Australia is a multicultural country with 49% of the Australian population (24.77 million) either born overseas or having at least one parent who was born overseas [1]. As in many other fields, multiculturalism affects the health professional workforce [2]. For example, the 4244 internationally qualified midwives (IQMs) who received their midwifery qualification in countries other than Australia and are currently practicing in Australia represent 12.99% of all registered midwives (4244/32,669) in the country [3]. Globally, there has been increasing reliance on IQMs and internationally qualified nurses (IQNs) within the health workforce of some developed countries [4-6]. A shortage of nurses and midwives, coupled with increased demands for health care, may be two of the factors driving this increase [7,8]. However, the transition of this group of health professionals into the Australian health care system has been accompanied by various challenges [8-11]. Pilette [12] explains that the process of adjustment into a foreign health care system may take about one year and is comprised of four different phases, including acquaintance, indignation, conflict resolution, and integration. He noted that each phase is associated with unique challenges [12]. Furthermore, it is possible that IQNs from culturally and linguistically diverse backgrounds may find it takes longer to adjust [13].

Differences in nursing practices, along with a lack of familiarity with local technologies, policies, and guidelines, are reported as major challenges for IQNs [11,14,15]. IQNs from different educational backgrounds may face stressful situations due to different ways of undertaking clinical procedures [16], which can result in frustration and anxiety [17]. Deskilling and lack of recognition of IQNs’ capabilities, skills, and experiences can cultivate feelings of invisibility and marginalization, which may have a negative effect on self-esteem, confidence, and well-being [14,18]. These factors are important to consider and acknowledge as these may be similar for IQMs. The literature also highlighted multidimensional discrimination and cultural impositions experienced by IQNs in some health care systems of destination countries [11,15]. Diversity in race, color, culture, or language can be a trigger of inequality of opportunities and racism in the form of bullying by staff or rejection of care by some patients [13]. For IQMs and IQNs, racial discrimination can lead to intimidation, public humiliation, social exclusion, and loss of confidence and professional authority [6,15,19].

Proceeding on the basis of Cooper's Taxonomy [20], a structured literature search was conducted by the authors [21]. The five steps that guided the literature review included formulate the problem, search the literature and gather information, evaluate study quality, analyze, and interpret the data [20]. Only two studies reported the experiences of midwives practicing in a foreign country; one study examined UK midwives’ experiences of working in Australia [6] and another in New Zealand [10]. The literature appears to focus mainly on internationally qualified nurses and doctors, with midwives usually included within the broader category of nurse migration. However, the International Confederation of Midwives has stated that “midwifery should be recognised as an autonomous profession globally” [22].

Although midwifery is an internationally mobile profession, there appears to be a global gap in literature that explores the transition experiences of IQMs moving between countries [23]. Hence, this lack of research, as well as the need to investigate and explore the transitional experiences of IQMs as they transition into Australian maternity services, is clear justification for undertaking this doctoral study. Understanding the transitional experiences of this group of midwives into the Australian midwifery system, as well as disseminating the findings, will increase awareness of challenges that IQMs may experience.

Given the identified gap in the literature, this study aims to explore the transitional experiences and views of IQMs practicing in Australia. The objectives of this study are to investigate demographic profiles of IQMs in Australia and to explore the key challenges that promote or hinder a smooth transition into this workforce. The research questions for this study are as follows:

The researchers will use an explanatory, sequential, mixed methods design, incorporating two phases to provide valid and credible outcomes [24]. This mixed methods design is underpinned by the philosophical assumptions of pragmatism, which guides both phases [24-26]. The research emphasizes the use of the pluralistic approaches in order to achieve a deeper understanding of the transitional experiences of individual IQMs, as well as the challenges they confront during their transition into the Australian midwifery workforce [24-27]. Regarding pragmatism, the criterion of “what works?” will be used to select the best methodologies to address the research questions and, ultimately, to find some strategies to solve any challenges, as required [26].

This research protocol incorporates an e-survey and individual interviews. Phase one includes an e-survey study that is currently being undertaken to capture IQMs’ demographic profiles, their transitional experiences, and positive and negative factors contributing to their transition during the first year of their practice in Australia. The exploratory nature of the second phase requires a qualitative approach to identify and describe the transitional experiences and views of individual IQMs. Hence, qualitative descriptive design based on semistructured interviews will be used for phase two to provide a detailed description of the experiences and views of IQMs in language similar to their own forms of expression [28,29].

The results from the e-survey will assist in determining questions for the interviews to explore, clarify, and affirm the experiences and perspectives of IQMs [26]. The findings of the interviews will provide further explanations for unexpected results that may emerge during the e-survey study [24-26]. The final inferences will be presented on the basis of integrated data from both phases of the study [27].

The target population for this study is a sample of midwives who obtained their midwifery qualifications outside of Australia, who practiced for a minimum of 12 months in the countries in which they obtained their midwifery qualifications, and who are presently practicing as midwives in Australia. In order to maximize recruitment opportunities, a specific length of time of employment in Australia will not specified. It is beyond the scope of this research to consider the experiences of midwives who obtained their midwifery qualifications within Australia.

IQMs will be invited to participate in this study nationally within Australia.

Findings from the e-survey study and interviews will be drawn together and compared in order to synthesize the final results and to reach an overall interpretation. To integrate data, triangulation protocol will be followed, a technique that has been explained by O'Cathain et al [43]. For this technique, findings from each phase of the study will be listed on the same page, helping to identify findings that are potentially convergent, complementary, or discrepant. In order to interpret the data from a multidimensional perspective, the datasets will first be separately analyzed deductively and inductively; we will then move back and forth between the datasets, with knowledge produced by each one, and will finally bring them together [44]. It is anticipated that data collection and analysis will be completed by June 2019 and results will be disseminated through peer-reviewed publications in late 2019.

To promote integrity and quality in this mixed methods study, appropriate strategies will be applied during each phase of the study as follows [24,26]. Regarding the e-survey, content and face validity were conducted for the adapted questionnaire prior to administration of the e-survey. Regarding the interviews, credibility, transferability, dependability, and confirmability will be considered to ensure trustworthiness of the study [45,46]. Consistent use of interview guidelines will ensure consistent data collection [39]. Participants' views will be accurately reflected via the use of audio recording; to maintain consistency between the transcripts, a consistent template will be used for each transcript [35]. Moreover, participant validation will occur in which participants will review and verify the interpretations [47]. Confirmability will be ensured through the use of an audit trail, where the activities exercised in the study, both in the collection of data and its analysis, will be accurately detailed and recorded [46]. Furthermore, the researchers will achieve confirmability through the use of participant quotes to support the findings. A reflexive process will be documented to reduce subjectivity bias. This will be supported by a clear audit trait of decision making throughout the study [48]. Publication and presentation of findings for target readers, such as the study participants, researchers, and other IQMs, will provide opportunities to enhance credibility [46]. In addition, a mixed methods design has been employed for this study, which will enable data triangulation to take place [24-26].

This study has obtained ethical approval from the University of South Australia Human Research Ethics Committee on July 4, 2017 (protocol number: 0000036397). All information about the nature and aim of the study, confidentiality, anonymity, voluntary nature of participation and withdrawal, potential benefits and risks of the study, contact details of a person designated to receive complaints, and contact details of the research team will be provided to participants of this study, according to ethical guidelines [49,50]. Consent to participate in the e-survey is implied by the respondent’s voluntary completion of the SurveyMonkey questionnaire. Written consent will be obtained from all participants who agree to be involved in phase two interviews. Phase one responses will be collected anonymously in SurveyMonkey. Participants who agree to be involved in phase two will be interviewed, either face-to-face or by telephone, at a mutually convenient date, time, and place. All data collected will be stored securely for 5 years. Participants will not receive any incentive for agreeing to be involved in this study.