participants mentioned dissatisfaction in their roles, stress due to low organizational and collegial support, linguistic challenges, and unmet career aspirations.Taormina (1997) shared a model of organizational socialization in which continuous competence development, an understanding of individual tasks and roles, support from colleagues, and eventual job satisfaction and career development are critical to retention within the organization.

Strengths and limitations
This research had certain inherent strengths and weaknesses.The main strength of the research was that the participants represented various nationalities; thus, they provided diverse and rich descriptions of their experiences.However, we could not establish whether the experiences were linked to the participant's cultural background, as this type of analysis would require a more extensive data set as well as the segregation of these data into specific groups.Nursing is a femaledominated profession, and this was also seen in the characteristics of the study participants.The analyzed results were not differentiated based on female and male nurses' experiences, years lived in Finland, or the level of language proficiency.The trustworthiness of the research was enhanced by strict adherence to the standards for reporting qualitative research (SRQR) (O'Brien et al., 2014).

Conclusions
A culturally diverse healthcare organization will equally prioritize diversity and acceptance within the workforce, patients, and care quality.Integrating CALD nurses into a culturally diverse organization is a continuous process that does not start and end at employment.These healthcare organizations need to make significant conscious efforts to ensure a conducive and receptive work community and environment.
At the organizational policy level, anti-discrimination, anti-racism, and multicultural policies need to be clearly defined and disseminated across the workforce.A healthcare organization may need to use strategies such as organizational equity to meet the specific needs of the CALD nursing workforce; this can include supporting their language and cultural learning, tailored induction, mentorship, and preceptorship.
Nurse managers have an important role in fostering CALD nurses' competence development, defending employees in cases of racism, resolving ward-level disputes, ensuring fair work practices, and serving as a link to top management.A healthcare organization can leverage CALD nurses' unique competences, for instance, multilingualism and specialized expertise, to provide effective, high-quality care as well as efficiently integrate the nurses into the workforce.However, these types of actions can only occur if fair labor practices are in place and the organization has clear policies that discourage deskilling and any form of discrimination.

Declaration of competing interest
Given their role as Editor on this journal, Professor Kristina Mikkonen had no involvement in the peer-review of this article and has no access to information regarding its peer-review.Full responsibility for the editorial process for this article was delegated to an independent Editor.
The authors have no conflict of interests to declare.

Table 1
Participants' experiences identified through the content analysis of interview responses.