The experiences of internationally educated nurses who joined the nursing workforce in England

The Department of Health and Social Care (DHSC) has stated that it has achieved the Government's manifesto pledge of increasing the number of nurses by 50 000 by 2024 (DHSC, 2023). However, the Nuffield Trust (Rolewicz, 2023) has warned that increases have not been achieved in some branches of nursing and in some English regions. Previously, The King's Fund (2022)commented that the NHS could have a shortfall of 108 000 full-time equivalent nurses by 2029. To fill the large gap in the nursing workforce meant the UK government had little choice but to increase international recruitment. For decades, the UK has been recruiting nurses from developing countries (Haves, 2021).

This integrative review of literature published between 2002 and 2022 has been conducted to better understand the experiences and needs of internationally educated nurses (IENs) working in the UK and identify researched-based recommendations to address some of the issues and challenges they experience.

Background

In the period 1990/1991 to 2021/2022, the percentage of new IEN Nursing and Midwifery Council (NMC) registrants rose from 10% to 53% of the total annual number. In 2022-2023, more than 40% of new NMC registrants were trained outside the UK, which is the highest in two decades (Buchan et al, 2023).

Concern has been raised that, although the UK nursing workforce has been growing in the past few years, the NHS and social care remain understaffed (Haves, 2021). A joint report by The King's Fund, the Health Foundation and the Nuffield Trust (Beech et al, 2019) concluded that reducing the nursing vacancy rate in England to 5% by 2023/2024 would require recruiting around 5000 IENs per year.

The demand for NHS and social care services in England has also been increasing. Between 2010/2011 and 2018/2019, the number of hospital admissions rose by 15% and the number of patients accessing emergency departments rose by 13%. The number of people needing cancer treatment rose by 27% and the number of GP referrals for suspected cancer more than doubled (Haves, 2021).

The shortage of nurses across the NHS and social care is a major risk to the NHS's recovery after the COVID-19 pandemic (Buchan et al, 2023), and could potentially have a damaging impact on patient care and on the wellbeing of nurses themselves. In 2022, 40 365 NHS nurses in England left active service according to the Nuffield Trust (Palmer and Rolewicz, 2022). Reasons for leaving were retirement, feeling exhausted, feeling undervalued, too much pressure and low staffing levels. The NHS Long Term Workforce Plan, published in June 2023, acknowledged that in England staffing shortages limit the capacity of the NHS to deliver the quantity and quality of services that people expect, impacting on staff wellbeing, and hindering the NHS's ability to perform and provide value for money for taxpayers (NHS England, 2023).

Aim

The primary aim of this integrative review was to understand the experiences of IENs in the first 12 to 24 months following joining the nursing workforce in England in relation to integration and cultural adaptation into the NHS.

Key objectives were to:

• Explore and analyse the experiences of IENs as they integrate into the nursing workforce in England
• Identify the cultural, pastoral and training needs of IENs during their first 2 years of working in England
• Produce research-informed recommendations to better support and retain IENs working in England.

Design

This integrative review was conducted following the Whittemore and Knafl (2005) five-stage framework, comprising problem identification, literature search, data evaluation, data analysis and presentation of findings.

Using an integrative review generated a wealth of data from quantitative, qualitative and mixed-methods data collection approaches and resulted in a comprehensive portrayal of the significance of the topic being explored.

Method

The integrative literature review method was used to examine, evaluate, analyse and synthesise data from multiple sources. A systematic approach in reviewing the literature using the Joanna Briggs Institute (JBI) qualitative checklist was adopted to ensure that the research, results and conclusions were reliable (Lockwood et al, 2015; JBI, 2020). This also enabled the development of new theoretical perspectives as data emerged from the literature being reviewed, which combined insights from different research traditions (Snyder, 2019).

Literature search

The literature review provided context and background on previous related experiences of IENs and their UK integration (Blaxter et al, 2010). This enabled the authors to make sense of the research carried out over the past 20 years and gave insights into what further research might be needed in the future (Aveyard, et al, 2016).

A modified Population, Intervention, Context and Outcome (PICO) framework was used to develop a search strategy. Each term was searched individually using truncation and wildcards to include different spellings and word endings (Table 1). The results were then combined using Boolean operators (AND/OR) to further refine the search to achieve more specific results.

CINAHL was the principal database used because it covers all aspects of education policy and administration, evaluation, assessment, technology and the particular educational needs of nurses and other health professions. It encompasses UK journals and other English language titles, including international nursing and midwifery journals.

However, because of the limited number of studies found, the British Nursing Index (BNI) was also accessed using the same search strategy, but no related studies were found on the topic. Finally, Google Scholar was used to cover a wide range of journals, grey literature and other citations related to the experiences of IENs in the UK.

The search strategy achieved its goal to ‘cast a wide net’ online to catch related literature but, admittedly, this was not an exhaustive search. Fink (2014) warned researchers that over-reliance on databases and other online resources could potentially miss valuable materials, including those that are not included in the key words. So the ‘snowball method’ (Perez-Bret et al, 2016) was used to look at studies cited in the articles. The inclusion criteria were original research articles in English, published between 2002 and 2022 in the UK, on the experiences of IENs in their first 12-24 months in England.

Fifty-six studies were found and looked at initially. After duplicates were removed, 30 studies remained and were examined, of which 15 were excluded because they dated from before 2002. The remaining 15 studies were assessed by full text and a further five were excluded because they were literature reviews rather than original primary research. The remaining 10 studies were quality assessed using the JBI checklist for qualitative research (Lockwood et al, 2015). This resulted in the exclusion of one further study, leaving nine qualitative studies for this integrative review.

Quality appraisal

All nine studies were appraised using JBI checklists and analysed using the principles of thematic analysis by combining the key findings from multiple data sources (Thomas and Harden, 2008). Twenty-two descriptive themes were identified from the key findings of the studies included. These themes were grouped by similarity and further coding and analysis identified the following broad analytical themes: expectations, challenges, and belongingness.

Findings

The experiences of 321 IENs (246 female and 75 male) trained outside the UK were explored and analysed across the nine studies included in this review. Most IENs came from the Philippines and India. Other countries of origin included Nepal, Spain, Jordan, Jamaica, Ghana, Finland, New Zealand, Nigeria, South Africa, Malawi, Kenya, Zambia, Zimbabwe and Cameroon. Table 2 summarises the key characteristics and findings of the nine analysed studies.

Discussion

Three broad analytical themes emerged from this integrative review: expectations, challenges and belongingness.

Expectations

There was a concerning mismatch in the expectations of the IENs and their actual experience when they arrived in England. Most of them were experienced nurses in their home countries. They thought themselves to be competent enough to adapt to the many differences in social and nursing practices in the UK (O'Brien and Ackroyd, 2012). Some of them formerly worked in senior and managerial positions in their home countries, yet they were not allowed to work as nurses when they first arrived in England (Winkelmann-Gleed and Seeley, 2005). They needed to conform to the NMC registration process, which includes passing the International English Language Testing System (IELTS) or the Occupational English Test (OET) and passing the Computer Based Test (CBT) and the Objective Structured Clinical Examinations (OSCE). These are the competence tests required to secure NMC registration to be able to practise nursing in England and across the UK (NMC, 2024).

Without NMC registration, IENs were employed as healthcare assistants when they first arrived in the UK. Some of them reported that they were treated like students instead of qualified nurses (Alexis and Shillingford, 2012). As a result of this treatment, many of the IENs felt that they were being deskilled and losing their status as nurses. They were unable to practise autonomously and were given little independence (Stubbs, 2017). They felt that they were going ‘back to zero’, back to ‘being students again’ and losing their self-confidence as their experience and skills were not being recognised by their English colleagues (Taylor, 2005; Al-Hamdan et al, 2015).

IENs have high expectations of working and living in England, both financially and socially. However, many of them reported that these expectations were not met. As a result, some returned to their home countries while others migrated to other countries, although a number remained (Al-Hamdan et al, 2015). The study focused only on individuals and did not evaluate the ‘pros’ and ‘cons’ or motivation of nursing migration from home to host country. They also did not mention what information was given to these IENs during their recruitment while they were still in their own country. Some of these expectations might be due to lack of understanding of the regulations and of the costs of living in the UK.

Challenges

IENs encountered significant challenges when they migrated to England, both in their personal lives and in the enormous professional adaptation demands. They were confronted with new policies, working patterns and job specifications (Al Hamdan et al, 2015). All nine analysed studies highlighted the differences in the nurse's role in England compared to their country of origin.

One of the most common differences in societal values is in relation to the care of older people. The majority of the IENs, especially those from the Philippines, China and Nigeria, stated that, unlike in England, in their home countries families are more actively involved in the care of their older relatives when admitted to hospital or in community settings (Taylor, 2005). Furthermore, spiritual care and support, including praying for or with patients and relatives, are common practices for some IENs in their home countries. This is not a feature of nursing care in England or across the UK (Taylor, 2005). It should be noted that Taylor's study was published nearly 19 years ago. In 2022, NHS England published a national preceptorship framework for nursing. The aim was to welcome and integrate newly registered practitioners into their new team and place of work, and help them embed their knowledge into everyday practice, grow their confidence and have the best possible start to their careers (Cox and Wray, 2022).

Many IENs also reported that there were significant changes to their role in terms of decision-making and responsibility. In their home countries, doctors are the primary decision-makers. They prescribe treatment and interventions for nurses to deliver. They are the ones who discuss the diagnosis and prognosis with patients and relatives. In England, nurses are involved in the decision-making processes and are expected to carry out interventions based on their own professional judgement. It should be noted, however, that both studies used purposive sampling techniques that could not be used for generalisation. One study focused only on three critical care units in London hospitals, which may not be representative of the experiences of other IENs in other NHS trusts (Stubbs, 2017).

Another major challenge encountered by IENs was communication. They found it difficult to understand different English accents (Stubbs, 2017), to adjust to the speed with which English people speak and the use of colloquial terms (Okougha and Tilki, 2010). They recognised this as barrier to communicating with colleagues, patients and patients' significant others. Passing English language tests for overseas nurses (Table 3) was also perceived as a major significant barrier to joining the UK nursing workforce (Allan and Westwood, 2016).

In January 2023, the NMC introduced changes to the English language proficiency requirements, allowing applicants to combine test results (IELTS results first attempt plus IELTS results second attempt or IELTS results plus OET results). The combined results must still meet the required passing scores. The period of combining the test scores is from 6 to 12 months; results achieved more than 12 months apart cannot be combined (NMC, 2023). This gives more flexibility for people who need to resit a test, while still maintaining the high standard of English language proficiency required to ensure public safety. Another change introduced by the NMC in 2023 is beneficial to those IENs who are not yet NMC registered but have been working in the UK for at least 12 months. Instead of passing IELTS or OET, they can now submit supporting information from their employer (SIFE). Detailed information about these changes is available on the NMC website (NMC, 2023).

Belongingness

Migrating and integrating into the NHS healthcare workforce is not easy for IENs. They experienced ‘culture shock’ when they first arrived in England (Winkelmann-Gleed and Seeley, 2005; Okougha and Tilki, 2010; Alexis and Shillingford, 2012; Al-Hamdan et al, 2015; Likupe, 2015; Stubbs, 2017). They must adjust to a less formal society and more relaxed working relationships with senior members of multidisciplinary teams. For example, in their home countries, when talking to senior colleagues, they are expected to stand up to show respect. Also, in most of their home countries, a job title is used to address colleagues rather than their first name, which is the norm in the UK (Okougha and Tilki, 2010).

Most of the IENs experienced loneliness and dissatisfaction (Al-Hamdan et al, 2015), discrimination and injustice (Allan and Westwood, 2016), were distressed and confused (Likupe, 2015), and felt humiliated (Alexis and Shillingford, 2012). They experienced racism and unfair conclusions about their work ethic and character from some patients and colleagues (Winkelmann-Gleed and Seeley, 2005; Alexis and Shillingford, 2012).

When they first arrived, the majority of IENs felt they were strangers in England (Winkelmann-Gleed and Seeley, 2005). The experience gained in their home countries was not recognised and they were excluded from the planning and development of their induction programme (Taylor, 2005; Alexis and Shillingford, 2012). This may be a result of a lack of information and understanding, especially regarding cultural awareness and diversity between internationally educated nurses and the UK-trained nurses supporting them. This understanding is vital to support cultural transition (Matiti and Taylor, 2005), to fill the gap relating to the impact of language barriers and ethnocentric assumptions on nursing care and relationships in the workplace. The seminal work by Cross et al (1989) entitled ‘Towards a culturally competent system of care’, developed a framework explaining the processes towards achieving cultural competency, which occurs along a continuum following six stages from cultural destructiveness through cultural incapacity, cultural blindness, cultural pre-competence, cultural competence to cultural proficiency (Cross et al, 1989).

Cross et al (1989) emphasised that achieving cultural competence is a complex process and there is no ‘quick fix’ recipe or easy solution. They advised organisations to conduct a self-assessment and use the results to identify goals and priorities, and develop clear strategies and tactics towards meaningful growth in facilitating and enabling integration.

The model of ‘acculturation’ devised by Oberg (1960) and discussed by Muecke et al (2011), identified that cultural awareness should be included in the predeployment stage of IENs, and they must be involved in the shaping and delivery of their orientation programme. Future employers have some responsibility to manage IENs' expectations pre- and post-arrival in England. Societal transformation is a vital part of engaging and supporting IENs. These include professional bodies such as the Royal College of Nursing (RCN), UNISON, Florence Nightingale Foundation, international nursing diaspora associations, policymakers and so on in the host country (Al-Hamdan et al, 2015). Indeed, it must be recognised that acculturation can be facilitated or hindered by the way the host society receives the newcomers (Han and Humphreys, 2005; Hayne et al, 2009).

Arakelian et al (2003) developed a ‘cultural adjustment curve’ illustrating different stages on the journey of cultural adaptation from a ‘honeymoon’ period through ‘disintegration’, ‘reintegration’ ‘independence’ to ‘autonomy’. They stated that each individual journey is unique. Some may stay longer in a particular stage than others, and the length of journey varies from person to person and may take between 6 to 15 months or longer in some cases.

According to Alheit (1992), ‘biographicity’ is our ability to shape and reshape our lives through self-construction and self-projection, as products of our historical and current social interactions. Biographicity is multifactorial, scaffolded by layers of experiences coming together in a synergistic way (Alheit and Dausien, 2002). The emotional domain has the most impact on the biographicity of IENs. The feelings of loneliness, frustration and dissatisfaction caused significant emotional disruption in their lives. Analysis of the results of the nine studies reviewed suggests that the greater the emotional disruption in the lives of IENs, the more difficult it becomes for them to exercise biographicity. Although this was unclear in the studies being reviewed, this might be part of the reason why some IENs migrated to other countries or went back home for good.

Social interactions through formal and informal processes were reported by IENs as the biggest contributor to their integration into the NHS workforce. However, it seemed that other forces, such as motivation, aspiration, beliefs and goals, have also contributed to coping with challenges and rebuilding their lives in the UK.

In social cognitive theory, Bandura (1997) asserted that human behaviour is governed by multiple determinants operating through varied levels of motivation that are influenced by self-evaluation, perceived self-efficacy and personal goals. IENs migrating to England have clear goals of bettering their lives, learning new technologies, exploring the culture, earning money to support themselves and their families back home, and taking up opportunities to travel.

Socialisation through formal and informal interactions is key to the integration of IENs into the NHS workforce. However, cultural integration is complex and multifactorial. This integrative review highlighted the problems faced by both IENs and the employers and managers involved in the international recruitment and retention of staff.

Conclusion and recommendations

The results of this integrative review provide insight into the potential strategies that could be employed to better support IENs, especially during their first few months in England and, indeed, anywhere in the UK, to facilitate their integration into the healthcare workforce (Wenger, 2018). This review supports the findings of several previous studies. It is concerning that, despite the increasing need and ongoing reliance on IENs to fill the gaps in the English healthcare workforce, there has been too little improvement in the past decade. Therefore, the following actions are recommended:

Organisations should conduct a self-assessment to eliminate any institutional or systemic biases and racial discrimination. They should invest in training and development that facilitates cultural and linguistic competence and values the human and civil rights of IENs and every member of their workforce.

The implementation of the national preceptorship framework for nurses must be made mandatory, and monitored and evaluated to ensure the needs of newly qualified nurses, including IENs, are met.

International recruitment agencies should work in partnership with host country agencies to deliver pre-departure seminars for IENs focusing on cultural awareness, social integration and pastoral care. Pre-departure seminars will help manage the expectations of IENs when they arrive in the host country.

Employers should consider allocating mentors to IENs. Where possible, this would be someone from the same country or culture who has been in the organisation for some time and has been successfully integrated into the organisation. They may help address the issue of ‘culture shock’ and could motivate and inspire.

Employers should work with international nursing associations to gain better understanding of cultural diversity and insights on how to address the challenges faced by IENs, including their pastoral care needs, and enable them to establish a successful career in their host country.

In view of the findings of this integrative review, and the lack of research on the experiences of IENs who have successfully integrated into the NHS workforce, a longitudinal phenomenological research study using a semi-structured interview is suggested. Future research is needed to explore specific aspects of IENs' lived experiences in more depth, such as the relationship between self-efficacy, community of practice and success in the context of IENs' lifelong learning processes.