A literature review of research exploring the experiences of overseas nurses in the United Kingdom (2002–2017)

The migration of nurses has become a global phenomenon in the 21st century.1 Indeed, the World Health Organization (WHO)2 has highlighted the prominence of nurse migration, especially since 2000, to the UK and the USA. In the UK, a decades-long tradition of recruiting overseas nurses to make up for the shortage of nurses has become entrenched.3 In recent years, recruiting overseas nurses has become an indispensable task of the Department of Health to alleviate staffing shortages. In 2012, the Department of Health recruited 5,000 Spanish nurses to serve within the British health-care system. It is planned to recruit more nurses from China.4 Meanwhile, the government has signed several relevant agreements with countries facing a surplus of nurses. For example, an agreement was made with India to import approximately 6,000 nurses to work in the UK. This was beneficial in alleviating the staffing crisis to some degree.4 The Royal College of Nursing (RCN)5claimed that there is still an estimated national shortage of 22,000 nurses. Long-term nursing shortages in the UK mean that managers must actively recruit experienced nurses from both developed and developing countries.5

However, although the government has worked on importing a number of overseas nurses for many years through active policies and strategies, the shortage of nurses has not yet been rectified, in large part due to the rapidly increasing domestic needs of caregivers. Lintern6 believed that this chronic shortage of nurses would last for several years, but he predicted that the National Health Service (NHS) is likely to have more nurses than it needs by 2016. The statistics from the Nursing Times confirmed these predictions (Table 1). In 2010, there was a balance between supply of and demand for nurses in the British health-care system. However, this balance was immediately upset in 2016, again resulting in a shortage of 47,545 nurses. The Nursing Times revealed that it is a large challenge for managers to sustain the supply and demand of the future nursing workforce, particularly when funds are limited. Additionally, it was acknowledged that the health-care service is failing to provide communities with enough care and is therefore in urgent need of nurses to fill emergency departments.6 The RCN7 also highlighted the fact that this shortage of nurses will continue in the UK and that the scale of the shortage cannot be predicted. The RCN argued that this shortage will affect not only the health of current nurses, which may lead to a high turnover rate, but also the quality of care and even patient safety.

Table 1

Inclusion and exclusion criteria

Overseas nurses come from different countries or regions and have different beliefs and cultures.8 Statistics from the Nursing and Midwifery Council (NMC) provide information on the top 10 countries of origin (Figure 1). Over the past 10 years, the majority of overseas nurses have come from non-European Union countries. The main countries to export nurses were the Philippines, India, South Africa, and Australia. Until 2015, there were as many as 22,500 overseas nurses from the Philippines working in the UK. However, the health-care systems in those countries have many differences relative to the British health-care system due to a number of economic, social, and cultural factors.8 This means that overseas nurses may have more difficulties during their career in a new working environment. Therefore, Nichols and Campbell highlighted the importance of exploring the experiences of overseas nurses working in the current British health-care system.9

Figure 1

Statistics from the NMC demonstrate the proportion of foreign nurses in the UK. Although foreign nurses accounted for only approximately one-sixth of the nursing labor workforce, the population of overseas nurses in the UK is quite large, numbering 94,851 nurses (including 28,570 European Union nurses and 66,281 non-European Union nurses) (Figure 2). Numerous overseas nurses are working in the UK, and their experiences are a topic of concern for the British health-care system. In addition, after reviewing several case studies, Buchan and Dovlo10 found that managers are heavily dependent on overseas nurses as a core group of the workforce in the NHS and some private sectors. Many clinical fields currently rely on overseas nurses to satisfy their staffing needs.9 Overseas nurses are becoming increasingly important in the development of the British health-care service.9 Hence, it is necessary to pay more attention to their experiences, particularly given the limited supply of nursing labor. In addition, some negative experiences of overseas nurses have increased the levels of stress and burnout for numerous nurses on the frontline, and their turnover rate is higher than ever before.11 Developing a complete picture of their experiences will be beneficial for policymakers and employers, allowing them to take action in terms of retention. Furthermore, this information will help in the creation of a friendlier and more culturally diverse workforce.

Figure 2

Most previous research12,13 has only focused on the negative experiences of overseas nurses in the UK. However, there is little research assessing both sources of challenge and sources of support.14,15 Additionally, many studies have only studied nurses from 1 country or race. The results, therefore, cannot be generalized to all overseas nurses working in the UK. Furthermore, although Nichols and Campbell16 have produced an integrative review on this topic, they only reviewed articles written between 1995 and 2007. With the rapid development of medical technology and many changes in the nursing workplace,17 the findings of these review articles are too old to reflect the current experiences of overseas nurses. Additionally, their research used a qualitative approach, but their findings were merely extracted from qualitative research. By contrast, by adopting a systematic approach, this literature review further explores this topic from both qualitative and quantitative perspectives, thus providing a more comprehensive understanding of both the negative and positive aspects of overseas nurses’ experiences.

What challenges do overseas nurses experience during their working careers in the UK?

To critically explore the challenges faced by overseas nurses during their working careers in the UK;

The reviewer adopted the Critical Appraisal Skills Programme (CASP) and Critical Appraisal of a Descriptive Study to appraise selected articles. CASP, produced by Oxford University, offers a convenient and effective method to critically appraise diverse study methods.21 Eight CASP appraisal tools were suitable to differentiate between the study designs of the articles to be appraised. One of these tools was included in the CASP Qualitative Checklist, which is useful to appraise the quality of qualitative research. The reviewer used the CASP Qualitative Checklist to assess the 6 selected qualitative research studies. The quality and rigor of the methodology of these qualitative research studies was examined. Additionally, the Critical Appraisal of a Descriptive Study is a useful measure of the methodological quality of a given descriptive study. The 11 questions in this appraisal were particularly valid due to the detailed explanation of the criteria for every item. In the case of purely quantitative research, the reviewer used this appraisal approach. Importantly, appraisal of mixed-method research articles was conducted with both the CASP Qualitative Checklist and Critical Appraisal of a Descriptive Study. A summary of the assessment of each of the articles selected using these tools can be found in Appendix 1.

Gathering studies in a generic format can simplify data presentation and make data synthesis easier. In this review, the following pieces of information were extracted from the 8 selected articles: author, research focus, sampling method, location/setting, and type of research methods (Table 2).

Table 2

Data extracted from the 8 selected articles

In accordance with the research guidelines, ethical considerations were undertaken as required. Since this review was based on secondary data and did not recruit individual participants, it involved a very low risk from an ethical standpoint. In addition, among the 8 selected articles, 7 included clear ethics considerations and obtained ethical approval from specific agencies or committees.

One pressing challenge encountered by overseas nurses was cultural differences. Being from a different part of the world, overseas nurses had experienced a different culture. Alexis,23 Matiti and Taylor,15 Alexis and Shillingdord,26 Taylor,25 and Winkelmann-Gleed and Seeley28 all focused on this theme, showing the negative effects of cultural differences on the experiences of overseas nurses. Alexis23 highlighted the effects of the culture shock experienced by overseas nurses. He found that these overseas nurses had to learn a new approach to patient care due to differences between the British health-care systems and their former health-care system. For example, overseas nurses may be familiar with the medical equipment used in their country of origin but may not be familiar with the equipment used in the UK. Additionally, overseas nurses from North America were accustomed to standard approbation but had to change this usual practice into documentation because there is no standard approbation or a nationally agreed-on approbation in the UK.

Similarly, both Matiti and Taylor15 and Alexis and Shillingdord26 also acknowledged that internationally recruited nurses often experience cultural shock while adapting to their new life and new workplace. Matiti and Taylor15 noted that nursing practices were new to them, ranging from basic practices, such as cleaning patients after defecation and bed baths, to complex practices, such as using Dynamap and percutaneous endoscopic gastrostomy feeding. Additionally, the degree of paperwork required by the UK medical system is often reported as being overwhelming to overseas-trained nurses, and they often must spend much more time on paperwork than on providing actual patient care.15 Moreover, the National Service Framework for Children advocates that family-centered care should be of primary importance in the delivery of care and all nurses must align their care according to this framework.29 However, the findings of Alexis and Shillingdord’s study26 revealed that internationally recruited neonatal nurses were not familiar with the family-centered care system emphasized in the UK. The nurses often found it challenging to adjust to a system in which health education was provided to the family during the care of neonates. Alexis and Shillingdord26 highlighted how this unfamiliarity can directly influence the quality of patient care.

In addition, Taylor25 noted that differences in nursing roles created many barriers to overseas nurses’ work, especially when caring for elderly patients. For instance, in Nigeria, the role of the family includes caring for the elderly in the community settings. By contrast, in the UK, community nurses play a more important role in caring for the elderly who are waiting for a residential home placement. Surprisingly to these nurses, the family was included in patient care in the UK. Apart from new ways to perform patient care and different nursing roles, the different levels of autonomy in decision-making also required these overseas nurses to adapt to the ward culture of the UK.25 Thus, due to cultural differences, it is quite challenging for overseas nurses to adapt to the values and norms that underpin the British health-care system.28

Differences in accent and pronunciation restrict overseas nurses’ understanding and expression.30 Likewise, to these nurses, understanding the sociocultural aspects of communication is very challenging. Previous findings15,23,24,25,28 acknowledged that the effects of communication issues in nursing practices were evident for overseas nurses. Alexis23 reported that internationally educated nurses felt isolated when they were unable to communicate fluently with patients and host nurses. Taylor25 strongly supported this viewpoint. He also found that these nurses not only experienced difficulties in communication but were also isolated by UK nurses. Full integration into the ward is not possible for these overseas nurses when their capacity to communicate is restricted. In addition, Matiti and Taylor15 reported that internationally recruited nurses could often not even understand other foreign nurses’ accents. They also found that some internationally recruited nurses could not answer the phone due to comprehension issues. The absence of nonverbal cues makes telephone communication extremely stressful given their fear of miscommunication and subsequent harm to patients.15 Importantly, communication issues negatively contribute to career development to a large extent.24 Some overseas nurses had difficulties in applying current buzzwords and professional language to express themselves in applications or during interviews. Henry24 also found that some African nurses’ career stagnation was due to their poor communication skills compared to their UK-trained colleagues. The importance for adhering to professional discourses and improving communication skills in achieving successful career development was also highlighted in Henry’s24 research.

However, Winkelmann-Gleed and Seeley28 believed that language issues can function as a double-edged sword. On the one hand, since many overseas nurses speak English as a second language, rather than their mother tongue, cross-cultural communication issues can arise. On the other hand, overseas nurses recognize the value of their language skills when communicating with minority ethnic patients, especially in multicultural parts of the UK, such as London.

Another pertinent theme regarding the challenges experienced by overseas nurses focused on equity. In the UK, unequal treatment in the workplace was commonly reported by overseas nurses.22,24,25,27,28 Alexis23 noted that many internationally educated nurses encountered marginalization in the form of separation. Moreover, overseas nurses described that they felt unappreciated although they worked extra shifts.22 That is, they felt that their colleagues and managers did not appreciate the hard work that they performed. Alexis and Vydelingum22 also found that often, overseas black and minority ethnic nurses were given the most difficult tasks. Sometimes, a few senior staff members make more demands of foreign nurses than UK-trained nurses. Despite these poor conditions, foreign-trained nurses had little choice but to accept this treatment, as they often have had few other opportunities. They were also unwilling to stand up to authority. Winkelmann-Gleed and Seeley28 also found that overseas nurses often felt helpless when they experienced unfair work assignments and requirements.

In addition, a number of international nurses claimed that they had no opportunities for career development.28 Henry24 as well as Alexis and Vydelingum22 confirmed this finding. Henry24 reported that the process of promotion often lacked transparency. He also wrote that these nurses could not gain management experience and had no access to appropriate training compared with UK-trained nurses. Importantly, Alexis and Vydelingum22 also stated that their ethnic identity led to the refusal of training to some extent. They wrote that overseas nurses did not have access to a training course to develop themselves, even though additional training is a requirement for skill development and career progression.

Additionally, Alexis and Vydelingum22 attributed this unfairness to the British health-care system’s hierarchical nature. Other studies identified discrimination as a major reason for this unequal treatment.25,27 Alexis27 stated that internationally recruited nurses were discriminated against in the clinical environment (P<0.000). It was found that their experiences were largely different from those of UK-trained nurses. The hospital staff, patients, and their relatives were often aggressive toward them through harmful or offensive actions. Moreover, Taylor25 illustrated that racial discrimination was apparent in the NHS. He found that the humor used in the workplace referred to overseas nursing practices as being inferior. In response to this, many overseas nurses also used humor to suggest that the UK technology was inferior. Both groups of nurses used this method to highlight their differences, which was harmful for the creation of a multicultural workplace.

Some of the selected studies identified the resentment and frustration felt by overseas nurses when their skills and knowledge were questioned by their UK counterparts.15,22,25,26,28 Winkelmann-Gleed and Seeley28 found that migrant nurses were always regarded as student nurses, although they come to the UK with years of professional experience. Worse, the feelings of being treated as a novice in the workplace had a negative influence on their confidence and self-esteem.26 Alexis and Vydelingum’s22 study also confirmed this impact on internationally recruited nurses. They22 noted that it is important to recognize the clinical competence and value the knowledge that overseas nurses had already acquired. They also reported that overseas nurses’ experience can benefit the British nursing system, rather than their services being viewed only as a crisis intervention to rectify the shortage of nurses.

Additionally, Matiti and Taylor15 noted that nurses hoped that the skills they were accustomed to in their home country could still be used in the UK, but they could not use these skills due to policy restrictions. They found that these nurses felt confused about which nursing practices they were allowed to use in different wards. The “nursing” that they valued and thought was nursing was not recognized. This was a challenge to what they perceived as “nursing”.15 There was thus a mismatch between the organizational values and individual nurses’ values. Moreover, Taylor25 wrote that professional recognition of their qualifications did not automatically mean that their clinical competence and knowledge were recognized. This was not only indicated in the lowest grade for qualified nurses but was also reflected in their tasks. For example, they were often asked to assist patients with personal care rather than be involved in catheterization or venipuncture, which are often viewed as basic skills in their country. Taylor25 noted that this assumed ignorance denied their skills and experience the recognition they deserved and served to reinforce their junior status.

Some of the challenges experienced by overseas nurses are largely associated with technical issues and culture. These technical problems, such as challenges in interviewing or producing a curriculum vitae, can be solved by formal training and mentoring.24 Before these nurses work in the UK, it is necessary and helpful to provide support in the preparation and adaptation processes.15,24,25 Taylor25 stated that an adaptation program can be one of the best methods of support to help overseas nurses become familiar with the British health-care system. In addition, Matiti and Taylor15 noted that internationally recruited nurses could go to the British Embassy to acquire important documents, such as the NMC information sheet and a working permit. Apart from this, induction programs from the hospitals or other agencies often play a vital role for these nurses.15 However, most orientation programs did not focus on the specific cultural needs of internationally recruited nurses.15 They instead emphasized the necessity of culturally oriented information provided by various sources in minimizing “culture shock”. Moreover, Matiti and Taylor15 and Henry24 argued that accommodation issues also need to be addressed immediately after professional training programs, as well as providing sufficient informational support. Appropriate accommodation offered by employers can make their adaptation to the new environment easier. In addition, Taylor25 wrote that some special arrangements, such as matching their shifts to their partner’s shift patterns on another ward and coordinating off-duty time to ensure access to public transport, should be included in the support package.

Although some logistical support, such as help with accommodations and airport greetings, has been provided, several studies have suggested that foreign-trained nurses have limited access to equal, adequate, and transparent formal support.15,24 Specifically, the findings of Henry24 noted that these nurses had to repeatedly request formal support and when they did receive it, it was often interior to the support given to UK-trained nurses.

Alexis27 stated that internationally recruited nurses could receive support (P < 0.001) in the clinical environment. Although this research did not mention which type of support, it demonstrated that the support received by African-trained nurses was minimal compared to that of nurses trained in other countries.

All of the reviewed articles highlighted the importance of informal networks and social support systems for adapting to new environments. Taylor, Henry, Alexis, Winkelmann-Gleed and Seeley, and Alexis and Shillingdord all admitted that the formal systems of support were not major sources of help to foreign-trained nurses and that the far more effective support system was composed of their colleagues from the UK and overseas.23,24,25,26,28 Despite this, there were some differences between the supportive populations. For example, Winkelmann-Gleed and Seeley28 illustrated that most overseas nurses were more willing to ask for help from more supportive senior nurses, while Alexis23 found that overseas nurses preferred to seek support from nurses of the same color than from their senior nurses or managers. Importantly, Alexis and Shillingdord26 stated that, although their UK-trained colleagues could provide mixed support, the support was unable to fully guide foreign-trained nurses or provide them with valid information for caring. Importantly, the experiences of other overseas nurses were more effective and valuable in minimizing culture shock because of their similar cultural background and communication issues. In addition, the findings of Taylor25 indicated that these overseas nurses could benefit from pastoral support from their UK colleagues. Indeed, their local coworkers could be of great help by doing such things as taking them to areas of local or scenic interest on their day off or driving them home.

However, in contrast to these 5 studies, Alexis and Vydelingum22 deemed that this type of support mostly came from their shared affinity with other black and minority ethnic nurses. They found that the absence of support from UK-trained white nurses caused a large amount of difficulties and produced an unpleasant workplace environment. In addition, black and ethnic minority nurses were more willing to care for each other without the participation of white nurses. This type of collaborative environment, even if it does not cross racial or ethnic lines, may still lead to stress reduction and increased clinical confidence.