Whole-scale approach needed to help overseas nurses thrive

As the UK continues to rely on international recruitment as part of its solution to addressing the ongoing shortage of nurses, health and care leaders have come together to discuss what action is needed to ensure this is happening ethically and effectively. At the core of our latest roundtable event, sponsored by DataFlow, was the importance of overseas recruits being appropriately supported to live, work and progress in the UK.

Between April 2021 and March 2022, almost half of those who joined the UK’s nursing register – 23,408 – were from overseas, the majority from India or the Philippines. Meanwhile, the NHS in England has seen, on average, more than 1,700 overseas nurses join every month for the past year.

These recruitment efforts come against a backdrop of a shortage of an estimated 60,000 nurses across the UK and alongside predictions from the International Council of Nurses that up to 13 million more nurses will be needed globally over the next decade – in part because of the coronavirus pandemic and nurses heading for retirement.

Jim Buchan

Professor Jim Buchan, visiting professor at the University of Edinburgh, said some countries across the globe have remained reliant on overseas recruitment since the coronavirus pandemic, and in some cases, were ramping up their efforts.

There were also now higher levels of international recruitment from a broader range of countries than before the Covid-19 pandemic, he noted, such as in Germany and the US. In some cases, this was down to rising care demands and because of retention issues and the ageing nursing workforce seen in many high-income countries, he added.

For the UK, this meant that countries it had traditionally recruited from may also now be targeted by others, resulting in more competition. Professor Buchan warned the UK “might see a situation where our own nurses are attracted to other countries”.

Crucially, Professor Buchan said in countries such as the UK, it was important to ensure international recruitment efforts were “coordinated” with domestic recruitment and retention work, to allow for a “sustainable approach” which was both long- and short-term. “I think that is emerging here,” he said about the UK. “It is less apparent in some other countries, which perhaps don’t have a national health system infrastructure.”

Linda Everet

The roundtable also reflected on the importance of ensuring international recruitment was ethical and saw the Nursing and Midwifery Council (NMC) asked what its role was in ensuring this happens. Linda Everet, interim deputy director for professional regulation at the NMC, explained this was an issue its governing council was “very alive” to, especially given the increase in overseas recruits.

“We are here to regulate nurses, but obviously we have a wealth of data, we have a wealth of information that we can use to help inform policy, support and influence,” explained Ms Everet, whose portfolio includes international recruitment. It was the “influencing” part of this that the NMC council “probably wants to stray into a bit more” she added, to help protect the workforce.

Participants also highlighted the rise in nurses coming to the UK from “red list” countries – of which the World Health Organization says targeted recruitment should not occur due to health workforce shortages.

The roundtable heard how these nurses were more vulnerable and likely to be at the hands of unethical recruitment agencies. Recognising that nurses moving from countries, such as Nigeria or Ghana, had the freedom to choose where to work, participants acknowledged steps must be taken to ensure they had the same support and protection as those from outside the red list.

During the discussion, the focus moved from the recruitment of nurses from overseas, to the retention of these staff. Pockets of good practice and strong “wraparound” support for these nurses when they first landed in the UK and joined organisations, were highlighted.

This included schemes to support nurses with visas, driving lessons and with finding accommodation and schools, for example. The group also discussed the vital role of diaspora organisations and networks, which provide pastoral care and help support and connect nurses from overseas.

It was also recognised that nurses moving to the UK were now researching, more than before, which organisation they might like to work at. Nurses were deterred from trusts with poor Objective Structured Clinical Examination (OSCE) scores or those without good pastoral support and career pathways, the roundtable heard.

Ms Everet said the NMC was focused on the “treatment” of overseas nurses working in the UK. She believed work was needed at a management and infrastructure level to “make sure that they are treating people in the right way”. “I don’t think it was that long ago that I have heard nurse colleagues talking about ‘why are they coming over here and taking our jobs’ kind of thing,” she said.

Nursing Times has frequently reported concerning accounts of nurses from overseas who have faced bullying, harassment or discriminatory behaviour towards them, especially during the pandemic.

Ruth Oshikanlu

Ruth Oshikanlu, chief executive of coaching service Goal Mind, and a nurse by background, said she had supported nurses from overseas, who had come to her “sobbing” because of their poor experiences when moving to work in the UK. Efforts were needed to make sure the system supported these colleagues and learned from their lived experiences, she said.

Career progression was also a cause for concern among participants. Ms Oshikanlu told how she had supported nurses from overseas who, despite being ready for the next step in their careers, had been told it was too quick, and that they had to wait a few more months before officially climbing the ladder. Participants also discussed how many nurses from overseas have worked in the UK for decades while stuck at band 5 and unable to move up the career ladder.

When asked why this was happening, Felicia Kwaku, a Royal College of Nursing International Committee member, said: “The honest answer is racism.” Pointing to latest data, she explained it was evident nurses from minority ethnic backgrounds were overrepresented at lower band levels. “There is something about having an honest conversation with the system about being anti-racist,” added Ms Kwaku.

Meanwhile, deputy chief nursing officer for England, Duncan Burton, reiterated how prior experience of nurses coming from overseas had to be recognised. “International nurses are not newly qualified, they have years’ worth of experiences,” he said during the discussion. Mr Burton pointed towards a new NHS England funding offer, which aims to help trusts “push this agenda forward around accelerated development goals” for international nurses.

As part of this, he said there needed to be some thinking around interviewing nurses from overseas for roles higher than band 5 and about “what we can do to progress people much quicker into senior clinical roles or senior leadership roles”. “We have got to move this forward,” Mr Burton urged.

Deborah Sturdy

In addition, Professor Deborah Sturdy, chief nurse for adult social care in England, said the fact that these nurses were not always given opportunities to progress was “alarming”.

She highlighted how colleagues from the UK would not expect to move to another country, such as Nigeria for example, with a critical care qualification and master’s degree, and start at the bottom – as was happening for many nurses moving here from overseas.

She felt that data on this issue should be shared more widely and highlighted to the whole workforce to help enact change. In addition, she felt health and care leaders should “come out much stronger” against some of the issues raised, including discrimination, racism and a lack of career progression. While it was important to be aware that these things were happening, “it has got to be much more action focused” when it comes to addressing it, she said.

Caroline Waterfield, director of development and employment at NHS Employers, also flagged the importance of data sharing, noting how this would help “hold the mirror up to things that are not as good as they should be”. Ms Waterfield felt that in terms of retention, the “initial wraparound” support for nurses landing in the UK was “really strong”. But it was once these nurses were on the register that it becomes “a little bit more variable”.

Rafi Hattar

Ms Waterfield recognised that the UK had moved away from recruiting internationally in an “ad hoc” way and now had a “nationally coordinated set of infrastructure” and increased funding to do so. But her question was: “What happens next?”

Looking to the next few years, she said: “How do we have something in place which is sustainable and complementary to the domestic recruitment activity that we are also investing in and needing to focus on?”

In bringing the conversation to a close, participants reflected on their main take aways from the discussion. It was clear that among the key areas of concern were retention, wellbeing, and career progression. There was also a need for a whole- scale approach – from the workforce on the ground to senior management, system leaders and regulators – to ensure that international nurses are supported to thrive in the UK.