In their own words: The experience of professional nurses in a Northern Vietnamese women's hospital.

Copyright © eContent Management Pty Ltd. Contemporary Nurse (2014) 47(1–2): 168–179.

In their own words: The experience of professional nurses in a Northern Vietnamese women’s hospital

Njoki Ng’ang’a, Mary Woods Byrne and Toan Anh Ngo*,1 Columbia University School of Nursing, New York, NY, United States of America; *Prenatal Diagnosis Center, The Northern Vietnamese Women’s Hospital, Vietnam

Abstract: Background: Nurses in Vietnam, as is typical of many low-income countries, are hampered from impacting health outcomes by low occupational status, overcrowded hospitals and few career development opportunities. In order to understand the current practice environment encountered by nurses in Vietnam in the most realistic way, we listened to the voices of nurses currently performing nursing roles in Vietnam. Purpose: The purpose of this study was to explore the emic (insider) perspectives on cultural meaning applied by nurses at a northern Vietnamese women’s hospital to influence professional practice and interpret experience. Design: A micro-ethnography approach was used. Methods: Seven nurses and one Vice Dean of a school of nursing were interviewed. Data collection consisted of open-ended interviews, participant observation and journal recordings. Spradley’s (1979, 1980) Development Research Sequence was used to guide data collection and analysis. Results/Findings: Five themes emerged. These were the big number of patients is a burden for nurses; nurses do not, cannot make their own decisions (but they can and do); my feeling depends on doctor’s feeling; nurses learn more from doctor; and just a few nurses can attend the [Vietnamese Nurses Association] meeting. Conclusion: The experiences described by the nurses and the Vice Dean of a nursing school reflect the challenges of practicing nursing in one Vietnamese hospital and the resourcefulness of nurses in overcoming those challenges. Recurrent themes highlight the need to better position nurses in Vietnam to advance toward full expression of the professional nursing role.

Keywords: nursing, professionalism, low-income countries, ethnography, Vietnam

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rofessional nursing practice is inextricably linked to the concepts of caring and social responsibility. Universally, this image is commemorated in early lithographs depicting Florence Nightingale at the inception of modern day nursing surrounded by wounded Crimean War soldiers recovering in immaculate wards while clutching her oil lamp. Today, nurses are represented not only at the bedside, but in the halls of academia, research and policy, striving to honor the principles firmly implanted by Nightingale. Models of nursing practice have undergone a sustained evolution consistent with shifts in the dynamic and complex health services delivery landscape to yield a workforce richly diverse in composition, structure and practice. The reality is that these advances remain unequal within individual countries and across borders. Social, In keeping with the expressed request of the Scientific & Ethics in Biomedical Research Committees of the northern Vietnamese Women’s Hospital to keep their institution anonymous, we refrain from including the affiliation of this author.

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economic and political factors unique to each country determine the extent to which the nursing role is expressed. A prime example of the unequal advances experienced by nurses is observed in the global arena. On one hand, important events, including release of the World Health Organization’s (WHO) Global Standards for Initial Education of Professional Nurses and Midwives mark the global community’s consensus that nurses are essential partners in the fight for better health and health care. On the other hand, the International Council of Nurses’ (ICN) call for a Chief Nurse Scientist position at WHO has gone unheeded. Amidst the significant deliberations endeavoring to secure a future in which nurses worldwide play a significant role in influencing health and health outcomes, the voices of frontline nurses must be heard. In Vietnam, professional nursing remains in nascent stages while endeavoring to negotiate past many barriers reported to impede advancement of nurses. These include low occupational status, overcrowded hospitals, and few career

Volume 47, Issue 1–2, April/June 2014

Vietnam nurses development opportunities (Jarrett, Hummel, & Whitney, 2005; Jones, O’Toole, Nguyen, Tran, & Pham, 2000; Walsh & Poremba, 1998). To strategically strengthen the capacity of nurses to meet health care needs in Vietnam, triumphs and challenges encountered during delivery of nursing care must be understood. The existing literature predominantly reports observations and anecdotes of the practice environment experienced by nurses in Vietnam (Jarrett et al., 2005; Jones et al., 2000; Petrini, 2000; Walsh & Poremba, 1998). Little empirical research has been conducted to explore the experience and aspirations of Vietnamese nurses. Therefore, the aim of this ethnographic study is to discover and describe, through the emic (insider) perspective of nurses at one major women’s hospital in northern Vietnam, the cultural meaning they apply to shape professional nursing practice and interpret their experience. Methods This study used systematic ethnography, an approach which defines the structure of a culture to provide insight into the shared norms and values of a given society (Muecke, 1994). Compared to classical ethnography which requires months of field immersion or with critical ethnography which focuses on power and oppression in society, systematic ethnography allows a researcher to enter a culture for a brief time with no prior hypotheses and develop understanding of the tacit meanings participants assign to culturally accepted behavior (Streubert, 2011). Systematic ethnography can encompass the breadth of a culture’s values but discovers these through exploration spanning longer or shorter scopes of time and settings. The role of the ethnographer is to discover the tacit meanings that people assign to their cultural understanding of ordinary situations (Spradley, 1979, 1980). The research process involves interweaving what is learned through indepth and repeated interviews with frequent participant observations. Collectively, these methods comprise Spradley’s (1979, 1980) Developmental Research Sequence (DRS). This process can be conducted through broad and long-term cultural studies or in the form of a micro-ethnography

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accomplished within one cultural scene, in this case a northern Vietnamese women’s hospital. Muecke’s (1994) definition of ethnography and Spradley’s (1979, 1980) DRS comprise classic examples of the qualitative inquiry methodology referred to in noted contemporary nursing texts as relevant to nurse researchers investigating subjects of interest to the profession today (Streubert, 2011; Wolf, 2007). The existing evidence illustrates the application of Spradley’s (1979, 1980) DRS by a cadre of international nurse researchers to gain understanding of cultural experience and meaning applied by different populations to their cultural experiences in diverse settings (Bernstein, Lee, Park, & Jyoung, 2008; Byrne, 2003; Davies, 2010; D’Alonzo, 2012; Gallagher, 2010; Koskinen & Tossavainen, 2003; ZielkeNadkarni, 2003). More recently, Robinson (2013) outlined Spradley’s (1979, 1980) DRS in her argument that ethnography ‘provides the best means of understanding how people assign meaning to health behavior and experiences.’ Our study is the first to utilize Spradley’s (1979, 1980) DRS to explore the cultural meaning applied by nurses in a low-resource setting to influence their professional practice and interpret experience. Setting The study was conducted within the context of a consultation visit to establish a program to treat female incontinence through the partnership between a United States based non-governmental organization (NGO) and a 520-bed tertiary care northern Vietnamese women’s hospital. Ethnographic study procedures and aims were separate from the consultation work but its occasion provided a serendipitous opportunity to conduct this ethnographic study of Vietnamese nursing. Beebe (2001) posits that valid qualitative data can be gathered in condensed time periods when the prolonged fieldwork normally associated with traditional ethnography is not feasible. Researchers following Beebe’s Rapid Assessment Process (RAP), engage in ‘intensive, team-based qualitative inquiry using triangulation, iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from an insider’s perspective.’


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Njoki Ng’ang’a, Mary Woods Byrne and Toan Anh Ngo

Such rapid assessment procedures have been applied globally for swift appraisal of health interventions (Ash et al., 2008; Chin, Goepp, Malia, & Poordabbagh, 2004; Foster, Regueira, Burgos, & Sanchez, 2005; Goepp, Chin, Malia, & Poordabbagh, 2004). We operationalized our systematic ethnographic inquiry to fit the brief time frame by meticulously planning in advance of the consultation visit; research practicalities were discussed via telephone and electronic communications with the host institution and requisite ethics committee permissions were secured in the United States and Vietnam. Sample The charge nurse of the operating suite and a laboratory technician in the perinatal diagnostic unit who was a member of the research team served as gatekeepers who introduced informants to the investigator. A convenience sample comprising seven nurses and one Vice Dean of a school of nursing were interviewed. Four nurses and the Vice Dean were interviewed during the initial site visit in October 2009 and three additional nurses a month later by the same Vietnamese laboratory technician. Except the Vice Dean, all interviewees were female, aged between 22 and 50 years, and graduates of post-secondary training programs of between 1 and 3 years duration, the current norm for basic nursing education in Vietnam. One interviewee was enrolled in a baccalaureate program. Participants reported between 2 and 27 years of experience across various specialties in different hospitals, but their practice was concentrated in two specialty areas at this particular women’s hospital, perioperative nursing and prenatal diagnostics. Data collection Data collection comprised open-ended interviews, participant observations and journal recordings. During the on-site visit, questions were posed in English and responses made in Vietnamese with a member of the research team immediately translating the interviewer and interviewee comments. The primary interviewer was an African, English speaking woman and the translator a primary Vietnamese speaker bilingual in English. 170

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Interview questions proceeded deliberately from descriptive to structural to contrast formats (Spradley, 1979). Descriptive questions were asked first to gain understanding of the setting within which nurses worked and to begin to identify the domains comprising their experience. What Spradley (1979) identifies as structural and contrast questions were then asked to amplify answers to descriptive questions by exploring taxonomies of relationships and discovering both visible and subtle differences. Interviews were audiotaped and transcribed in English. Participant observations were overt with the identity of researcher either emphasized (participant-asobserver) or subordinated (observer-as‑participant) depending on how public the nature of what was being observed to use Junker’s (1960) classic schema. The researcher maintained the participant-as-observer role during observations of clinical nursing activities within the hospital operating suite while working in tandem with the Vietnamese medical or nursing staff during scheduled surgical procedures and post-operative recovery. An example of the researcher’s movement to the observer-as-participant role occurred during social encounters to which the researcher was invited by hospital staff (Wolf, 2007). The researcher kept a journal of activities and impressions of each day spent in-country. Field notes were made after every interview and planned observation. Participant observations were made consecutively at three levels that mirrored the question types: Descriptive, focused, and selected. Samples of some of the questions and concurrent observations used in this study are presented in Table 1. Participant narratives were clarified through participant observations which gave rise to interview questions. Interviews and observations informed one another iteratively until themes were identified and the rules of this nursing culture understood. Data collection and analysis occurred iteratively, with information obtained from earlier interviews informing subsequent interviews. Three additional staff nurses who had expressed interest in participating but their schedules could not be accommodated during the in-country visit were interviewed in identical fashion to the initial



Vietnam nurses

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Table 1: Sample of parallel ethnographic interview questions and participant observations in accord with Spradley (1979, 1980) developmental research

of sorting the terms in each domain so that their sequence relationships to each Questions Observations other could be discovered. Searching for attriDescriptive Broad butes across domains was Grand tour the goal of componential What is your typical clinical day like? Operating suite schedule analysis and culminated Mini tour in comparing all the Describe the process of transferring Written and oral communications required identified domains, a step a patient to another hospital? Condition of patients being transferred called macro-domain Native language paradigm analysis. When Verbal exchanges between doctors and How would you tell a surgeon that several such componeninstruments are in short supply for a nurses; personal space; body language tial analyses are conscheduled procedure? sidered together they Structural Focused clearly show the nuanced Domain verification Is a primary nurse someone with a Activities of personnel with differing threads of meaning and 3-year basic nursing education? education their sources in the data. Domain cover term A sample of compoVNA flyers and meeting programs How does a nurse qualify to be a nential analysis as it was member of the Vietnamese Nurses applied to one domain is Association? presented in Table 2. Contrast Selective These steps required Contrast verification consideration of two levClinical conditions under which nurses Are some courses offered by the assume authority Ministry of Health organized by els of culture at the same doctors and others by nurses? time. Identifying cultural categories in ever group by the same member of the research team greater detail led to gaining a sense of the culin Vietnamese. He made notes during the inter- ture’s broader features as a whole and the ability views and translated them later. Transcriptions in to derive universal meaning from the abundance of particular details. Finally, cultural themes were English were sent to the principal investigator. obtained by immersion in the data through rereading and reflecting on interview transcripts Data analysis The discovery of cultural meaning was facilitated and field notes, by writing summaries of themes through four types of ethnographic analysis spe- as they emerged, and by comparing identified cific to Spradley’s (1979, 1980) DRS. Domain themes with those reported for similar cultural analysis is key to identifying large categories of scenes in the international literature on profesthe cultural scene, in this case the central elements sional nursing practice. of professional nursing practice from Vietnamese nurses’ point of view. Domains are not synony- Rigor mous with themes, the common outcome of most Measures were taken to ensure the dependability of qualitative approaches, but are only the first cul- findings and test their credibility and transferabiltural elements identified in a sequential process ity. Communication with participants, who speak that does finally culminate in a thematic analysis. primarily Vietnamese and little or no English, Domains are initially identified in pragmatic and was facilitated by an interpreter and verified by an semantic terms as lists of: Ways to do, a kind of, additional translator. In the first set of interviews, places in, results of, steps in, characteristics of, or replies varied in length from a few words to sevreasons for doing. Taxonomic analysis consisted eral sentences so it is possible some answers were



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Table 2: Sample componential analysis for the domain: Kinds of clinical activities Dimensions of contrast Contrast set (domain’s Professional Constrained Responsibility Time as pride enhanced by resources to patient pressure included terms) Setting up for surgery Assessing patient Fulfilling MD orders Reducing doctor’s anger Providing emergency care Maintaining schedule Adding unscheduled surgery Educating patients Transferring patients Teaching novice nurses

Yes Yes No No Yes

Yes No No Yes No

Yes Yes Yes Sometimes Yes

Yes Yes

Yes Yes

Yes Yes

Yes No Yes

Yes Yes Yes

Yes Yes Yes

condensed because of difficulty in remembering exact wording of longer answers or to overcome limitations in English and Vietnamese vocabulary. It is also possible that efforts to maintain social desirability may have prompted omission or editing of exact responses. To preserve credibility, a native Vietnamese speaker with English fluency living in the United States volunteered to listen to one interview and compare it to the written transcript. He verified that the essential meaning had been preserved. Additionally, he identified cultural nuances attached to words used within Vietnamese context. For example, he clarified phrases used to categorize various educational levels that appeared contradictory when the translator attempted to explain them in terms of the United States education system but in fact did convey consistent meaning when subtleties of language are weighed. A summary of findings sent by electronic mail was verified as accurately reflecting the intent of each interview. Our findings were congruent with other reports of Vietnamese nursing and theoretically resonant with the situation of nursing in similar settings. Ethical considerations The study was approved by the human subjects review boards at both the researchers’ and the host’s institutions. In accord with the request of the host, the name of the hospital and of the 172

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Depends on Makes things doctor run smoothly

Yes Slightly Sometimes No No Yes No Yes Yes Yes, but can circumvent Yes Yes Yes Yes Yes Yes Yes

No Yes No

Yes Yes Yes Yes Yes Yes Yes Sometimes Yes Yes

nurses who agreed to be interviewed have been kept confidential. Results Taken collectively, the accounts from all informants provided a rich understanding of the cultural scene within one Vietnamese hospital with consensus across interviews and supported by observations. Five themes comprising the practice of nursing emerged from the eight interviews and multiple observations. Consistent with ethnographic tradition they are reported in the words native informants used. The themes were derived from 38 domains whose structures were explored. Attributes crossing domains and their taxonomies were compared. The overarching macro-domain was: I love my job in nursing and I wish I had more opportunity. Paradigm analysis of this macro-domain showed several key attributes, linked domains and tacitly informed cultural norms, values and attitudes: Nurse’s acceptance of responsibility for the patient, pride in acquiring clinical experience, duty to make things run smoothly under all circumstances, tensions inevitable in the clinical environment, waiting for ways to increase professional respect, and critical role of physician as source both of knowledge and authority. Elements of paradox or contradiction were in all the attributes as well as in the expression of the macro-domain, and pervaded the five discrete themes.



Vietnam nurses Theme I: The big number of patients is a burden for nurses We learned from the perioperative nurses that their clinical practice is largely focused on operational efficiency despite the strain of expanding volume of patients on the existing infrastructure. An informational pamphlet provided upon our arrival reported that at least 15,000 obstetric and gynecologic surgeries are performed annually in this hospital. Nurses frequently shared their perceptions of pressures associated with functioning under these circumstances. In the words of one nurse: the big challenge is the tools [surgical instruments]. We do not have enough tools in operation because the number of patients is increasing day by day …

A detrimental consequence of this rapid turnover of surgical cases and concomitant shortage of surgical instruments is that tension builds between physicians and nurses. One nurse expressed that: if we do not have enough tools, the doctor do not satisfy. The doctor will ask the nurse why the tools is not enough and the doctor’s attitude during operations is not OK …

As the process of interviewing and observing were analyzed, the nature of nurse–physician relationships at this hospital became more apparent and evolved into another distinct theme (presented below). In addressing the high volume of cases, a significant portion of nurses’ responsibility is dedicated to meticulous preparation of surgical instruments used in both planned and unanticipated or emergent surgeries. The nurses attach a great sense of pride and personal fulfillment to their role in successfully facilitating a seamless succession of daily operations. One nurse reported that, ‘… if you love your job you’ll do a good job. For me it is my life, I love my job …’ The considerable importance nurses place on extending themselves to overcome emerging obstacles was observed during our visit when the visiting team could not locate a piece of equipment within their own cache, the Vietnamese charge nurse quickly opened her own stock for our use. When the quantity of sterile surgical equipment diminishes from a surging number of operations, nurses often find creative solutions to accruing bottlenecks.


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One respondent cited commonly re-purposing instruments specific to obstetrical surgeries for gynecological ones, stating: in that case, if the lack of the tools, I’ll borrow from another operation room to their current operation. But it’s not the set of tools so they do not assure the uniform of the tools.

Another nurse referred to her role in passing information regarding shortage of instruments up the chain of command, stating, ‘… for the long run, I inform the director to buy new [instruments] …’ They described themselves as a link to easing and even resolving those intractable disruptions that may impact delivery of care. Theme II: Nurses do not, cannot make their own decisions (but they can and do) When issues about nursing autonomy emerged in the interviews, they were presented in competing ways. First, it was clear that a great degree of dedication is applied toward patient care. For example, a nurse in the operating suite was observed reassuring a patient awaiting a scheduled cesarean section that was delayed when her slot was reassigned to a more emergent case. And, a nurse from the prenatal diagnostic center who was asked what she liked most about her job, stated that: I feel this job is suitable with me and I feel happy with even a little thing I have done for patients such as explain the result [of laboratory tests] and the management after ultrasound …

However, nurses alluded to low expectations of them set by the system and restrictions placed on the full expression of the nursing role. This was true even during events where there may be an opportunity for nurses to contribute. For instance, one respondent specified that in a situation where a patient’s status is deteriorating and requires transfer to an alternative specialty care site that only ‘… the doctor will do all those things …’ [in reference to transferring the care of the patient, including communicating with the receiving hospital]. Alternatively, in the case of life threatening emergencies when swift action is required, nurses who have extensive experience will intervene as one nurse who has more than 25 years experience described.


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Njoki Ng’ang’a, Mary Woods Byrne and Toan Anh Ngo In emergency cases, we have to act quickly, real quick. There were cases when the doctor got here things already done because if otherwise the patient may already die. There are cases of [seizures] last only about 2 seconds, we had to act quickly to prevent the patient from biting their tongues. In the operating room there are moments I needed to act first then the doctors will sign later based on the experiences that I have here. Others may not act this way …

characterized by a paternalistic orientation. In the operating room, a nurse was observed drawing medications for the anesthesiologist to administer. In this case, the nurse confers most, if not all, clinical decision making capacity to that physician. Another nurse from the prenatal diagnostic center stated that a frustrating aspect of her job was when:

All the nurses interviewed agreed that clinical expertise is perceived to correlate with cumulative number of years in practice and is a desirable goal. One nurse stated that, ‘… in Vietnam, we do not encourage, we are not encouraged to change our job …’ She clarified that this is because longevity in nursing employment, as in other disciplines in Vietnam, is highly valued and subject to the bestowal of respect by nurse and physician colleagues alike.

… sometimes I assisted bad tempered doctors, they often shout at our face even when we made no mistake. My feeling depends on doctor’s feeling. If they happy, it [the work environment] is all right …

Theme III: My feeling depends on doctor’s feeling The relationship between nurses and physicians is characterized by a well-established hierarchical distance. One nurse reported that: so have the position the nurses [is] lower than physicians. In social activity or out of the hospital they may be equal but when they enter the hospital have [lower] position …

On one hand, respondents repeatedly pointed to physicians in the clinical setting as the primary source of their clinical knowledge. This relationship extends the reach of the classroom by establishing a culture of learning at the point of care. On the other hand, the nurses were aware that this leads to their subordinate status as clinicians and creates an unequal distribution of power. In one nurse’s view: some physicians look down on nurses because the physician, doctor know that the knowledge and practice themselves is better than nurses, nurses’ knowledge

With goals to advance nursing education and develop highly trained nurse educators in Vietnam being relatively new, all the nurses reported receiving their basic nursing instruction from physicians. These physician-taught classes perpetuated a nurse–physician relationship that is

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A worrying consequence of the deliberate distance between nurses and physicians within this arrangement is underscored by the nurses’ emphasis on the expectation that they remain passive bystanders and refrain from disagreeing with physicians’ judgment even when the impending action is potentially harmful. One respondent stated that she, ‘… must follow the doctor’s order even when I feel that it is wrong. We do not allow to say no to doctor …’ Theme IV: Nurse learn more from doctor Post-secondary academic preparation for all the nurses in our sample comprised of hospital-based training with a strong focus on clinical practice and little foundation in nursing theory. A participant’s response reflected a common theme amongst the nurses when she stated that: most of the knowledge is from actual working, from watching the doctors, dealing with patients, but mostly doctors …

Another nurse described her career trajectory: after completing second level of high school [equivalent to the 11th grade in US system], I came to this school [at the women’s hospital], graduated from this hospital and stay here working since then …

All the nurses acknowledged acquiring most of their clinical knowledge at the bedside with physicians as a central source of that knowledge. One respondent stated that: the basic knowledge I got from the school is not enough. Many situation can happen for the patients so the doctor teach more



Vietnam nurses In order to gain a better understanding of nursing education in Vietnam from an educator’s viewpoint, we interviewed the Vice Dean at a nursing school. We observed that this Vice Dean of a nursing school is a physician with a doctorate in physiology. According to the Vice Dean, instruction at the nursing school is carried out primarily by baccalaureate prepared nurses. There are currently 39 instructors, 13 of whom are physicians, 2 masters prepared nurses and 24 nurses with a baccalaureate degree. The current curriculum at this nursing school requires students to spend approximately 1500 hours attending didactic lectures and 1500 hours in the clinical setting. Students have access to Vietnamese text books specific to the nursing philosophy, authored by both nurses and physicians, in addition to reference text books authored by Western nurses. The nursing school’s mission, according to the Vice Dean, is to implement a learner focused curriculum designed to prepare nurses for lifelong learning in a rapidly changing healthcare landscape, utilizing technology and to develop independent, self-directed learning. Of the seven nurses interviewed, only one was able to take advantage of these opportunities available for nurses in Hanoi. One nurse told us that: the leaders here encourages the staff to go for further study but the actual situation do not allow them to go study further because we are very busy …

Speaking to the work load, one nurse stated that, ‘… the motto of this hospital is until no more patients of the day before we can go home …’ Long work hours and the challenge of striking a perfect work-home and family life-school balance were cited as the chief deterrents faced by nurses wishing to pursue higher learning. Nevertheless, they aspired to the hope that significant professional benefits may accrue to corresponding academic achievement. As one nurse summed this up: maybe in the future the nurses here have further education and degree that they can get respect from the doctors …

Returning to school was not spoken of in terms of a concrete plan but rather as a vague and distant wish.


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Theme V: Just a few nurses can attend the meeting We explored the nurses’ knowledge of the Vietnamese Nurses Association (VNA) and what their expectations of the organization were. We learned that the nurses felt disconnected from the VNA and unable at this time to exploit potential opportunities. For example, even while stating that she participates in annual association meetings, one nurse responded that: the MoH [Ministry of Health] did not allow it [VNA] to be officially formed. It runs but it’s not formally so the association is not useful for my work …

Still speaking to the reach of the VNA, another nurse stated that, ‘… the big disadvantage is that not all nurses can attend [a VNA] meeting so it is quite limited …’ Another interviewee noted that, ‘… the chief nurse choose person who attend [VNA] meeting …’ This lack of uniformity in the responses we received regarding the VNA suggests inadequate awareness of the organization’s central role and its potential to advance the nursing profession in Vietnam. One nurse thought that only, ‘… in the association … always the member is chief nurses …,’ while the regulations of the VNA as posted on their website state that individual nurses can gain membership into the association (Vietnamese Nurses Association [VNA], 2008). Another stated that: a department can assign one or three people who have the research or have the innovation in practice that they can attend meeting or workshop of the association and the rest of them do the routine work as usual …

Her colleague mentioned that, ‘… the director selects four or five nurses to attend each meeting.’ Another nurse perceived that ‘… the VNA functions limitedly so the impact is do not gain a lot.’ Discussion In their interview narratives and as observed, participants expressed and displayed intense focus on meeting assigned responsibilities for large numbers of patients and longing for opportunities to expand their practice knowledge. They also shared a sense of distance from their national professional association and linked inadequate basic


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education directly to their low status marked by subservience to physicians. An overarching theme of ‘loving my (nursing) job’ was shadowed by the desire for ‘more’ to achieve complete satisfaction: More continuing education, equipment, decision making, and status. These circumstances have been mirrored in other accounts. Faculty from Salem State College in Massachusetts created a web journal with captioned photos to document nursing as observed during teaching visits to Vietnam in 1998. Captions pointed out that: ‘Nurses’ role is primarily to assist the doctor …’; ‘Equipment is limited and outdated by western standards. Notice the rusty metal [on a photo of frequently sterilized surgical instruments]’ (Walsh & Poremba, 1998). Petrini (2000) evaluated the status of nursing through interviews with nursing leaders in three main regions of Vietnam and concluded that hospital administrators placed a strong value on continuing education but, ‘… The challenge is to find nurses with new knowledge to teach with a nursing focus rather than a medically oriented focus …’ Jones et al. (2000) similarly observed that Vietnamese nurses lacked control over their own education and a clear separation of purpose from physicians. More recently, Baumann, Blobner, Binh, and Lan (2006) described Vietnamese nurses’ limited access to decision making opportunities as a barrier to delivering a new diabetes education program to patients. The hospital system’s responsibility to meet the needs of large numbers of patients with minimal staff was frequently cited by our nurse participants. They spoke about accepting long hours and working around expectations that held them accountable for expediting overloaded case schedules. Reasons for these realities include 5552 dong (US$0.50) is spent per capita on health care annually, a physician/nurse ratio of 1:0.6, and persistent nursing shortages, especially in urban areas where women have more occupation options (Petrini, 2000). Yet, meeting the proposed national education agenda could facilitate the expansion of nurse practice scope and potentially address burgeoning patient care needs in the future. Existing staff nurses educated in the 176

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older model will need more innovative assistance to escape their dilemma of limited education and high patient care burden in a milieu of physician dominance. The themes revealed through these interviews can be viewed together as a window into the evolutionary process in which the nursing profession in Vietnam is engaged. Our findings were consistent with existing literature describing the status of nursing in Vietnam as being in a transitional phase (Jarrett et al., 2005; Jones et al., 2000; Petrini, 2000). Universally, the idea of professionalism comprises a set of shared attributes that have been enumerated as: Autonomy, possession of a specialized body of knowledge, competence, continuing education, integrity, subscribing to a code of ethics, contributing to knowledge through research and altruism (Hafferty, 2006; Joel, 2011; Matthews, 2012). In nursing, the concept of professionalism is closely linked with duty and remains central to nurses’ raison d’être (International Council of Nurses [ICN], 2006). While the fundamental elements of professionalism are well understood, achieving this status is an iterative and developmental process experienced by individual professions globally. Nursing has been an emblem for the quest for professional identity (de Castro Santos, 2008). Nurse leaders such as Florence Nightingale (UK), Ethel Bedford-Fenwick (UK), Anna-Emilie Hamilton (France), Mary Adelaide Nutting (USA) and Lavinia Dock (USA) have laid the foundation, but nursing has evolved unevenly into a discipline recognizable in essence but varied in implementation from one part of the world to another. Joel (2011) highlighted key weaknesses inherent in nursing that prevent attainment of the full privilege of a profession. These include absence of autonomy and the lack of a designated academic standard for entry into practice. Autonomy remains a major unrealized goal for Vietnamese nurses. Their academic entry level goals are just beginning to reach the baccalaureate level while majority of currently practicing nurses possess 1–3 years of post-secondary training. The plan for nursing education outlined by the Vice Dean who agreed to be interviewed



Vietnam nurses suggests that his school of nursing, as one exemplar of Vietnamese nursing education, upholds the broad and universal construct of professionalism. At the national level, the VNA has endorsed that advanced nursing degrees should be available, qualifications for nurse educators standardized, and a university-level school of nursing established (Jarrett et al., 2005). The VNA has been instrumental in facilitating training for Vietnamese nurses locally and abroad. Through scholarships granted by international partner Friendship Bridge Nurses Group, six Vietnamese nurses earned a masters degree in nursing administration in Thailand in 2001 (Jarrett et al., 2005). With the support of the MoH and international partners, the VNA has laid the foundation for an in-country graduate training program at the University of Medicine and Pharmacy in Ho Chi Minh City. Support from a central professional organization is important in a country that uses national curricula. However, it is the government’s power that ultimately effects implementation and further momentum along the lines of the MoH invitation to the VNA to provide input a decade ago will be crucial (Petrini, 2000). Hesitancy to grant nurses the privilege of full professional status is detrimental, especially in resource poor countries, because it severely undermines their ability to impact health outcomes. In a conceptual discussion on the social responsibility of nursing and its implications for global health, the authors asserted that: ‘As a human caring science, nursing has the expertise to advance society and the capacity to focus on the well-being of a society in advocating for social change’ (TyerViola et al., 2009). Limitations This study is limited by the brief time frame within which interviews and observations were conducted on site and by the restriction of the study to nurses in two specialty departments of one hospital in Vietnam. Despite a brief 10 days in-country, we made the most of this extraordinary opportunity by extensive planning prior to the visit. We discussed our plans


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with the host hospital through electronic mail and third party personal communication via the NGO liaison until mutual agreement was reached. IRB approvals in the United States and Vietnam were secured. These intense preparatory steps allowed us to implement a rigorous, systematic plan of inquiry within the available time. Although 38 domains were categorized it is certain in any ethnography that the first inventory is not comprehensive. For instance, the researchers’ knowledge of the VNA’s mission was informed by the association’s web site alone. We might have gained a more balanced understanding if attempts to obtain an appointment with an association official during our stay were successful or if we had received answers to our electronic mail messages and telephone calls after we returned. Again, these communications may have been impeded by translation gaps. The lack of Vietnamese speaking nurses on the research team was a challenge although the translations were validated in several ways. The detail of Spradley’s analytic methods can also be perceived as offering a semantic challenge with their unique understanding of domains as very early structural components finally leading to thematic analyses and to both the jargon and the tedious detail of the interim taxonomic and componential analyses before the more familiar thematic analyses can be approached. Nevertheless, it is suggested that this detail provides more specific accountability for data meaning than can typically be derived from a more generic emergent content analysis approach. Conclusion The separate interview and participant observation themes mesh to suggest ways for nursing in Vietnam to accelerate its journey to professionalism. The burden of increasing hospital census can be addressed in part through major system changes that create better educated nurses and permit them to make more autonomous clinical decisions. These changes can lead to more satisfying and effective physician/nurse relationships. The professional association can prompt these outcomes


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especially if empowered to work in alliance with the MoH. In this future environment it is also conceivable that culturally relevant adaptations of proven Magnet™ program characteristics can be incrementally included by the hospital system and continue promoting the status of nurses while also tying nursing excellence to improved patient outcomes (American Nurses Credentialing Center [ANCC], 1983; Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2007). Vietnam continues to invite international nursing participation including short-term medical consultation visits. Worldwide, such efforts have been based historically on an ‘export model’ of imposing visitors’ methods on the host (Asgary & Junck, 2013). Ethical principles to guide such endeavors have been articulated more recently (Asgary & Junck, 2013; Suchdev et al., 2007). Imbedding into our brief health consult visit a study of host nurses’ own perspectives operationalizes such principles. Ethnographic methodology served well to elicit understanding of the in-country nursing perspective and serves as a basis for collaboration and sustainability in this partnership. The synergism produced by these newly opened gateways lends itself to a potentially powerful platform for nurses to share and create, with mutual understanding across cultures, practice innovations that impact health and health outcomes. Acknowledgments The authors thank the institutional Center for Children and Families for providing scholarly resources toward the completion of this paper. We would like to acknowledge Barbara Margolies and the International Organization for Women & Development for serving as a liaison to the host institution and Hao Nam Le for assistance in translation. Funding The authors are grateful for grant support from the institutional Center for Evidence Based Practice in the Underserved: Grant number T32NR07969.

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Accepted 09 April 2014

C A L L F O R PA P E R S What can Qualitative Research Contribute to Work and Family Policy? A special issue of Journal of Family Studies – Volume 21 Issue 1 Co Editors: Michelle Brady and Judy Rose (University of Queensland, St Lucia, QLD)

DEADLINE FOR PAPERS: 13th SEPTEMBER 2014 This special issue provides an opportunity to reflect on the kinds of contributions that qualitative research can make to social policy. We welcome articles that develop the conversation about current qualitative policy work, examples of successful policy engagement and areas for development. http://jfs.e-contentmanagement.com/archives/vol/21/issue/1/call/

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