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Researching equal opportunities for internationally recruited nurses and other health care professionals

REOH aims at ...

The broad focus of the study Researching equal opportunities for internationally recruited nurse and other health care professionals (REOH) was on the experiences of employment mobility and career progression of overseas-trained healthcare professionals currently working in the UK and their perceptions of equal or unequal opportunities as compared to locally trained staff. The research has explored the experiences of overseas-trained nurses and some other health professionals, in the UK’s health services in both the National Health Service (NHS) and in the private sector.

Its main aims are (i) the analysis of overseas-trained healthcare professional’s experiences of working in the UK, including the (ii) research and analysis their patterns of employment mobility and career progression. Moreover, the research aims at (iii) illuminating whether and how overseas-trained healthcare professionals’ social relations abroad and in the UK might support or influence employment strategies and choices, in order to (iv) inform policy debates aimed at supporting the career paths of overseas-trained healthcare professionals in the UK. One of the key goals of the project is to (v) inform policy development related to international recruitment.

Methodology

The qualitative research design allowed an in-depth understanding of overseas-trained nurses’ and other health care professionals’ opportunities for career development in the UK. Three case studies were conducted. Data collection involved individual and in-depth semi-structured interviews with overseas’ trained nurses, other health care professionals and their employers in the NHS and independent sector in three UK regions. In addition, one case study was undertaken with a Diaspora community in the UK and country of origin. A total of 93 interviews were completed as part of the case studies plus interviews with 13 national and 24 local stakeholders. Data analysis involved all members of the team in developing themes and categories in consultation with an interactive advisory board and workshops with stakeholders to develop and validate the emerging findings into higher level concepts.

Research findings

There has been a shift from recruiting directly from countries of origin or intermediary countries, in batches or as individuals, to recruiting overseas-trained nurses from the commercial sector. This shift increases the costs of migration for overseas-trained nurses and may act as a means of circumventing the largely ineffective and contradictory Department of Health Ethical Recruitment Guidelines. The commercialisation of health and social care in the care of older people has been associated with an increased segmentation and hierarchy of nursing specialist expertise, skills and tasks between the NHS and the independent care home sector. In particular, overseas-trained nurses have experienced a devaluing of the experiences and skills that they bring to the health and social care sector.

Overseas-trained nurses’ skills poorly recognised
Overseas-trained nurses’ experiences of mentoring and adaptation were shaped by inflexible accreditation and assessment systems which did not adequately recognise their skills and experience and led to them being graded below their appropriate level, deskilling and skills waste. Healthcare professionals migrate to the UK for a variety of reasons but these are not understood by British colleagues and managers which may lead to stereotyping which in turn may create a barrier to their subsequent career progression.

Overseas-trained nurses face multidimensional discrimination in the workplace
Relationships between overseas-trained nurses and their colleagues and managers are often discriminatory and many lack social and professional support. Racial discrimination in the workplace took a range of guises including direct discrimination and indirect discrimination embedded in organisational cultures, structures and practices. Workplace discrimination and favouritism may take different forms and relationships between ethnic groups is more complex than White on Black discrimination. Tensions and allegations of discrimination were evident amongst a range of ethnic groups whose interaction is framed by their position in a post-colonial hierarchy of ethnicities within the NHS. Promotion systems are not always transparent and can institutionalise disadvantage and create an environment which facilitates discriminatory practices which may not be based on merit. Rather, promotion into management positions appears to involve navigating systems of patronage and sponsorship based on meeting subjective and culturally specific criteria, which in turn facilitate racial and ethnic discrimination.

Mistakes made by overseas-trained nurses are more likely to be regarded as clinical malpractice
Overseas-trained nurses are over-represented in cases of clinical malpractice reported to the Nursing and Midwifery Council (NMC). Our data illuminate how this is related to insufficient diversity awareness and a lack of recognition of non-British health care experience and expertise. Some managers’ overuse of systems of complaints and grievances is underpinned by a lack of support which can lead to overseas-trained nurses experiencing social and professional isolation. These practices based on subjective judgments and social negotiation imply that there is scope for identifying good practice in dealing informally and effectively with these issues before they escalate into formal complaints and legal procedures. Overseas-trained nurses respond to these difficult environments by resisting, entrenching or re-negotiating and overcoming discriminatory conditions. As a reaction to repeated failure to achieve career progression, overseas-trained nurses and others may become alienated from their workplace and deeply demoralised. These responses have the potential to become self-sustaining and self-fulfilling collective narratives of racial and ethnic discrimination and exclusion based on an interplay of race, ethnicity and nationality.

 

Overseas-trained nurses have diverse backgrounds and contrasting experiences in the UK
There are many commonalities in the experiences of overseas trained nurses, but there are also significant differences, the most notable of which were attributable to nationality, race and ethnicity; UK location; and employment sector. Racism and discrimination took different guises, had different effects on and elicited different responses from different ethnic and national groups. Locality played a crucial part in shaping experiences inside and outside the workplace with a striking contrast between metropolitan and provincial areas in relation to social isolation, forms of discrimination and sources of support. Significant differences were found in the quality of support, exploitation and marginalisation of nurses in the NHS and private care home sectors. The findings allow us to hold up a mirror that enables British nurses, managers and doctors to examine and address current issues and problems in UK nursing practice, health service workforce organisation and education and make a strong case for valuing and recognising the talents of a diverse workforce.

 

 

 

 

 

 

 

Key messages

Our recommendations are framed by a central concern for staff morale and retention and utilising skills appropriately within the workforce in order to ensure resources are spent wisely. Within health and social care in general and the NHS in particular, Agenda for Change (AfC) and the Knowledge and Skills Framework (KSF) will address these issues although overseas-trained nurses and other health care professionals will need to have their needs met as an explicit component of AfC and the KSF. We suggest patient care and staff retention would be improved through paying attention to the following recommendations:

Career progression
With regards to career progression, a (i) period of preceptorship is recommended after registering with the NMC, General Medical Council (GMC) or Health Professions Council (HPC). Moreover, (ii) Personal Development Plans (PDPs) are to be undertaken with overseas-trained nurses and others in NHS and elsewhere. It is also increasingly necessary to (iii) include interview training, curriculum vitae preparation, career planning. Finally, (iv) formal systems of support are important in order to develop career progression skills, particularly when formalising, and making transparent, systems for interview preparation.

Diversity management
As far as diversity management is concerned, the research findings suggest the need for more (i) support and guidelines for managers and clinical directors to implement and monitor zero-tolerance policy. Diversity awareness training for healthcare staff should (ii) include positive recognition of overseas-trained staff’s skills and competences and provide assistance in transferring these skills and competences to the British setting. At last, in order to allow a better diversity management, (iii) overseas-trained staff should be included in the development and implementation of local diversity management practices.

Mentoring
The following recommendations are to be taken into account when addressing mentoring. Firstly, (i) mentoring systems need to make training and learning needs of overseas-trained nurses and others visible and valued. Moreover, (ii) overseas-trained nurses and others in supervised practice need to be recognised as trained staff and to be referred to in this way rather than as students or learners. (iii) Review of mentor update courses should ideally include diversity training/issues, language differences/support and emotional effects of migration. To conclude, (iv) mentoring systems should include support for mentors who mentor overseas-trained nurses and other health professionals.

Promotion
As far as promotion is concerned, the research findings suggest that (i) transparent promotion systems emphasise merit rather than sponsorship; moreover, promotion enhances an (ii) increased flexibility in the recognition and use of talents and skills of overseas trained staff within Trusts and other health and social care facilities. A (iii) review of portfolio evidence for previous overseas experience is necessary at registration/start of employment and use of relevant APEL systems in order to accredit prior learning experiences. Furthermore, (iv) single assessment of particular skill or a period of supervised practice of a skill is recommended in order to ensure that local safety standards are met. Finally, (v) formal feedback procedures for unsuccessful candidates should ensure that the problems or weaknesses are subsequently addressed by the applicant and their manager.

Health care practice/ nature of nursing work
When addressing health care practices and the nature of nursing work, it is relevant to promote (i) acceptance of cultural differences in clinical practice within standards of safe practice, to operationalise (ii) diversity in practice and improve working within diverse, multicultural teams and to diffuse (iii) information on Nursing and Midwifery, General Medical and Health Professional Councils, Department of Health, Care Home and Trust websites about register and different parts of the register. Being information an central aspect of heath care practice, constant contact with the following institutions and source of information should be integral part of an effective nursing work and health care practice: • Information on Nursing and Midwifery Council, Department of Health, Care Home and Trust websites about (i)nature of nursing and care work in UK and different roles of health care professions including Health Care Assistants and about (ii) differences between systems of training globally and expectations of UK employers. • Information on Nursing and Midwifery Council, Department of Health, Care Home websites about what care home adaptation placements offer e.g. opportunity to enter UK labour market in quieter working environment

Complaints
As far as complains are concerned, REOH has identified the need to disseminate more effectively to overseas-trained nurses and other health professionals information on Nursing and Midwifery Council and other professional councils’ complaints procedures and employment rights. Nursing and Midwifery Council is advised to investigate the underlying reasons for the increase in reports of overseas-trained nurses’ malpractice and to direct more attention to the importance of informal social processes that may prevent difficulties escalating into formal complaints and grievances.