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Labour Market Integration of Refugee Health Professionals in Germany: Challenges and

Strategies

Sidra Khan-G€okkaya* and Mike M€osko*

ABSTRACT

Refugee health professionals are a vulnerable group in a host country’s labour market as they experience several barriers on their path to labour market integration. This study aims to iden- tify challenges refugee health professionals and their supervisors experience at their work- places and strategies they have developed to overcome these barriers. Semi-structured interviews were conducted with refugee health professionals who have been living in Germany for an average of four years and their supervisors (n = 24). The interviews were analysed using qualitative content analysis. Nine themes were identified: (1) recognition of qualifica- tions, (2) language competencies, (3) differing healthcare systems, (4) working culture, (5) challenges with patients, (6) challenges with team members, (7) emotional challenges, (8) dis- crimination and (9) exploitation. Results indicate the need to implement structural changes in order to improve the labour market experiences of refugee health professionals.

BACKGROUND

The global healthcare workforce is facing skilled labour shortage. The World Health Organization (WHO) estimates a global shortage of 14.5 million health professionals by 2030 (World Health Orga- nization, 2006). The European Commission estimates a shortfall of 1 million health workers in Europe by 2020 (European Commission, 2012), and employment agencies in Germany predict a nationwide lack of health professionals (Bundesagentur f€ur Arbeit, 2018). In order to address this shortage, nearly all European countries depend on the recruitment of foreign-trained health professionals (Organisation for Economic Co-operation and Development (OECD), 2017). Another strategy that has been imple- mented by the German government to address this shortage is the so-called “activation of domestic potential” (Bundesregierung, 2018). With that, the German government aims to address those groups that have difficult access to the labour market, such as refugees in order to improve their employability and use them to fill shortages (Bundesregierung, 2018). As the number of refugees in Germany has increased since 2015, the German government has recognized the need to address their labour market integration (Bundesregierung, 2016). However, refugees belong to a particularly vulnerable group in the labour market facing unemployment or underemployment (Tanay et al., 2016).

University Medical Center Hamburg-Eppendorf, Hamburg, This paper is part of a special issue on the “Labour Market Integration of Highly Skilled Refugees in Sweden, Ger- many and the Netherlands”

doi: 10.1111/imig.12752

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf

of International Organization for Migration International Migration

ISSN 0020-7985

This is an open access article under the terms of the Crea tive Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non- commercial and no modifications or adaptations are made.

The barriers and difficulties that refugees face in the context of their labour market integration are multidimensional and manifold. First, their access to the labour market in Germany is restricted and depends on their legal status and the likelihood of getting a residency permit which in turn depends on the country of origin (Bundesministerium f€ur Arbeit und Soziales, 2019). In Germany, there is a ban on employment for all refugees within the first three months. After three months, their access to the labour market is dependent on the individual residency status. As of the fourth month, refugees need work permission from the foreign authority office in Germany and the local employment agencies in order to work (Bundesministerium f€ur Arbeit und Soziales, 2019). Their access to language courses depends on their legal status and the likelihood of receiving a residence permit (Bundesministerium f€ur Arbeit und Soziales, 2019). Moreover, participating in job-related language courses is described as challenging either due to long waiting times or course availability (United Nations High Commissioner for Refugees-Organisation for Economic Co-operation and Development (UNHCR-OECD), 2016). Second, refugee health professionals need to go through a difficult and long recognition process (K€ortek, 2015; Desiderio, 2016) which is described as the starting point for permanent downward mobility (Hawthorne, 2002). Moreover, refugees may not be able to provide identity documents (Bucken-Knapp et al., 2019) or official documents about their education (Bloch, 2008) due to the flight which impedes the recognition process. Third, a lack of information about career pathways (Cohn et al., 2006), such as knowledge about job search strategies (Willott and Stevenson, 2013) and unfamiliarity with the healthcare system of the host country (Ong et al., 2004), are reported barriers. Fourth, due to their flight they may have had a break in their professional career and/or experienced the loss of their professional status (Willott and Stevenson, 2013) which is related to the loss of professional identity (Peisker and Tilbury, 2003). It may also result in deskilling (Stewart, 2003), loss of self-confidence (Willott and Steven- son, 2013), high levels of frustration (Mozetic, 2018) and negative psychological impacts (Cohn et al., 2006). Additionally, the lack of recognition of their previously gained experiences leads to a feeling of being disadvantaged compared to locally trained team members (Mozetic, 2018) which might be intensified by the experience of multiple forms of discrimination (Jirovsky et al., 2015) and exclusion (Bloch, 2008). Studies in Germany have also focused on the working experiences of migrant physicians and

international nurses from within the European Union as well as from non-European countries. They report similar barriers as the above-mentioned. A study on migrant physicians (Klingler and Marck- mann, 2016) describes difficulties in three fields. The first field refers to the organization of health- care institutions and other institutional difficulties such as insufficient support or being assigned to tasks below their level of expertise. Moreover, difficult career advancement opportunities and unfair treatment of migrant physicians were mentioned as institutional difficulties. The second field relates to experienced difficulties with own competencies such as language competencies and knowledge about the healthcare system. The third field relates to difficulties in interpersonal relations and inter- actions such as inadequate treatment of patients and co-workers. In this context, a study on the workplace integration of internationally recruited nurses in Germany points out that conflicts often arise between migrated nurses and locally trained team members. These conflicts arise because locally trained team members either hold back or do not comprehensively share key information in order to organize their work. Thus, the incorporation of migrated nurses into daily work routine is impeded and the potential for conflicts in everyday work is increased (P€utz et al., 2019). These studies illustrate that international healthcare professionals and refugee healthcare professionals experience similar barriers at their workplaces. However, refugees were forced to flee by the cir- cumstances of their home countries (Yarris and Casta~neda, 2015), whereas internationally recruited health professionals may be considered as voluntary migrants. This distinction between refugees and voluntary migrants has effects on the barriers they experience. While voluntary migrants were most likely able to prepare for their migration, refugees had to flee under extreme conditions (Jack- son et al., 2004). Stressors of the flight, the loss of family members, traumatic experiences and the

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of International Organization for Migration

uncertainty about their residency permit (Carlsson and Sonne, 2018) may also influence their pre- requisites to work. Rather, in comparison to other highly qualified migrants, highly qualified refu- gees are more likely to stay in jobs they are overqualified for which mainly relates to the fact that documentation of their education is missing (Tanay et al., 2016). Moreover, some other barriers, such as housing, health, absence of networks or childcare, may indirectly influence employment outcomes (OECD/UNHCR, 2018). The European Parliament recommends qualification programmes to prepare refugees for work

and strengthen their employability (Konle-Seidl, 2016). These recommendations comprise individu- ally tailored programmes to the specific needs of refugees. Amongst others, it is recommended to provide (occupational specific) language courses combined with working opportunities, skills assessment, mentoring and career advice. For highly skilled refugees, it is especially recommended to increase availability of on the job trainings, recognize existing qualifications and offer vocational training. However, in order to implement tailored programmes that match the host countries’ legal and social requirements it is essential to identify and analyse the barriers refugee health profession- als face when entering the labour market. While the legal situation of refugees and their access to the labour market in Germany is documented through policy papers (European Commission, 2012; Platonova and Urso, 2012; Konle-Seidl, 2016; Tanay et al., 2016; UNHCR-OECD, 2016; OECD, 2017; United Nations Department of Economic and Social Affairs Population Division, 2017; UNHCR, 2017; Bundesministerium f€ur Arbeit und Soziales, 2019), little attention has been paid to the challenges they face in everyday working life and their own perspective and strategies. Thus, in this study, refugee health professionals and their supervisors across Germany were interviewed about the challenges they faced at their workplaces as workplaces are a “key site of sociocultural incorporation” (van Riemsdijk et al., 2016). Moreover, this paper advances this field by giving rec- ommendations for healthcare providers and organizations based on the experiences of refugee health professionals and their supervisors in order to implement changes on structural levels and improve the working environment. These changes refer to establishing supporting structures as well as measures of diversity management and anti-discrimination.

METHODS

The reporting of methods is in accordance with the consolidated criteria for reporting qualitative research (COREQ) guidelines (Tong et al., 2007).

Researcher characteristics

Qualitative research depends on the personal qualities of the researcher and the theoretical sensitiv- ity that the researcher brings to a research (Strauss and Corbin, 1990). Thus, it is important to reflect on the researcher’s characteristics and its impact on the interview situation. All interviews were conducted in person by the first author, female, person of color, PhD student of the Depart- ment of Medical Psychology at the University Medical Center Hamburg-Eppendorf. The first author is trained in cultural studies, international migration and intercultural studies and has several years of training in conducting qualitative studies. For transparency reasons, participants were informed that the study was part of a PhD study.

Recruitment

Major educational organizations and projects for the labour market integration of refugee health professionals (RHPs) across Germany were identified through internet research. The organizations

Labour market: Refugee health professionals 3

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of International Organization for Migration

(n = 15) were contacted and informed about the study. Their consent was obtained. Three of the major organizations agreed to participate in the study. Participants were divided into RHPs and supervisors as the refugees’ self-perception about their experiences might differ from the supervi- sors’ perception. Since the group of RHPs comprises different professions, we decided on subdivid- ing the stratum of RHPs into two groups: physicians and other health professions. In terms of data saturation, it is recommended to conduct six to twelve interviews per stratum (Guest et al., 2006). Thus, 24 interviews were conducted in three major cities in Germany (Hamburg, Hannover and Frankfurt). All three organizations provided persons that matched the inclusion criteria with infor- mation on this study and either arranged appointments or provided participants with the research- ers’ contact information. Inclusion criteria for participants referred to the following aspects: Target group1.:

• Refugees (regardless of their residency status and form of protection) who have obtained a qualification in a health profession in their home country or a country other than Germany;

• Supervisors that were responsible for the integration of refugee health professionals, their supervision or support

Language competencies:

• Required minimum level of German language competencies on the European Reference level of A2-B12.

Working experiences in Germany:

• RHPs must have had contact with the German healthcare system with a minimum duration of one month – be it a steady job, an internship or job shadowing

• Supervisors had to work in jobs with close contact with refugee health professionals regard- less of their hierarchical status. They must have had supervised RHPs at their ward or as an external supervisor

Context:

• RHPs and supervisors in all healthcare institutions comprising primary, secondary and ter- tiary care were included

Providers were informed about the inclusion criteria and selected fitting participants. All inter- views were conducted in German. In one case the inclusion criteria did not match as the participant was a student of the educational organization without sufficient working experience. Participants that matched the inclusion criteria were approached via phone followed by an invitation to live interviews. Participants received two consent forms: one for their participation in the study and one for their consent to audio recording. The consent form and the study information were orally explained prior to the interview.

Data collection

The interview guide was developed based on literature focused on the daily work experiences of refugee health professionals using the SPSS3. approach by Helfferich (2009). The interview guide was sent to experts in the field of migration research to be critically reviewed. Based on this review, the authors discussed and adapted the interview guide. Finally, the interview guide was

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of International Organization for Migration

piloted with two migrant nurses that resulted in the specification of some questions. The interview guide was structured into six main themes:

(1) General experiences while working in a hospital (2) Experiences with team members and supervisors (3) Experiences with patients (4) Experiences with the working culture (5) Experiences with the healthcare system (6) Suggestions for improvement

In each interview, the same semi-structured guide was used. After the interview was finished and the audio recorder was switched off, demographic data were retrieved. The interviews lasted from 00:18 to 00:55 min with a median range of 00:40. Some (n = 4) interviews were transcribed by a student researcher but the majority (n = 20) of the interviews were transcribed verbatim by a pro- fessional agency. All transcripts were proofread by the first author.

Data analysis

The interviews were analysed using content analysis (Mayring, 2015). The first author coded all interviews by means of a computer-based coding programme (MAXQDA, version 10). Deductive codes were derived from the interview guide but as an explorative approach was preferred more inductive categories were derived from the material. Code memos were created for all codes includ- ing a description of the code and typical quotes. For the purpose of quality assurance, a research assistant coded a random selection of one-quarter of all interviews. Differences in coding were dis- cussed until a consensus was reached that led to the creation of some new sub codes and a revision of the category system. Results were presented and discussed with other experts in an interdisci- plinary research colloquium to ensure comprehensibility and intersubjective reproducibility. The revised system was then crosschecked by the main author in a second round of coding taking all interviews into consideration.

Description of sample

Sixteen RHPs and 8 supervisors participated in the study. Two interviews were conducted via tele- phone due to reduced mobility of the participants. The sample is described in Table 1.

RESULTS

In general, nine major challenges could be identified which either RHPs or supervisors described as relevant: (1) the recognition of professional qualifications, (2) language competencies, (3) different healthcare systems, (4) working culture, (5) challenges with patients, (6) challenges with team members, (7) emotional challenges, (8) discrimination, (9) exploitation. Table 2 provides an over- view of the identified fields and their specifications.

Recognition4. of professional qualifications

Both supervisors and RHPs pointed out the challenges they faced with regard to the recognition process of their professional qualifications. Supervisors especially emphasized the difficulties regarding the recognition process. They criticized the long waiting times for the recognition process

Labour market: Refugee health professionals 5

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of International Organization for Migration

TABLE 1

SAMPLE DESCRIPTION (REFUGEE HEALTH PROFESSIONALS AND SUPERVISORS)

Refugee health professionals (RHPs)

Participant Sex Age Country of birth Occupation

Working experience in Germany

Working experience in birth country

A1 m 26 Iran Nurse 1 month 6 years as a nurse A2 m 23 Iraq Physician 3 months 2 years as a general

physician and 3 years as a surgeon

A3 m 28 Syria Physiotherapist 2 years 4 years as a physio- therapist

A4 m 28 Syria Physician (specialized in Anaesthesia)

8 months 2,5 years as a medi- cal assistant in sur- gery

A6 m 33 Syria Physician 5 months 5 years as a physi- cian

A7 m 38 Afghanistan Physician one year 1 year as a medical assistant, 3 years in public health depart- ment

A8 w 29 Syria Physician 1,5 years 1 year as a physician A9 m 30 Afghanistan Physician 3 months 1 year as a medical

assistant A10 m 44 Syria Physician

(specialized in anaesthesia)

3, 5 years 4 years as a medical assistant, two years as a senior physi- cian, 9 years as a chief physician

A11 w 52 Afghanistan Physician (specialized in gynaecology)

6 months 23 years as a gynae- cologist (also as a chief gynaecologist)

A12 m 39 Yemen Physician 4 months 10 years as a physi- cian

A13 m 45 Afghanistan Physician 2 years 2,5 years as a physi- cian

A14 m 51 Syria Dentist 3 months 21 years as a dentist A15 m 39 Afghanistan Physician

(specialized in otorhinolaryngology)

6 weeks 3 years as an ear- nose-throat (ENT) specialist

A16 w 33 Senegal Midwife and Nurse 3 months eleven months as a midwife, 15 years as a nurse

A17 w 36 Azerbaijan Nurse 3 months 2 years as a nurse

Supervisors

Participant Sex Age Country of birth Education Current job Experience

B1 m 34 Germany Physiotherapist Part time physiothera- pist, part time supervi- sor for RHPs and migrants

5 years as a physiotherapist, 1 year as a supervisor

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of International Organization for Migration

(B2-B4, B8) and noted that the bureaucratic procedures for recognition in Germany were not clear and prolonged the recognition process (B4, B7, B8). RHPs also criticized the length and complex- ity of the recognition process (A4, A7, A8, A11, A12). Two supervisors (B4, B8) criticized that former positions such as leadership titles of RHPs were not recognized in Germany. They also criti- cized that RHP’s specialist

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