Impact of immigration-specific stress on safety attitudes: a national cross-sectional study on overseas qualified nurses in Japan

Abstract

Background

Many countries have addressed the global issue of nursing shortage by recruiting overseas nurses who are also qualified in the host country. Nevertheless, such nurses may encounter various obstacles in their personal and professional lives in the host country, leading to apprehensions about their perceptions of workplace safety in healthcare organisations.

Objective

This study investigated the current state of immigration-specific stress among overseas qualified nurses (OQNs) working in Japan and its impact on safety attitudes.

Settings

Invitation letters with a Quick Response (QR) code for a survey were sent to 119 hospitals across Japan that accepted OQNs as per the Ministry of Health, Labour and Welfare. Additionally, the survey QR code was shared with OQN-specific social media groups.

Participants

The inclusion criteria were being born and having received basic nursing education outside Japan, passing the Japanese national nursing examination, and current employment in the Japanese healthcare organisations. Valid responses were received from 214 OQNs.

Methods

Data were collected via an online survey, including the Demands of Immigration Scale and Safety Attitudes Questionnaire-Short Form (SAQ-SF) to measure stress and safety attitudes evaluation, respectively. Spearman’s correlation analysis and a generalised linear model were used to analyse the relationship between immigration-specific stress and safety attitudes as perceived by OQNs.

Results

The findings showed that various safety attitude dimensions were significantly impacted by stressors such as ‘Not at home’, ‘Occupation’ and ‘Discrimination’. Notably, ‘Occupation’ disadvantages perceived by OQNs significantly affected all the safety attitude dimensions, such as ‘Teamwork climate’ (B=−5.69, [−7.78, –3.60], p<0.001), ‘Job satisfaction’ (B=−9.38, [−12.32, –6.44], p<0.001) and ‘Stress recognition’ (B=5.86, [3.17, 8.54], p<0.001).

Conclusions

The findings underscore the significance of implementing effective strategies such as enhancing the sense of belonging, providing better career advancement prospects and opportunities and addressing workplace discrimination to improve safety attitudes among OQNs. These interventions are crucial for enhancing patient safety in Japan.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This is the first cross-sectional survey to elucidate the impact of immigration-specific stress on the quality and safety concerns among overseas qualified nurses (OQNs) in healthcare organisations.

• Data collection efforts encompassing OQNs across Japan using various reliable methods enhance the diversity and robustness of our research findings.

• The cross-sectional study design limits its ability to establish causal relationships.

• A significant proportion of the participants in our study were Chinese, potentially limiting the generalisability of our findings to OQNs of other nationalities working in Japan.

Background

The growing disparity between the global supply and demand for nurses has become a significant concern.¹ The shortage of nurses not only poses risks to patient safety and compromises the quality of healthcare services but also has detrimental effects on hospital budgets.2,5 It is suggested that there may be a shortfall of 12.9 million skilled healthcare professionals by 2035.⁶ In response, the WHO introduced the Global Code of Practice on the International Recruitment of Health Personnel in 2010, emphasising the potential benefits of global migration of health workers in enhancing and fortifying health systems.⁷ Many countries have turned to the recruitment of Overseas Qualified Nurses (OQNs) who are now working in the host country after receiving nursing qualification. According to the Organisation for Economic Cooperation and Development, there has been a 20% increase in the number of foreign-trained nurses over 5 years spanning from 2011 to 2016.⁸ OQNs primarily choose to work abroad to improve their standards of living, secure higher salaries, enhance their working conditions and access superior professional growth opportunities.^{9 10}

Japan’s medical sector is experiencing a growing nursing shortage exacerbated by a confluence of factors such as a diminishing birth rate, an ageing population and heightened burnout.¹¹ The Ministry of Health, Labour and Welfare has warned that even with a steady increase in the number of nurses and other staff in the future, the shortage could reach 130 000 by 2025.¹² The demand for nursing personnel is expected to further increase by 2040.¹³ Under the Economic Partnership Agreement initiated in 2008, the Japanese government has been actively recruiting healthcare workers, including nurses and nurse assistants, from Indonesia, the Philippines and Vietnam.¹⁴ Furthermore, Japan has recruited OQNs from other countries, including China, Korea and Mongolia.¹⁵ According to the Japanese Immigration Service Agency, as of June 2023, 2564 foreign nationals were in Japan under the ‘medical services’ visa; however, the specific number of individuals qualified in nursing is unclear, since this category also encompasses doctors and other related professions.¹⁶

The recruitment of OQNs involves several challenges. In addition to the daily stressors inherent in their work environment, they must cope with the immigration-specific stress experienced in a foreign country.¹⁷ Pung and Goh conducted a literature review highlighting the unequal treatment encountered by OQNs, including language barriers, discrimination, marginalisation and obstacles to personal and professional development.¹⁸ Studies have shown that immigration-specific stressors negatively affect their job satisfaction.¹⁷ Additionally, immigration-specific stress, such as discrimination, language barriers and limited career development opportunities, exacerbate work-related stress.¹⁹ Decreased job satisfaction and increased work stress may further influence their safety attitudes.²⁰ Patient safety attitude refers to the shared attitudes, beliefs, values and assumptions that underlie how people perceive and act on safety issues within their organisation.²¹ Widely accepted safety attitude dimensions in healthcare include teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management and working conditions.²² Positive safety attitudes have been identified as key factors in enhancing patient safety.²³ Nurses with positive safety attitudes generally receive higher assessments in patient care.²⁴ Therefore, we hypothesised that the immigration-related stress experienced by OQNs could adversely affect their safety attitudes, ultimately compromising patient safety.

Given the paramount importance of patient safety in healthcare settings, as highlighted by the European Commission in 2008, inadequate patient safety is a critical public health concern.²⁵ The Organization for Economic Cooperation and Development reported that approximately 1 in every 10 patients experiences harm in healthcare organisations, and unsafe care contributes to over 3 million deaths annually.²⁶ Considering this global issue, a greater focus on medical quality and safety is crucial for the future of Japan.²⁷ Therefore, ensuring safety should be the fundamental principle behind the OQNs’ credentialing processes.²⁸ However, the recruitment of OQNs does not adequately address the quality and safety issues in healthcare organisations. Meanwhile, there is diversity in nursing practices; thus, OQNs should be supported to strengthen their patient-safety competencies.^{3 29 30} Owing to the well-established link between safety attitudes and patient outcomes,^{31 32} maintaining positive safety attitudes could serve as an effective measure.

However, a notable gap remains in the literature regarding the potential impact of immigration-specific stress on patient safety attitudes among OQNs. Therefore, our study seeks to bridge this gap by providing an in-depth investigation of the immigration-specific stress experienced by OQNs in Japan and determining the impact of stress on safety attitudes in healthcare systems. The novel findings obtained in this study are imperative for elucidating the relationship between OQNs’ immigration challenges and their safety attitudes, thereby contributing to the development of support mechanisms that enhance patient safety and care quality.

Methods

Study design

The present study used a cross-sectional survey methodology to elucidate the experiences of OQNs employed in Japan. Data were collected between September 2023 and January 2024.

Participants and recruitment

The participants were required to meet specific inclusion criteria, including being born and having received basic nursing education outside of Japan, passing the Japanese National Nursing Examination, currently being employed as a registered nurse in a Japanese healthcare organisation and possessing the ability to autonomously respond to a Japanese questionnaire. The survey was conducted online among participants recruited using the snowball sampling method. The procedure was as follows. (1) We distributed an online flyer with the survey Uniform Resource Locator to WeChat groups of Chinese OQNs employed in Japanese hospitals to request their participation. (2) Using the publicly available list of hospitals that employed OQNs from the Ministry of Health, Labour and Welfare, we sent invitation letters to 119 hospitals using the Quick Response (QR) code for the survey. (3) The survey QR code was shared among OQN-specific groups on social media platforms, such as Facebook and TikTok, which are dedicated to OQNs. (4) Participants were encouraged to share the survey QR code with other OQNs they knew were working in the Japanese healthcare organisations to broaden the study’s reach.

Measures

The Demands of Immigration (DI) scale was adapted to assess the immigration-specific stress experienced by OQNs.³³ Additionally, the Safety Attitudes Questionnaire-Short Form (SAQ-SF) was used to measure the participants’ safety attitudes.²² The researchers independently translated the English scales into Japanese. After completing the translation process, the researchers discussed and collaborated with three additional translators to refine the initial draft. Subsequently, two translators with expertise in English and Japanese and extensive translation experience performed the back-translation. After verifying the accuracy of the questionnaires, 10 OQNs employed in Japan were invited to participate in a preliminary test to determine unclear or difficult-to-understand expressions in the translated version. Minor modifications were made to the Japanese version of the questionnaires based on their feedback. These modifications primarily targeted sections that were difficult to understand or had unclear phrases to enhance clarity and ensure that participants could easily comprehend and respond to the questions.

Immigration-specific stress experienced by OQNs

The DI scale is designed to assess the sources of distress experienced by immigrants. It includes 23 items under 6 dimensions: ‘Loss’, ‘Not at home’, ‘Occupation’, ‘Novelty’, ‘Language’ and ‘Discrimination’. The items are rated on a six-point Likert scale (1=very low, 6=very high). The average score is calculated for each dimension, with a higher score indicating a higher level of stress experienced during the reference period.³³

In this study, participants were asked to reflect on immigration-specific stress in their personal lives and workplaces in Japan over the past 3 months. Participants were particularly asked to reflect on their lives in Japan when responding to items about ‘Loss’ and ‘Not at home’. ‘Loss’ refers to the longing for and preoccupation with people, places and things in the homeland. ‘Not at home’ refers to feeling like a foreigner or stranger in one’s surroundings. Concerning the items on ‘Occupation’, ‘Novelty’, ‘Language’ and ‘Discrimination’, participants were required to recall their experiences in their work environment in Japan. ‘Occupation’ pertains to lowered work status, difficulty in finding an acceptable job and limited capacity for adjusting or adapting to work. ‘Language’ reflects the perception of not being understood or having an inadequate command over the Japanese language as per patients or colleagues in the workplace. ‘Discrimination’ refers to not deserving the same rights as those born in the host country. ‘Novelty’ refers to unfamiliarity and feelings of newness due to a lack of understanding of workplace social norms and information deficits regarding simple and complex tasks. Two items about ‘Novelty’ were modified to enhance the participants’ ability to accurately visualise their workplace scenarios. Specifically, the items ‘I must learn how certain tasks are handled, such as renting an apartment’ was revised to ‘I must learn how certain work tasks are handled’, and ‘I have to depend on other people to show or teach me how things are done’ was revised to ‘I have to depend on other people to show or teach me how work tasks are done’. Please refer to online supplemental appendix A for the questionnaire.

SAQ-SF

The SAQ-SF comprises items across six patient safety dimensions: ‘Teamwork climate’, ‘Safety climate’, ‘Job satisfaction’, ‘Stress recognition’, ‘Perceptions of management’ and ‘Working conditions’. These items are rated on a five-point Likert scale ranging from ‘1: Strongly Disagree’ to ‘5: Strongly Agree’. An additional response option, ‘Not applicable’, was provided to accommodate participants for whom certain items were not relevant. Online supplemental appendix B provides the details of this questionnaire. The safety attitude score is calculated for each domain as follows: (mean value of item scores within the domain – 1) × 25. The total score ranged from 0 to 100, with a higher score indicating a high perception of safety attitude.³⁴

Statistical analysis

Confirmatory factor analysis (CFA) was performed to assess the validity of the DI and SAQ-SF. Cronbach’s alpha was used to measure internal reliability. Cronbach’s alpha of 0.70 or higher is considered a good reliability level³⁵ while a value of 0.60 or above is considered an acceptable level.^{36 37}

For each dimension of the DI and SAQ-SF, the Kolmogorov–Smirnov test was applied and the data distributions were determined to be non-normal. Therefore, nonparametric tests, such as the Mann–Whitney and the Kruskal–Wallis tests, were used to investigate the differences in immigration-specific stress and safety attitudes by sociodemographic factors of sex, age (20s or ≥30s), nationality (east Asia or southeast Asia), educational level (vocational school/junior college, university or higher), residential condition in Japan (living alone or living with others), qualification years in Japan (<3, 3–5 or >5 years) and nursing experience in the current setting (<3, 3–5 or >5 years).

Spearman’s rho test was used to identify correlations between immigration-specific stress and the safety attitudes of OQNs. Furthermore, a generalised linear model was used to investigate the influence of immigration-specific stress (independent variable) on safety attitudes (dependent variable). Sociodemographic factors were set as the adjusted variables in the model. There was no multicollinearity because the variance inflation factors for all variables were below 1.18.³⁸ Since all the questions were mandatory, there was no missing data. All data were analysed using SPSS V.27.0 and Mplus V.8.3, and the statistical significance was set at p<0.05.

Ethical consideration

Before initiating this study, participants were clearly informed about the research objectives. They were assured about the maintenance of confidentiality, emphasising that the collected data were anonymous and would only be used for research purposes. Additionally, they were informed that their participation was entirely voluntary and that nonparticipation would have no adverse consequences. The survey was administered after obtaining their consent. The Ethics Board of the Institute of Science Tokyo approved this study (No. 2023083).

Results

Sociodemographic characteristics

About 245 OQNs employed in Japan completed the survey. We applied the instructed response items and LongString Index to screen inattentive participants. Subsequently, 214 valid responses were included in the final analysis. The majority of the OQNs in the sample were female (n=186, 86.9%), in their 30s (n=120, 56.1%), Chinese (n=168, 78.5%), had graduated from university (n=129, 60.3%) and lived alone (n=124, 58.0%). Table 1 displays the characteristics of the survey sample.

Table 1. Sociodemographic characteristics of survey participants (n=214).

Attribute	N (%)
Gender
Female	186 (86.9)
Male	28 (13.1)
Age (years)
20–29	91 (42.5)
30–39	120 (56.1)
≥40	3 (1.4)
Nationality
China	168 (78.5)
Vietnam	19 (9.0)
Philippines	17 (7.9)
Indonesia	8 (3.7)
Myanmar	2 (0.9)
Educational level
Vocational school/junior college	68 (31.8)
University (bachelor’s degree)	129 (60.3)
Graduate school (master’s or doctorate degree)	17 (7.9)
Residential condition in Japan
Living alone	124 (58.0)
Living with friends	15 (7.0)
Living with family	70 (32.7)
Others	5 (2.3)
Qualification years in Japan
<3	60 (28.0)
3–5	85 (39.8)
>5	69 (32.2)
Experience in the current setting (years)
<3	110 (51.4)
3–5	72 (33.6)
>5	32 (15.0)

Reliability and validity

Cronbach’s alphas for all the six dimensions of the immigration-specific stress (DI) scale were in good (>0.70) or acceptable (>0.60) levels: ‘Loss’ (α=0.66), ‘Not at home’ (0.84), ‘Occupation’ (0.74), ‘Novelty’ (0.67), ‘Language’ (0.67) and ‘Discrimination’ (0.79). The CFA results suggested an acceptable fit for the survey sample,^{35 36} as evidenced by the following goodness-of-fit indices: comparative fit index (CFI)=0.90, Tucker–Lewis index (TLI)=0.89 and root mean square error of approximation (RMSEA)=0.07.

Concerning the safety attitudes scale (SAQ-SF), the internal reliability of all the six dimensions was good: ‘Teamwork climate’ (α=0.72), ‘Safety climate’ (0.78), ‘Job satisfaction’ (0.89), ‘Stress recognition’ (0.71), ‘Perceptions of management’ (0.80) and ‘Working conditions’ (0.80). Similarly, the CFA results indicate an acceptable model fit (CFI=0.86, TLI=0.85 and RMSEA=0.07).

OQNs’ immigration-specific stress status

OQNs in Japan perceived moderate levels of immigration-specific stress. Out of the six dimensions, the ‘Not at home’ feeling (mean=3.52) and the stress of ‘Novelty’ at the workplace (4.03) were relatively higher. Additionally, we investigated the differences in immigration-specific stress due to sociodemographic factors. Except for gender, significant differences were observed for all sociodemographic factors (table 2). For instance, participants who were younger (in their 20s), lived alone and had less work experience in their current setting perceived higher stress levels. Specifically, as presented in table 2, the years of qualification in Japan was the most noteworthy sociodemographic variable, and significant differences were observed for all dimensions across the three groups. Since no significant difference was observed between the two groups (<3 and 3–5 years), it was inferred that participants with more than 5 years of Japanese qualification perceived less stress such as on ‘Not at home’ (3.68, 3.80 and 3.04; p<0.001), ‘Occupation’ (3.16, 3.24 and 2.70; p=0.001), ‘Language’ (3.62, 3.34 and 2.91; p<0.001) and ‘Discrimination’ (2.99, 2.92 and 2.52; p=0.003) dimensions.

Table 2. Overseas qualified nurses’ immigration-specific stress by sociodemographic characteristics.

Attribute	1. Loss	2. Not at home	3. Occupation	4. Novelty	5. Language	6. Discrimination
Age
20s (n=91)	3.07 (0.90)	3.95 (1.11)	3.17 (0.82)	4.24 (0.75)	3.40 (0.92)	2.92 (0.83)
≥30s (n=123)	2.84 (0.87)	3.21 (1.07)	2.95 (0.92)	3.88 (0.80)	3.19 (0.98)	2.73 (0.89)
p1	0.111	<0.001	0.115	0.002	0.080	0.093
Nationality
East Asia (n=168)	2.86 (0.89)	3.63 (1.14)	3.01 (0.88)	4.03 (0.80)	3.17 (0.94)	2.76 (0.84)
Southeast Asia (n=46)	3.18 (0.85)	3.14 (1.09)	3.17 (0.89)	4.05 (0.83)	3.67 (0.95)	3.00 (0.97)
p2	0.030	0.009	0.275	0.731	0.002	0.162
Educational level
Vocational school/junior college (n=68)	3.06 (0.94)	3.68 (1.22)	3.05 (0.91)	4.19 (0.75)	3.44 (0.85)	2.93 (0.82)
University or higher (n=146)	2.88 (0.86)	3.45 (1.10)	3.04 (0.87)	3.96 (0.81)	3.20 (1.00)	2.76 (0.89)
p3	0.204	0.228	0.881	0.044	0.103	0.167
Residential condition in Japan
Alone (n=124)	3.00 (0.91)	3.75 (1.16)	3.13 (0.89)	4.18 (0.77)	3.35 (0.98)	2.89 (0.90)
With others (n=90)	2.84 (0.85)	3.20 (1.05)	2.93 (0.86)	3.83 (0.80)	3.18 (0.93)	2.71 (0.82)
p4	0.165	<0.001	0.120	0.003	0.171	0.207
Qualification years in Japan
<3 (n=60)	3.23 (0.82)	3.68 (1.13)	3.16 (0.83)	4.19 (0.73)	3.62 (0.80)	2.99 (0.86)
3–5 (n=85)	2.97 (0.90)	3.80 (1.24)	3.24 (0.85)	4.12 (0.76)	3.34 (0.98)	2.92 (0.84)
>5 (n=69)	2.64 (0.85)	3.04 (0.86)	2.70 (0.87)	3.79 (0.86)	2.91 (0.94)	2.52 (0.85)
p5	0.001	<0.001	0.001	0.018	<0.001	0.003
Experience in the current setting (years)
<3 (n=110)	3.12 (0.88)	3.62 (1.11)	3.10 (0.90)	4.16 (0.72)	3.34 (0.96)	2.81 (0.86)
3–5 (n=72)	2.74 (0.79)	3.59 (1.27)	3.10 (0.88)	4.01 (0.89)	3.27 (0.97)	2.92 (0.88)
>5 (n=32)	2.73 (1.01)	3.03 (0.82)	2.74 (0.82)	3.63 (0.74)	3.07 (0.93)	2.58 (0.86)
p6	0.015	0.052	0.178	0.003	0.314	0.179
Total (n=214)	2.93 (0.89)	3.52 (1.14)	3.04 (0.88)	4.03 (0.80)	3.28 (0.96)	2.81 (0.87)

Mean (SD), ranging from 1.00 to 6.00.

p1–p6: Significance level between groups using the Mann–Whitney test (for two groups) or Kruskal–Wallis test (for three groups).

OQNs’ safety attitudes status

Participants reported moderate levels of safety attitudes, with scores of the six dimensions ranging between 60 and 75. Similarly, we investigated the differences in safety attitudes according to the sociodemographic factors. No significant differences were observed in sex, residential conditions or work experience in the current setting. Table 3 illustrates the safety attitudes towards OQNs according to age, nationality, educational level and years of qualification in Japan. Specifically, those who were older (≥30s), Southeast Asian (Vietnam, Philippines, Indonesia and Myanmar) and had a shorter (<3 years) or longer (>5 years) Japanese qualification demonstrated more positive safety attitudes.

Table 3. Overseas qualified nurses’ safety attitudes by sociodemographic characteristics.

Attribute	1. Teamwork climate	2. Safety climate	3. Job satisfaction	4. Stress recognition	5. Perceptions of management	6. Working conditions
Age (years)
20s (n=91)	71.05 (15.83)	68.32 (15.60)	58.26 (23.41)	73.40 (17.02)	63.94 (22.00)	59.25 (22.46)
≥30s (n=123)	76.61 (13.47)	72.85 (14.17)	67.17 (18.63)	72.85 (19.99)	67.10 (18.92)	66.80 (19.40)
p1	0.019	0.037	0.008	0.749	0.482	0.030
Nationality
East Asia (n=168)	72.43 (14.78)	69.00 (15.13)	61.53 (21.71)	75.63 (15.97)	64.10 (21.51)	60.79 (21.79)
Southeast Asia (n=46)	80.89 (12.69)	77.95 (11.89)	70.16 (17.88)	63.77 (24.57)	71.82 (13.58)	73.82 (14.05)
p2	0.001	<0.001	0.011	0.005	0.059	<0.001
Educational level
Vocational school/junior college (n=68)	74.27 (14.01)	70.86 (15.12)	59.74 (21.44)	69.76 (18.87)	61.76 (20.19)	63.27 (21.66)
University or higher (n=146)	74.24 (15.12)	70.96 (14.90)	65.08 (20.96)	74.63 (18.55)	67.62 (20.14)	63.74 (20.83)
p3	0.968	0.472	0.122	0.045	0.056	0.861
Qualification years in Japan
<3 (n=60)	73.32 (15.77)	72.87 (13.62)	59.48 (25.06)	67.88 (20.05)	67.06 (19.46)	66.46 (20.78)
3–5 (n=85)	73.83 (14.51)	67.40 (16.12)	62.42 (19.37)	74.78 (18.83)	64.56 (21.64)	58.33 (22.11)
>5 (n=69)	75.57 (14.22)	73.58 (13.80)	67.97 (19.10)	75.51 (16.75)	66.10 (19.49)	67.57 (18.73)
p4	0.83	0.037	0.165	0.073	0.938	0.021
Total (n=214)	74.25 (14.74)	70.93 (14.93)	63.38 (21.21)	73.08 (18.74)	65.76 (20.30)	63.59 (21.04)

Mean (SD), ranging from 0.00 to 100.00.

p1–p4: Significance level between groups using the Mann–Whitney test (for two groups) or Kruskal–Wallis test (for three groups).

Correlations between immigration-specific stress and safety attitudes

Table 4 presents the results of the relationship between immigration-specific stress and safety attitudes of OQNs using Spearman’s correlation analysis. Except ‘Loss’, all the stress dimensions were observed to have significant correlations with one or more safety attitudes dimensions, notably for stress related to ‘Not at home’, ‘Occupation’ and ‘Discrimination’. When OQNs perceived higher ‘Occupation’ disadvantages, their attitudes were significantly lower for ‘Teamwork climate’ (ρ=−0.315, p<0.001), ‘Safety climate’ (ρ=−0.207, p<0.01), ‘Job satisfaction’ (ρ=−0.374, p<0.001), ‘Perceptions of management’ (ρ=−0.212, p<0.01) and ‘Working conditions’ (ρ=−0.263, p<0.001) but higher for ‘Stress recognition’ (ρ=0.255, p<0.001).

Table 4. Correlations between overseas qualified nurses’ immigration-specific stress and their safety attitudes.

	Safety attitudes
	1. Teamwork climate	2. Safety climate	3. Job satisfaction	4. Stress recognition	5. Perceptions of management	6. Working conditions
Immigration-specific stress
1. Loss	−0.102	0.043	−0.105	0.132	−0.063	−0.003
2. Not at home	−0.251*	−0.175†	−0.312*	0.227‡	−0.206‡	−0.232‡
3. Occupation	−0.315*	−0.207‡	−0.374*	0.255*	−0.212‡	−0.263*
4. Novelty	0.046	0.148†	−0.052	0.293*	0.132	−0.08
5. Language	−0.117	−0.067	−0.182‡	0.123	0.006	0.019
6. Discrimination	−0.303*	−0.220‡	−0.338*	0.103	−0.229‡	−0.172†

^*Correlation is significant at the 0.001 level (two-tailed).

^†Correlation is significant at the 0.05 level (two-tailed).

^‡Correlation is significant at the 0.01 level (two-tailed).

Impact of immigration-specific stress on safety attitudes

Figure 1 shows the results of the generalised linear model. All stress dimensions significantly influenced one or more safety attitude dimensions. Notably, OQNs’ perceived disadvantages in ‘Occupation’ and ‘Discrimination’ in the workplace significantly influenced all the safety attitude dimensions. Particularly, negative impact was identified on ‘Teamwork climate’ (B=−5.69, [−7.78, –3.60], p<0.001; B=−5.57, [−7.70, –3.44], p<0.001) and ‘Job satisfaction’ (B=−9.38, [−12.32, –6.44], p<0.001; B=−7.69, [−10.76, –4.62], p<0.001). However, a positive effect was observed on ‘Stress recognition’ in all dimensions of immigration-specific stress.

Figure 1. Influence of overseas qualified nurses’ immigration-specific stress on their safety attitudes by generalised linear models.

Discussion

Negative impact of perceived ‘Occupation’ disadvantages

The present study found that the perception of ‘Occupation’ disadvantages among OQNs was associated with all the safety attitude dimensions. Many OQNs choose to work in foreign countries because of the need for further education and better career opportunities.³⁹ However, they find that the reality often falls short of expectations due to a lack of career advancement.⁴⁰ Consistent with our findings, Pung et al’s study among OQNs in Singapore demonstrated that occupational disadvantages affected their job satisfaction, which is a critical dimension of safety attitudes.¹⁷ Our study extends these insights by establishing that low occupational stress due to low perceptions of occupational disadvantages could foster more positive views of teamwork climate, safety climate and management perceptions. It is likely that when OQNs perceive equitable career development opportunities, they can integrate more effectively into healthcare teams, collaborate more efficiently with colleagues and demonstrate better adherence to safety protocols and regulations.⁴¹

Negative impact of ‘Discrimination’ in the workplace

This study further observed that ‘Discrimination’ experienced by OQNs in the workplace negatively influenced their perceptions of all the safety attitudes dimensions. Encountering discrimination at work, such as a lack of respect and recognition from colleagues, language bias and disrespect from patients, constitutes an additional stressor for OQNs.⁴² This induces psychological and physical stress⁴³ and undermines the teamwork climate, which is a key dimension of safety attitudes. Discrimination hampers effective communication and collaboration in the healthcare team, which are vital for sustaining a strong safety culture. Several studies have established that OQNs face discrimination from colleagues as well as patients in their workplaces.44,47 When OQNs feel marginalised, they may be less likely to integrate into healthcare teams, which potentially reduces their ability to contribute to patient safety. These findings align with Abu-AlRub’s study, which demonstrated that social support from coworkers increases job performance and decreases the reported level of job stress.⁴⁸

Other negative impacts of immigration-specific stress

Our study revealed that OQNs’ safety attitudes are adversely affected by their feeling of being ‘Not at home’. Viken et al conducted a comprehensive review of qualitative research and identified ‘Being an outsider at work’ as a factor that compromises patient safety.³⁰ A sense of belonging is characterised by the feeling of being ‘At home’ in a place.⁴⁹ Moreover, the emergence of a sense of belonging necessitates the recognition of one’s value, identity and respect.^{50 51} Developing a sense of belonging in the host country may positively influence OQNs’ job satisfaction and their perceptions of the teamwork climate.

Moreover, Hooks suggested that language plays a pivotal role in fostering the feeling of being ‘At home’. This is consistent with our findings that language-related stress is a significant factor influencing ‘Teamwork climate’ and ‘Job satisfaction’.⁵² This aligns with the findings that language not only impacts job satisfaction among OQNs¹⁵ but also enhances their sense of belonging.⁵³ Language barriers are a challenge for OQNs, and their importance cannot be overlooked because they are directly associated with patient safety, satisfaction and quality of care.^{54 55}

Positive impact on safety attitudes dimension of ‘Stress recognition’

Notably, we found that immigration-specific stress among OQNs had a positive effect on their ‘Stress recognition’. As immigration-related stress intensifies, OQNs may develop a heightened ability to identify stressors and challenges in their work environment. This may suggest a coping mechanism through which OQNs become more attuned to workplace pressures as a means of self-preservation in high-stress environments. However, this finding may indicate a deeper concern. According to Taylor, stress recognition, as measured by the Safety Attitudes Questionnaire, is a separate and distinct measure of organisational buy-in and is not directly reflective of the safety climate.⁵⁶ Instead, it may indicate a state of fatigue, which can serve as a precursor to burnout.⁵⁷ Over time, OQNs may compromise their ability to maintain positive safety attitudes. In addition, decreased personal well-being could compromise their ability to maintain positive safety behaviours in the workplace.^{58 59}

Stress-level differences by sociodemographic factors

It was observed that OQNs who lived alone experienced significantly higher levels of immigration-specific stress. Many OQNs experience loneliness and isolation when living away from their families. However, having a family in the host country, particularly with children, significantly enhances their integration and socialisation within the community.⁶⁰ Significant support from friends and families in their countries of origin plays a crucial role in mitigating immigration-specific stress.⁶¹

Furthermore, our findings highlight the critical role of professional experience in the Japanese healthcare system in buffering immigration-specific stress, suggesting that the accumulation of work experience is instrumental in OQNs’ adaptation to the work and living environment in the host country. As observed by Yang et al, OQNs in Japan with over 6 years of nursing experience were better at formulating and coordinating interpersonal relationships and self-development.⁶² The adaptation process of OQNs is both cumulative and incremental, contributing to improved life satisfaction during their stay in the host country.⁶³

Implications for practice and management in the Japanese healthcare system

The findings of this study highlight the critical need for support from healthcare managers, policymakers and nursing practitioners in host countries to optimise the safety attitudes towards OQNs. Therefore, creating an inclusive, supportive and culturally adaptive healthcare environment is of paramount importance.

Concerning the workplace needs of OQNs in overseas healthcare systems, healthcare organisations should implement comprehensive strategies to support their adaptation and integration. This includes removing barriers to promotion by establishing a fair and transparent promotion system, ensuring equal promotion opportunities for expatriates and local nurses and providing professional training and continuing education to support their skill upgradation. Moreover, well-designed career paths, involvement in research projects and career consultations should be provided.⁶⁴

Healthcare organisations should adopt measures to conduct regular cultural diversity and antidiscrimination training to raise awareness of cultural sensitivity among healthcare staff, ensure that local nurses understand and respect their colleagues from different cultural backgrounds and promote nonbiased interactions in the workplace.⁶⁵ Additionally, clear antidiscrimination policies and complaint mechanisms should be established to ensure that all staff members know how to report incidents of discrimination and that these reports are handled fairly.

Concerning the needs of OQNs living under foreign conditions, establishing a support system from the initial phase to address their unique challenges, including living arrangements and social integration, plays a vital role in alleviating immigration-specific stress. Strategies include enhancing their sense of belonging, facilitating their language acquisition, supporting the relocation of their families to the host country, arranging for co-national colleagues to work in the same healthcare organisation and providing shared housing assistance. Additionally, organising activities by region or healthcare institution during national holidays or festivals in the home countries is recommended.

Limitations

This study has several limitations. First, the study had a small sample size. The most recent data suggest that approximately 2564 individuals hold ‘medical services’ visa in Japan.¹⁶ However, this figure comprises a broad range of healthcare professionals. The lack of updated and accurate data on the total number of OQNs in Japan posed a challenge in calculating the minimum sample size for this study. Second, our sample predominantly comprised Chinese nurses (78.5%) employed in Japan, which may not fully represent the diverse experiences of all OQNs in the country. However, according to the Japanese Immigration Service Agency, Chinese nationals account for approximately 70% of the individuals holding ‘medical services’ visa in Japan¹⁶; their representation in our study is very close to this percentage. Third, the cross-sectional design restricts our ability to discern temporal changes in the relationship between OQNs’ stress and safety attitudes. Fourth, although the internal reliabilities of three immigration-specific stress dimensions are acceptable, improvements are needed to achieve good levels.

Future studies should address these limitations by including a more diverse range of OQNs and adopting a longitudinal design to better understand the causal dynamics of stress and safety attitudes over time, thereby enhancing the generalisability of the findings.

Conclusions

The findings revealed that OQNs’ immigration-specific stress directly affected their safety attitudes in healthcare organisations. Specifically, ‘Not at home’ feeling, perceived ‘Occupation’ disadvantages and ‘Discrimination’ in the workplace emerged as primary factors associated with their safety attitudes, especially attitudes of ‘Teamwork climate’, ‘Job satisfaction’ and ‘Stress recognition’. Moreover, those who were living alone and had obtained nursing qualifications for up to 5 years reported higher stress levels. These insights are crucial for healthcare administrators and society as they underscore the significance of supporting OQNs in enhancing patient safety and the overall quality of the healthcare system. Therefore, it is crucial for social communities and healthcare organisations to provide targeted support to alleviate immigration-specific stress experienced by OQNs. This can be achieved by reducing their demand for immigration, improving their quality of life, ensuring positive safety attitudes, mitigating the risk of medical errors and fostering a more secure healthcare environment.

Data availability statement

Data are available upon reasonable request.