RESEARCH doi: 10.1111/nicc.12181
Recruitment of nurses from India and their experiences of an Overseas Nurses Program Fiona Stubbs ABSTRACT Background: Overseas recruitment has been vital to the contribution of staff growth in the National Health Service (NHS). In 2011, high nursing vacancy rates within critical care required that overseas nurses were recruited. The recruited nurses were placed in an Overseas Nurses Program (ONP), a course designed to assist overseas nurses in adapting to the NHS. Aim: To describe the experiences of nurses recruited from India who participated in an ONP. Design: A qualitative, research approach was chosen to gather descriptions of the lived experiences of nurses from India transitioning to London, to work in critical care settings. Method: A descriptive qualitative approach was taken using in-depth, semi-structured and audio-taped interviews. They were conducted over a 69-day period (30 November 2012 to 6 February 2013) with 16 nurses from India. The nurses were questioned about challenges, experiences and differences; they were also asked to make suggestions for other nurses undertaking an ONP in the future. Interviews were transcribed verbatim into a formal written style with NVivo10. Results: Eleven females and five males aged 25–33 years who had completed up to four years of university training participated in this study. The themes extracted were autonomy and responsibility, language, culture (food and climate), loneliness and work challenges (ONP and essay writing). Participants identified that they would have benefited if pre-allocated mentors from non-English speaking countries who had previously been through the transition process were available to assist them with their personal and professional integration into a new country. Conclusion: Autonomy disparity, language barriers and cultural differences need to be recognised and acknowledged by multi-disciplinary teams, by allowing sufficient time and additional support for non-English nurses undergoing ONPs. Relevance to clinical practice: Overseas nurses would benefit from being mentored by another nurse from a similar culture, with a non-English background. It may be feasible for overseas nurses to receive training in cultural competencies to improve disparities. Key words: Autonomy • Critical care • Language barriers • Overseas nurses • Recruitment
INTRODUCTION The Nursing and Midwifery Council (NMC) is a regulatory body for nurses and midwives working in the UK. In 2005, the NMC introduced an Overseas Nurses Program (ONP) whereby nurses who are trained outside the European Union (EU), European Economic Area (EEA) and Switzerland, wanting to register in the UK, must successfully complete an ONP. A 2008 Statistical Analysis of the NMC register revealed that 32 overseas countries had a nurse or midwife registered Author: F Stubbs, BSc, RN, MSc, GradCert AdNurs, Imperial College Healthcare Trust, St Mary’s Hospital, Paddington W2 NY1, London, UK Address for correspondence: Fiona Stubbs, Imperial College Healthcare Trust, St Mary’s Hospital, Paddington W2 NY1, London, UK E-mail: fi[email protected]
© 2015 British Association of Critical Care Nurses
by the year ending March 2008. The top three countries for the highest number of admissions were India with 1020 (44⋅17%), Australia 262 admissions (11⋅35%) and Philippines 249 admissions (10⋅78%) (Statistical Analysis Register, 2008). Current literature is internationally varied and focuses on Asian nurses’ experiences of moving to the UK (Buchan and Seccombe, 2006; Xu, 2007; Brush and Sochalski, 2009) or moving to the USA (Brush et al., 2004; Pittman et al., 2010); besides, there is literature focusing on Australian (Brunero et al., 2008), New Zealand and South African (Dovlo, 2007) nurses’ experiences of working in the National Health Service (NHS) (Buchan and Seccombe, 2006). Current research does not specifically focus on the experiences of nurses recruited from India to London who complete the ONP while working in critical care settings. 1
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BACKGROUND Overseas nurses programme In 2005, the NMC altered its education requirements by introducing an ONP. Jordan and Brown (2011) conducted a retrospective study reviewing a 20-day induction program using a web-based survey from 2007 to 2010 of non-EU overseas nurses (Australia, New Zealand, USA and South Africa), undertaking this compulsory learning program. The study collected experiences of nurses undertaking the ONP and obtained ‘information about the final destination of nurses in order to explore their impact within the UK’ (Jordan and Brown, 2011, p. 2). The online survey produced a disappointing response rate of 27⋅7%, although the study results indicated some barriers which the participants felt affected their learning while undertaking the ONP. These included: ‘ … too many policy documents (54%); financial need to work and study at the same time (52.1%); much of the content repeating their pre-registration training (48.8%); just arrived in the UK (43.7%); IT/Internet access problems (39.5%); not seeing the value in the ONP (36.3%); lack of peer support (21.4%) isolation and culture shock (14.9%).’ (Jordan and Brown, 2011, p. 6). As demonstrated by Statistical Analysis Register, 2008, there has been a large influx of Indian nurses into the UK, and there is an obvious research gap in exploring their experiences. The most significant research into an adaptation programme was conducted by Jordan and Brown (2011), and the study predominantly focused on nurses from Australia, New Zealand and South Africa. There is minimal current literature focusing on the experiences of nurses from India transitioning into the NHS to work in London.
Language Throughout the literature, various researchers (Xu, 2007; Jose et al., 2008; Rose, 2009; Ma et al., 2010) identify language as a barrier for Indian nurses upon transition. The NMC requirement for successful registration in the UK is an International English Language Testing System (IELTS 7). All overseas trained applicants must register for this proficiency test, regardless of which country they are from or if the majority speak English in that country (Nursing and Midwifery Council, 2008). In India, both secondary and tertiary education is conducted in English and even though a recruited nurse would have spoken adequate English to pass the entrance exam, she may react differently when in a work environment (Rose, 2009). Xu (2007) established that when Indian nurses migrated, the 2
English they learnt proficiently from a textbook was vastly different to the colloquial English to which they were exposed. Xu (2007) found that this influenced their care delivery to patients and also had an impact on their families. Xu (2007) also found that nurses from India had difficulty speaking over the telephone as well as understanding the accent of native English speakers.
Differences in culture Cultural challenges within the hospital environment have a major impact on nurses who migrate. In India, the physicians are more hands-on and are present in the critical care units at all times. Nurses rarely assess patients independently, and they are also discouraged from being assertive (Sherman and Eggenberger, 2008). In India, direct care is often provided by family members. In the UK, nurses from India are challenged by caring for a patient of the opposite sex; their pace of care is much slower and patients’ stay in hospital is longer (Sherman and Eggenberger, 2008). Xu (2007) also found that the cultural differences experienced by Asian nurses often left them with a feeling that they had to change on a personal level if they were to fit into the new culture and their work environment. Cultural challenges within society also have a major impact on migrant nurses. This is conveyed through a study conducted by Rose (2009) who established that setting up basics such as bank accounts, uniforms, making sure the nurses have a way of communicating with family back in their home country, ensuring nurses know how to use transport, provides individual independence, personal empowerment and achievement. This article explores the experiences of nurses recruited from India in 2011, who came to work specifically in critical care settings in London, both in intensive care and high dependency settings. The critical care settings include specialties such as major head and neck reconstructive surgery; plastic surgery; complex ear, nose and throat surgery; neurosurgery; neurology; cardiothoracic, interventional cardiology; major endocrine, hepatobiliary surgery; major surgery for gynaecological cancer; major trauma; vascular surgery; and upper and lower gastrointestinal surgery. The results from this article will provide evidence for recommendations to changes in policy and practice that will be relevant and transferable to any area of a hospital that has Indian nurses undertaking the ONP.
THE STUDY Aim The aim of the study was to explore the transition experiences of nurses recruited from India to London to work in critical care settings in 2011. Identifying their © 2015 British Association of Critical Care Nurses
Recruitment of nurses from India
experiences will ensure that appropriate strategies are in place to ease the transition of these nurses, and for informing educators and policy writers.
presumed that the data were correct. In conjunction with checking the data, congruency was also maintained by having computer-generated themes.
Design
Ethical considerations
A qualitative research approach was chosen in order to gather descriptions of the lived experiences, both work and social, of nurses transitioning from India to London. This design was specifically chosen to identify shared experiences of nurses from India who had experienced a common phenomenon. This is harmonious with the aim of the study.
Ethics approval was obtained from both the local Trust Research Committee (approval number: JRCOSM0353) and from the University (approval number: 2012/177). Informed and signed consent was also obtained from all participants, allowing them to opt out at any stage throughout the study. One barrier the researcher encountered was obtaining two ethics approvals (English hospital Trust and Australian University). The study was classified as a low-risk study by the hospital; however, the researcher required complete human ethics approval from the University.
Sample/participants This study is multi-centred (i.e. three separate hospitals that have critical care units within one Trust) with purposive sampling of the 16 nurses recruited from India, in 2011, specifically to work within the Trust. The study consisted of 11 females and 5 males aged between 25 and 33 years with 3–4 years university training. Each participant volunteered to join, signed a consent form with the understanding that she could withdraw from the study at any time.
Data collection With the participants’ permission, all interviews were in-depth, semi-structured and audio-taped over a 69-day period (30 November 2012 to 6 February 2013). Permission was obtained from the Senior Nurses of the critical care settings because all interviews were conducted at the nurse’s place of work. The responses to the nine questions were transcribed from oral into written language and the researcher utilised NVIVO Version 10 to extract themes from the data.
Data analysis All answers to the research questions were transcribed from tape-recordings and returned to the participants to check for accuracy. These transcripts were manually entered by the primary researcher into Nvivo10. Predominant themes were identified by the computer software using thematic analysis, and all themes were in keeping with the transcripts that had been verified by the participants. The themes were checked for consistency with the data by the researcher as well as by using the Nvivo program. Congruency was achieved within the research by ensuring that the semi-structured interview questions allowed participants to inform the researcher of their own lived experiences, where multiple truths are explored and respected. After the interviews were transcribed member checking was carried out to enhance rigor. If the participants did not return their answers, it was © 2015 British Association of Critical Care Nurses
RESULTS The predominant themes discussed in this article are autonomy and responsibility, language and work challenges with a focus on ONP and mentoring experiences. The participants’ age ranged from 25 to 33 years and disclosed multiple personal experiences in their transition from India to London. The main theme that emerged was autonomy and responsibility in relation to the bedside nursing and the freedom they have in decision-making. This was seen as a positive influence on their nursing practice because they did not have to rely as much on the medical team for decisions. Often the participants found it difficult to understand English accents, and there was a recognised language barrier with some participants highlighting the difficulties they had with communicating with patient families. The lack of knowledge on how to empathise with families was in contrast to their nursing experience in India because this was a task that was never expected in the majority of families; communication came from the doctors.
Differences in nurses’ roles: autonomy and responsibility Many of the participants indicated that there were significant changes in their nursing roles. One of these changes was autonomous decision making, and the study revealed that in India, doctors are the primary decision makers. ‘I have more freedom and responsibility; there is more responsibility over here (London). If the patient is on sliding scale I have to see how much insulin to give and if the patient becomes hypoglycaemic then that is my problem because there is already a sliding scale 3
Recruitment of nurses from India
that I need to use. Whereas in my unit (India) I would just do a blood sugar and tell the doctors they will give me a dose. I think what is expected of me here is being more grown up. That’s quite exciting.’ (Participant 1 – female)
Despite English being spoken in India and taught throughout Indian schools, for some people it is not used in day-to-day conversation. A common issue highlighted by two of the participants was the difficulty in understanding English accents.
Despite 50% of the participants indicating that nursing in London offers more freedom and more autonomy, it was also striking to note that one participant’s perception was that the patient care in India might sometimes have a direct link to patient mortality.
‘Some people say we speak fast but English (people) speak very fast and it is difficult to understand.’ (Participant 4 – male)
‘The mortality rate is much less here (London), once a while someone dies and I have seen a lot of people dying in India, and it can be a result poor nursing care sometimes, not always. When I first came here, I was wondering “no one is dying”. Even people with severe head injury come in and go to Trauma ward but if patients come in with that type of injury (India), they won’t survive; rarely one or two cases survive. If they did survive they would get an infection and definitely would get a pressure sore, one hundred per cent.’ (Participant 4 – male) Kramer and Schalenberg (2009) revealed a link between patient safety and high-quality patient care outcomes. Their study revealed that in order to achieve this link, nurses need to engage in clinical autonomy and practice collaboratively with physicians. As described by Participant 4, in India there is a less collaborative team approach to patient care. ‘When I was working in India I was literally following the orders of the doctor, no questions asked, that’s what happens there. Another thing, you don’t really think what you are doing you just follow orders but here it is different people are trying their level best to make the care better.’ (Participant 4 – male)
Language From 1 February 2007, the NMC increased the minimum IELTS requirement from 6⋅5 to 7 (of 9) to ensure greater public protection. The test is comprised of four components: listening, reading, writing and speaking. With the high level of English testing, language predominately featured as the Indian nurses’ biggest challenge as they transitioned into the working environment of critical care. One of the participants reported ‘When I first came here I had no clue what the doctors were saying because the type of English I learnt is totally different to what we speak here.’ (Participant 1 – female) 4
One participant found that her greatest challenge of the English language was she had never been out of India before ‘In my state we don’t speak English that often but most of the doctors are from other sites of India and they do speak English. They don’t know our language because in India there are a lot of languages. I have learnt this language (English) but I had never used it before . . . .. it was a bit difficult for me.’ (Participant 9 – female)
Work challenges The study also highlighted empathy and family communication as a difficult concept. Communication with families is a high priority and is a key to improving patient-centred care. Participant 16 described the supernumerary period (3–6 months as stipulated by the NMC) as helping bridge the gap with the language barrier because it gave him time to gain experience through listening to nurses’ conversations with both patients and relatives. ‘Back home we used to speak to patients and relatives in my mother tongue so that was a big transition for me … It’s not the language that is the problem it is how you talk to the relatives … relatives are so emotional so it is not like the academic writing and it is completely different to how we speak to relatives when they are emotional. We don’t counsel people or pacify people (in India) so we really need to hear how people are consoled, we don’t go through those types of situations … ’ (Participant 16 – male) Learning how to be empathetic cannot be taught through a textbook, but it is a key component to communication when speaking to patients and families. Participant 2 related his difficult communication experiences with families because in India, nurses rarely spoke to families about the patient’s condition or progress. © 2015 British Association of Critical Care Nurses
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‘Back home in India we don’t communicate that much with the family because we don’t have time, we have two patients … Here in London we communicate a lot to the patient’s families and I really love it but that is the biggest difference. Back in India the doctors communicate with the families, they lead the team; here in London we have a lot more autonomy which is a positively good difference. If a family (in India) comes and asks you questions about the patient’s condition or medical questions you are not confident to discuss it with them because the doctors don’t discuss it with you so you don’t know.’ (Participant 2 – male) Different forms of communication can be learnt in different ways, but it is unsurprising that the nurses from India lacked experience in this area of communication because their exposure to this form of communication was limited in India. The study revealed the acuity of the patients and the subsequent workload as another big work challenge for the participants. Many found patients who could talk to them challenging because the patients would be quite demanding and order staff around. If you are not accustomed to caring for patients who can verbalise their needs ‘for an ITU nurse I think it is very overwhelming’ (Participant 12 – female). Categorised under the theme of ‘Work Challenges’, participants were also specifically questioned about the ONP in relation to suggestions they could make to other nurses when they are undertaking the programme. The participants studied through a London University in partnership with a Trust for a period of 3to 6-months. Supervised practice was completed before being able work as a nurse in the UK. When the participants were asked about any changes they would make to the ONP, many suggested shortening the time by removing some of the legal sections. ‘When I came here, because of the adaptation programme and the NMC we were not allowed to do anything so that has affected my confidence. That’s quite traumatic, and one of the toughest parts you work in ITU, you have to take your patient where you cannot do anything and you tend to lose your skills. That really affected my confidence.’ (Participant 12 – female) It was not the ONP, which generated most discussion; the majority of the frustrations were over the time that took to receive their NMC registration. ‘You come over as an Overseas Nurse, you don’t have your Registration and you are not allowed to do a © 2015 British Association of Critical Care Nurses
lot of stuff that you would be doing on a regular basis … it gets a little stressful … and you are not so confident … That transition period was quite difficult because it’s not just about you … You can do things but you are not qualified, that was the worse bit.’ (Participant 14 – female) Despite completion of the ONP, their NMC registration was taking another 3–6 months. During this time, the qualified but not yet registered nurses remained unable to practice autonomously and were given little independence, leading to feelings of deskilling and loss of confidence in their ability. The ONP assessment structure was also highlighted as a challenge in transition from India to London. Despite their similarity in academic structure, the one major notable difference is their ability to structure and write in an essay format. Many participants had commented on this throughout their interviews and for some, 18 months onwards, it continues to be a struggle because the critical care course has an essay as a pre-entry requirement. ‘The Overseas Nursing Programme was a big challenge, to make sure you pass the essay because I didn’t know what it was or what was expected of me. We are not use to writing essays so that was a big challenge. The pattern of study here in the UK is very different, back home we have books and then exam pattern, it is the essay pattern it is very different.’ (Participant 6 – female) The predominant suggestion put forward by the participants to overcome this difficulty was to start writing essays much earlier to allow time for the mentors or educators to review it before submission.
Mentoring Mentoring was also felt to be a work challenge, and the participants were specifically questioned about what suggestions they could make for mentors to ensure a better working environment. The nurses from India felt frustrated with the ONP where there was a lack of independence and indicated they wanted to be given more freedom to work, but under supervision when they were being mentored. ‘ … The 20 days learning we were only observing and I think I did not learn much during that period but I did start learning when I was given my own 5
Recruitment of nurses from India
patient … the first day I was given a patient I was very late in writing my notes, I was late in handing over, but I think (the learning) was quicker than the previous 20 days period but I know it’s important.’ (Participant 1 – female) The participants also felt that a mentor who is not English or even a mentor who is from India would provide a better understanding of their Indian culture, potentially easing some of their anxieties. ‘If the mentor is someone from the outside like us it would be more helpful because they have adapted and they know the problems one faces. My mentor was someone who was not from England and I found it helpful with things like contract phone … My mentor could also relate to me when I said I missed home, if your mentor can understand that it is much easier.’ (Participant 3 – female) The results demonstrate the importance and impact of arranging mentors based on their backgrounds, as this may have a rewarding outcome for the mentees. It must be acknowledged that this is an ideal situation but not always realistic. It is important to recognise that the experiences of nurses from India through the transition period were not all negative. Many described the transition phase to be smooth, because the accommodation was pre-arranged and it was made clear how much the rent, food and travel would cost. The recruitment manager helped arrange bank accounts, and the participants had meetings with the Human Resources management team, they met their clinical educators before starting work, and the roster was given 1 month in advance which assisted the participants in planning their social activities around work.
DISCUSSION Autonomy and responsibility were the main themes identified within the study. Unlike Western society where nursing is viewed as a profession, nursing in some parts of India is stigmatised and is viewed as low in terms of employment status. According to Evans et al. (2013) this is because of the country’s tradition and history where it is unacceptable for women to work at night and outside the home, touch strangers and mix with men and to come in contact with bodily fluids. The participants within this study did not reveal any of these barriers within their nursing practice. It would be naïve of anyone to think that language would not be a difficult concept for nurses recruited 6
from overseas. The English language for many reasons such as accents and the use of colloquialisms will always be difficult when transitioning from a non-English speaking country. Despite the English language being taught and learnt theoretically in schools in India, it is significantly different to the English language used in everyday interactions. There will be a natural adjustment and an expectation that there will be a language-orientation period. Rose (2009) supports the concept that new recruits will act differently to the change in language but given time, they will adjust. Takeno (2010) emphasised that the negative experiences of overseas nurses were caused by their poor understanding of English. In contrast, participants in this study did not blame language difficulties for any negative experiences. However, there was evidence to suggest confusion on how to address empathetic situations with family communications. Ma et al. (2010) found the language barrier caused miscommunication, isolation and loneliness. It could be argued that isolation and loneliness may be attributed to cultural differences and not associated with language. Feeling alone was an emotion experienced by participants because of leaving their family and friends back in India. A 2012 study conducted in America, which reviewed nurses’ communication in an intensive care unit found that nurses have many interactions with families and patients where they addressed worries and concerns, encouraged questions and listening (Slatore et al., 2012). Interestingly, a study conducted by McCabe (2004) revealed, when nurses were sympathetic, the patients felt that their feelings were justified. It made them feel like the nurses cared about them as a person and were understanding of the patient’s situation. The ONP for these nurses was especially tailored to the needs of critical care nurses. This was experimental, whereby 50% of the study days were delivered by a university senior lecturer and 50% by intensive care educators. The latter delivered core components of the programme but these applied to the specialty of Intensive Care (e.g. pharmacology). The ONP Course Handbook (University of West London, 2013) contained five sections: Key Information, Structure and Content, Learning Teaching and Assessment, Student Support and Guidance, Quality Management and Enhancement. Some of the participants revealed that during the course it was important to be prepared and start writing essays early. One suggestion made was to carry a diary because there was so much to learn when you first start; writing things down would have been helpful. The participants also recognised that it takes time to learn how the systems work and to recognise their limitations. © 2015 British Association of Critical Care Nurses
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The adaptation programme allows time for learning because of the allocation of mentors. According to the NMC, a mentor is defined as ‘A registrant who has met the outcomes of stage 2 and who facilitates learning, and supervises and assesses students in a practice setting’ (2008, p. 45). Some of the participants experienced minimal learning within the first 20-days protected time and found the hands-on approach to be of a greater benefit. The majority of participants had ‘great’ mentors because some mentors were from India and others from the Philippines. This relationship between these mentors and overseas nurses was strengthened because of the mentors’ ability to relate to feelings and language, associated with work and social life. These mentors understood what it was like for the overseas nurses, especially the cultural changes and feelings of insecurity associated with not being home in India. There was also a genuine understanding and recognition of their learning. Many of the mentors had been in similar situations when they relocated to London. Some of the negative comments associated with mentoring focused around mentors not working with the overseas nurses on a consistent basis or mentors leaving the critical care unit when the overseas nurses had not completed the ONP. This was found to be disruptive, and the overseas nurses felt less supported as a result.
Limitations The findings of this study should be interpreted in view of limitations. The sole purpose of the research study was to focus on nurses specifically recruited from India to London to work in Critical Care settings. The results should not be taken to represent all nurses completing the ONP working in other parts of the UK and other specialty areas or wards, although this would not be expected in qualitative research. It must also be recognised that the researcher’s role as a senior nurse may have influenced responses to questions.
CONCLUSION This article has outlined that there should be a degree of expectation of cultural differences with nurses undertaking the ONP and that these differences will impact on their transition. The implications of this study are that managers who are recruiting from overseas need to acknowledge these nurses may require a more extensive period of support. Future studies could review the retention of overseas nurses (compared with UK nurses) as anecdotally it has been noted that overseas nurses may remain working in the critical care environment for longer than UK-trained nurses; thus it could be argued that the initial time investment and support is warranted.
WHAT IS KNOWN ABOUT THE TOPIC •
Previous literature has reviewed the approach of 20 days protected learning time for overseas nurses and the transition of these nurses into the UK. Currently, no research has specifically focused on the transition/experiences of nurses from India into London critical care settings.
WHAT THIS PAPER ADDS • • • •
Expectations of registration should be made clear to nurses who complete the mandatory ONP. Limited information is available on the NMC website indicating timeframes for registration of nurses who are trained outside Europe. The nurses from India would benefit by being mentored by other nurses from a similar culture, with a non-English background. Re-examining education strategies to ensure that essay writing is more familiar to overseas nurses. This may be achieved by providing example essays into their information packs and outlining the marking structure. The results are potentially transferable to any area within the NHS.
REFERENCES Brunero S, Smith J, Bates E. (2008). Expectations and experiences of recently recruited overseas qualified nurses in Australia. Contemporary Nurse; 28: 101–110. Brush B, Sochalski J. (2009). International nurse migration: lessons from the Philippines. Policy Politics & Nursing Practice; 8: 37–46. Brush B, Sochalski J, Berger A. (2004). Imported care: recruiting foreign nurses to United States health care facilities. Health Affairs; 23: 78–88.
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Buchan J, Seccombe I. (2006). Worlds Apart? The UK and International Nurses. London: Royal College of Nurses. Dovlo D. (2007). Migration of nurses from sub-Saharan Africa: a review of issues and challenges. Health Services Research; 42: 1371–1388. Evans C, Rafath R, Cook E. (2013). Building nurse education capacity in India: insights from a faculty development programme in Andhra Pradesh. BMC Nursing; 12: 1–8. Jordan G, Brown P. (2011). ‘20 days protected learning’ – students’ experiences of an overseas nurse’s programme – 4 years on: a retrospective survey. BMC Nursing; 10: 1–9.
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Jose J, Quinn Griffin M, Click E, Fitzpatrick J. (2008). Demands of immigration among Indian nurses who immigrated to the United States. Asian Nursing Research; 2: 46–54. Kramer M, Schalenberg C. (2009). The practice of clinical autonomy in hospitals: 20,000 nurses tell their story. Critical Care Nurse; 28: 58–71. Ma A, Quinn GM, Capitulo K, Fitzpatrick J. (2010). Demands of immigration among Chinese immigration nurses. International Journal of Nursing Practice; 16: 443–453. McCabe C. (2004). Nurse-patient communication: an exploration of patients’ experience. Journal of Clinical Nursing; 13: 41–49. Nursing and Midwifery Council. (2008). Standards to Support Learning and Assessment in Practice. London: Nursing and Midwifery Council. Pittman P, Folsom A, Bass E. (2010). US-based recruitment of foreign-educated nurses: implication of an emerging industry. American Journal of Nursing; 110: 38–48. Rose S. (2009). Nursing shortage: the challenge of nurse recruitment from India. Professional Nursing Today; 13: 4–5.
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Sherman R, Eggenberger T. (2008). Transitioning internationally recruited nurses into clinical settings. The Journal of Continuing Education in Nursing; 39: 535–544. Slatore C, Hansen L, Ganzini L, Press N, Osbourne M, Chesnutt M, Mularski R. (2012). Communication by nurses in the intensive care unit: qualitative analysis of domains of patient-centered care. American Journal of Critical Care; 21: 410–418. Statistical Analysis Register. (2008). Statistical Analysis of the Register 1 April 2007 to 31 March 2008. http://www.nmc-uk.org (accessed 20/03/13). Takeno Y. (2010). Facilitating the transition of Asian nurses to work in Australia. Journal of Nursing Management; 18: 215–224. University of West London. (2013). Overseas Nurses Programme. Course Handbook. London: University of West London. Xu Y. (2007). Strangers in strange lands a metasynthesis of lived experiences of immigrant Asian nurses working in western countries. Advances in Nursing Science; 30: 246–265.
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Recruitment of nurses from India and their experiences of an Overseas Nurses Program Fiona Stubbs ABSTRACT Background: Overseas recruitment has been vital to the contribution of staff growth in the National Health Service (NHS). In 2011, high nursing vacancy rates within critical care required that overseas nurses were recruited. The recruited nurses were placed in an Overseas Nurses Program (ONP), a course designed to assist overseas nurses in adapting to the NHS. Aim: To describe the experiences of nurses recruited from India who participated in an ONP. Design: A qualitative, research approach was chosen to gather descriptions of the lived experiences of nurses from India transitioning to London, to work in critical care settings. Method: A descriptive qualitative approach was taken using in-depth, semi-structured and audio-taped interviews. They were conducted over a 69-day period (30 November 2012 to 6 February 2013) with 16 nurses from India. The nurses were questioned about challenges, experiences and differences; they were also asked to make suggestions for other nurses undertaking an ONP in the future. Interviews were transcribed verbatim into a formal written style with NVivo10. Results: Eleven females and five males aged 25–33 years who had completed up to four years of university training participated in this study. The themes extracted were autonomy and responsibility, language, culture (food and climate), loneliness and work challenges (ONP and essay writing). Participants identified that they would have benefited if pre-allocated mentors from non-English speaking countries who had previously been through the transition process were available to assist them with their personal and professional integration into a new country. Conclusion: Autonomy disparity, language barriers and cultural differences need to be recognised and acknowledged by multi-disciplinary teams, by allowing sufficient time and additional support for non-English nurses undergoing ONPs. Relevance to clinical practice: Overseas nurses would benefit from being mentored by another nurse from a similar culture, with a non-English background. It may be feasible for overseas nurses to receive training in cultural competencies to improve disparities. Key words: Autonomy • Critical care • Language barriers • Overseas nurses • Recruitment
INTRODUCTION The Nursing and Midwifery Council (NMC) is a regulatory body for nurses and midwives working in the UK. In 2005, the NMC introduced an Overseas Nurses Program (ONP) whereby nurses who are trained outside the European Union (EU), European Economic Area (EEA) and Switzerland, wanting to register in the UK, must successfully complete an ONP. A 2008 Statistical Analysis of the NMC register revealed that 32 overseas countries had a nurse or midwife registered Author: F Stubbs, BSc, RN, MSc, GradCert AdNurs, Imperial College Healthcare Trust, St Mary’s Hospital, Paddington W2 NY1, London, UK Address for correspondence: Fiona Stubbs, Imperial College Healthcare Trust, St Mary’s Hospital, Paddington W2 NY1, London, UK E-mail: fi[email protected]
© 2015 British Association of Critical Care Nurses
by the year ending March 2008. The top three countries for the highest number of admissions were India with 1020 (44⋅17%), Australia 262 admissions (11⋅35%) and Philippines 249 admissions (10⋅78%) (Statistical Analysis Register, 2008). Current literature is internationally varied and focuses on Asian nurses’ experiences of moving to the UK (Buchan and Seccombe, 2006; Xu, 2007; Brush and Sochalski, 2009) or moving to the USA (Brush et al., 2004; Pittman et al., 2010); besides, there is literature focusing on Australian (Brunero et al., 2008), New Zealand and South African (Dovlo, 2007) nurses’ experiences of working in the National Health Service (NHS) (Buchan and Seccombe, 2006). Current research does not specifically focus on the experiences of nurses recruited from India to London who complete the ONP while working in critical care settings. 1
Recruitment of nurses from India
BACKGROUND Overseas nurses programme In 2005, the NMC altered its education requirements by introducing an ONP. Jordan and Brown (2011) conducted a retrospective study reviewing a 20-day induction program using a web-based survey from 2007 to 2010 of non-EU overseas nurses (Australia, New Zealand, USA and South Africa), undertaking this compulsory learning program. The study collected experiences of nurses undertaking the ONP and obtained ‘information about the final destination of nurses in order to explore their impact within the UK’ (Jordan and Brown, 2011, p. 2). The online survey produced a disappointing response rate of 27⋅7%, although the study results indicated some barriers which the participants felt affected their learning while undertaking the ONP. These included: ‘ … too many policy documents (54%); financial need to work and study at the same time (52.1%); much of the content repeating their pre-registration training (48.8%); just arrived in the UK (43.7%); IT/Internet access problems (39.5%); not seeing the value in the ONP (36.3%); lack of peer support (21.4%) isolation and culture shock (14.9%).’ (Jordan and Brown, 2011, p. 6). As demonstrated by Statistical Analysis Register, 2008, there has been a large influx of Indian nurses into the UK, and there is an obvious research gap in exploring their experiences. The most significant research into an adaptation programme was conducted by Jordan and Brown (2011), and the study predominantly focused on nurses from Australia, New Zealand and South Africa. There is minimal current literature focusing on the experiences of nurses from India transitioning into the NHS to work in London.
Language Throughout the literature, various researchers (Xu, 2007; Jose et al., 2008; Rose, 2009; Ma et al., 2010) identify language as a barrier for Indian nurses upon transition. The NMC requirement for successful registration in the UK is an International English Language Testing System (IELTS 7). All overseas trained applicants must register for this proficiency test, regardless of which country they are from or if the majority speak English in that country (Nursing and Midwifery Council, 2008). In India, both secondary and tertiary education is conducted in English and even though a recruited nurse would have spoken adequate English to pass the entrance exam, she may react differently when in a work environment (Rose, 2009). Xu (2007) established that when Indian nurses migrated, the 2
English they learnt proficiently from a textbook was vastly different to the colloquial English to which they were exposed. Xu (2007) found that this influenced their care delivery to patients and also had an impact on their families. Xu (2007) also found that nurses from India had difficulty speaking over the telephone as well as understanding the accent of native English speakers.
Differences in culture Cultural challenges within the hospital environment have a major impact on nurses who migrate. In India, the physicians are more hands-on and are present in the critical care units at all times. Nurses rarely assess patients independently, and they are also discouraged from being assertive (Sherman and Eggenberger, 2008). In India, direct care is often provided by family members. In the UK, nurses from India are challenged by caring for a patient of the opposite sex; their pace of care is much slower and patients’ stay in hospital is longer (Sherman and Eggenberger, 2008). Xu (2007) also found that the cultural differences experienced by Asian nurses often left them with a feeling that they had to change on a personal level if they were to fit into the new culture and their work environment. Cultural challenges within society also have a major impact on migrant nurses. This is conveyed through a study conducted by Rose (2009) who established that setting up basics such as bank accounts, uniforms, making sure the nurses have a way of communicating with family back in their home country, ensuring nurses know how to use transport, provides individual independence, personal empowerment and achievement. This article explores the experiences of nurses recruited from India in 2011, who came to work specifically in critical care settings in London, both in intensive care and high dependency settings. The critical care settings include specialties such as major head and neck reconstructive surgery; plastic surgery; complex ear, nose and throat surgery; neurosurgery; neurology; cardiothoracic, interventional cardiology; major endocrine, hepatobiliary surgery; major surgery for gynaecological cancer; major trauma; vascular surgery; and upper and lower gastrointestinal surgery. The results from this article will provide evidence for recommendations to changes in policy and practice that will be relevant and transferable to any area of a hospital that has Indian nurses undertaking the ONP.
THE STUDY Aim The aim of the study was to explore the transition experiences of nurses recruited from India to London to work in critical care settings in 2011. Identifying their © 2015 British Association of Critical Care Nurses
Recruitment of nurses from India
experiences will ensure that appropriate strategies are in place to ease the transition of these nurses, and for informing educators and policy writers.
presumed that the data were correct. In conjunction with checking the data, congruency was also maintained by having computer-generated themes.
Design
Ethical considerations
A qualitative research approach was chosen in order to gather descriptions of the lived experiences, both work and social, of nurses transitioning from India to London. This design was specifically chosen to identify shared experiences of nurses from India who had experienced a common phenomenon. This is harmonious with the aim of the study.
Ethics approval was obtained from both the local Trust Research Committee (approval number: JRCOSM0353) and from the University (approval number: 2012/177). Informed and signed consent was also obtained from all participants, allowing them to opt out at any stage throughout the study. One barrier the researcher encountered was obtaining two ethics approvals (English hospital Trust and Australian University). The study was classified as a low-risk study by the hospital; however, the researcher required complete human ethics approval from the University.
Sample/participants This study is multi-centred (i.e. three separate hospitals that have critical care units within one Trust) with purposive sampling of the 16 nurses recruited from India, in 2011, specifically to work within the Trust. The study consisted of 11 females and 5 males aged between 25 and 33 years with 3–4 years university training. Each participant volunteered to join, signed a consent form with the understanding that she could withdraw from the study at any time.
Data collection With the participants’ permission, all interviews were in-depth, semi-structured and audio-taped over a 69-day period (30 November 2012 to 6 February 2013). Permission was obtained from the Senior Nurses of the critical care settings because all interviews were conducted at the nurse’s place of work. The responses to the nine questions were transcribed from oral into written language and the researcher utilised NVIVO Version 10 to extract themes from the data.
Data analysis All answers to the research questions were transcribed from tape-recordings and returned to the participants to check for accuracy. These transcripts were manually entered by the primary researcher into Nvivo10. Predominant themes were identified by the computer software using thematic analysis, and all themes were in keeping with the transcripts that had been verified by the participants. The themes were checked for consistency with the data by the researcher as well as by using the Nvivo program. Congruency was achieved within the research by ensuring that the semi-structured interview questions allowed participants to inform the researcher of their own lived experiences, where multiple truths are explored and respected. After the interviews were transcribed member checking was carried out to enhance rigor. If the participants did not return their answers, it was © 2015 British Association of Critical Care Nurses
RESULTS The predominant themes discussed in this article are autonomy and responsibility, language and work challenges with a focus on ONP and mentoring experiences. The participants’ age ranged from 25 to 33 years and disclosed multiple personal experiences in their transition from India to London. The main theme that emerged was autonomy and responsibility in relation to the bedside nursing and the freedom they have in decision-making. This was seen as a positive influence on their nursing practice because they did not have to rely as much on the medical team for decisions. Often the participants found it difficult to understand English accents, and there was a recognised language barrier with some participants highlighting the difficulties they had with communicating with patient families. The lack of knowledge on how to empathise with families was in contrast to their nursing experience in India because this was a task that was never expected in the majority of families; communication came from the doctors.
Differences in nurses’ roles: autonomy and responsibility Many of the participants indicated that there were significant changes in their nursing roles. One of these changes was autonomous decision making, and the study revealed that in India, doctors are the primary decision makers. ‘I have more freedom and responsibility; there is more responsibility over here (London). If the patient is on sliding scale I have to see how much insulin to give and if the patient becomes hypoglycaemic then that is my problem because there is already a sliding scale 3
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that I need to use. Whereas in my unit (India) I would just do a blood sugar and tell the doctors they will give me a dose. I think what is expected of me here is being more grown up. That’s quite exciting.’ (Participant 1 – female)
Despite English being spoken in India and taught throughout Indian schools, for some people it is not used in day-to-day conversation. A common issue highlighted by two of the participants was the difficulty in understanding English accents.
Despite 50% of the participants indicating that nursing in London offers more freedom and more autonomy, it was also striking to note that one participant’s perception was that the patient care in India might sometimes have a direct link to patient mortality.
‘Some people say we speak fast but English (people) speak very fast and it is difficult to understand.’ (Participant 4 – male)
‘The mortality rate is much less here (London), once a while someone dies and I have seen a lot of people dying in India, and it can be a result poor nursing care sometimes, not always. When I first came here, I was wondering “no one is dying”. Even people with severe head injury come in and go to Trauma ward but if patients come in with that type of injury (India), they won’t survive; rarely one or two cases survive. If they did survive they would get an infection and definitely would get a pressure sore, one hundred per cent.’ (Participant 4 – male) Kramer and Schalenberg (2009) revealed a link between patient safety and high-quality patient care outcomes. Their study revealed that in order to achieve this link, nurses need to engage in clinical autonomy and practice collaboratively with physicians. As described by Participant 4, in India there is a less collaborative team approach to patient care. ‘When I was working in India I was literally following the orders of the doctor, no questions asked, that’s what happens there. Another thing, you don’t really think what you are doing you just follow orders but here it is different people are trying their level best to make the care better.’ (Participant 4 – male)
Language From 1 February 2007, the NMC increased the minimum IELTS requirement from 6⋅5 to 7 (of 9) to ensure greater public protection. The test is comprised of four components: listening, reading, writing and speaking. With the high level of English testing, language predominately featured as the Indian nurses’ biggest challenge as they transitioned into the working environment of critical care. One of the participants reported ‘When I first came here I had no clue what the doctors were saying because the type of English I learnt is totally different to what we speak here.’ (Participant 1 – female) 4
One participant found that her greatest challenge of the English language was she had never been out of India before ‘In my state we don’t speak English that often but most of the doctors are from other sites of India and they do speak English. They don’t know our language because in India there are a lot of languages. I have learnt this language (English) but I had never used it before . . . .. it was a bit difficult for me.’ (Participant 9 – female)
Work challenges The study also highlighted empathy and family communication as a difficult concept. Communication with families is a high priority and is a key to improving patient-centred care. Participant 16 described the supernumerary period (3–6 months as stipulated by the NMC) as helping bridge the gap with the language barrier because it gave him time to gain experience through listening to nurses’ conversations with both patients and relatives. ‘Back home we used to speak to patients and relatives in my mother tongue so that was a big transition for me … It’s not the language that is the problem it is how you talk to the relatives … relatives are so emotional so it is not like the academic writing and it is completely different to how we speak to relatives when they are emotional. We don’t counsel people or pacify people (in India) so we really need to hear how people are consoled, we don’t go through those types of situations … ’ (Participant 16 – male) Learning how to be empathetic cannot be taught through a textbook, but it is a key component to communication when speaking to patients and families. Participant 2 related his difficult communication experiences with families because in India, nurses rarely spoke to families about the patient’s condition or progress. © 2015 British Association of Critical Care Nurses
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‘Back home in India we don’t communicate that much with the family because we don’t have time, we have two patients … Here in London we communicate a lot to the patient’s families and I really love it but that is the biggest difference. Back in India the doctors communicate with the families, they lead the team; here in London we have a lot more autonomy which is a positively good difference. If a family (in India) comes and asks you questions about the patient’s condition or medical questions you are not confident to discuss it with them because the doctors don’t discuss it with you so you don’t know.’ (Participant 2 – male) Different forms of communication can be learnt in different ways, but it is unsurprising that the nurses from India lacked experience in this area of communication because their exposure to this form of communication was limited in India. The study revealed the acuity of the patients and the subsequent workload as another big work challenge for the participants. Many found patients who could talk to them challenging because the patients would be quite demanding and order staff around. If you are not accustomed to caring for patients who can verbalise their needs ‘for an ITU nurse I think it is very overwhelming’ (Participant 12 – female). Categorised under the theme of ‘Work Challenges’, participants were also specifically questioned about the ONP in relation to suggestions they could make to other nurses when they are undertaking the programme. The participants studied through a London University in partnership with a Trust for a period of 3to 6-months. Supervised practice was completed before being able work as a nurse in the UK. When the participants were asked about any changes they would make to the ONP, many suggested shortening the time by removing some of the legal sections. ‘When I came here, because of the adaptation programme and the NMC we were not allowed to do anything so that has affected my confidence. That’s quite traumatic, and one of the toughest parts you work in ITU, you have to take your patient where you cannot do anything and you tend to lose your skills. That really affected my confidence.’ (Participant 12 – female) It was not the ONP, which generated most discussion; the majority of the frustrations were over the time that took to receive their NMC registration. ‘You come over as an Overseas Nurse, you don’t have your Registration and you are not allowed to do a © 2015 British Association of Critical Care Nurses
lot of stuff that you would be doing on a regular basis … it gets a little stressful … and you are not so confident … That transition period was quite difficult because it’s not just about you … You can do things but you are not qualified, that was the worse bit.’ (Participant 14 – female) Despite completion of the ONP, their NMC registration was taking another 3–6 months. During this time, the qualified but not yet registered nurses remained unable to practice autonomously and were given little independence, leading to feelings of deskilling and loss of confidence in their ability. The ONP assessment structure was also highlighted as a challenge in transition from India to London. Despite their similarity in academic structure, the one major notable difference is their ability to structure and write in an essay format. Many participants had commented on this throughout their interviews and for some, 18 months onwards, it continues to be a struggle because the critical care course has an essay as a pre-entry requirement. ‘The Overseas Nursing Programme was a big challenge, to make sure you pass the essay because I didn’t know what it was or what was expected of me. We are not use to writing essays so that was a big challenge. The pattern of study here in the UK is very different, back home we have books and then exam pattern, it is the essay pattern it is very different.’ (Participant 6 – female) The predominant suggestion put forward by the participants to overcome this difficulty was to start writing essays much earlier to allow time for the mentors or educators to review it before submission.
Mentoring Mentoring was also felt to be a work challenge, and the participants were specifically questioned about what suggestions they could make for mentors to ensure a better working environment. The nurses from India felt frustrated with the ONP where there was a lack of independence and indicated they wanted to be given more freedom to work, but under supervision when they were being mentored. ‘ … The 20 days learning we were only observing and I think I did not learn much during that period but I did start learning when I was given my own 5
Recruitment of nurses from India
patient … the first day I was given a patient I was very late in writing my notes, I was late in handing over, but I think (the learning) was quicker than the previous 20 days period but I know it’s important.’ (Participant 1 – female) The participants also felt that a mentor who is not English or even a mentor who is from India would provide a better understanding of their Indian culture, potentially easing some of their anxieties. ‘If the mentor is someone from the outside like us it would be more helpful because they have adapted and they know the problems one faces. My mentor was someone who was not from England and I found it helpful with things like contract phone … My mentor could also relate to me when I said I missed home, if your mentor can understand that it is much easier.’ (Participant 3 – female) The results demonstrate the importance and impact of arranging mentors based on their backgrounds, as this may have a rewarding outcome for the mentees. It must be acknowledged that this is an ideal situation but not always realistic. It is important to recognise that the experiences of nurses from India through the transition period were not all negative. Many described the transition phase to be smooth, because the accommodation was pre-arranged and it was made clear how much the rent, food and travel would cost. The recruitment manager helped arrange bank accounts, and the participants had meetings with the Human Resources management team, they met their clinical educators before starting work, and the roster was given 1 month in advance which assisted the participants in planning their social activities around work.
DISCUSSION Autonomy and responsibility were the main themes identified within the study. Unlike Western society where nursing is viewed as a profession, nursing in some parts of India is stigmatised and is viewed as low in terms of employment status. According to Evans et al. (2013) this is because of the country’s tradition and history where it is unacceptable for women to work at night and outside the home, touch strangers and mix with men and to come in contact with bodily fluids. The participants within this study did not reveal any of these barriers within their nursing practice. It would be naïve of anyone to think that language would not be a difficult concept for nurses recruited 6
from overseas. The English language for many reasons such as accents and the use of colloquialisms will always be difficult when transitioning from a non-English speaking country. Despite the English language being taught and learnt theoretically in schools in India, it is significantly different to the English language used in everyday interactions. There will be a natural adjustment and an expectation that there will be a language-orientation period. Rose (2009) supports the concept that new recruits will act differently to the change in language but given time, they will adjust. Takeno (2010) emphasised that the negative experiences of overseas nurses were caused by their poor understanding of English. In contrast, participants in this study did not blame language difficulties for any negative experiences. However, there was evidence to suggest confusion on how to address empathetic situations with family communications. Ma et al. (2010) found the language barrier caused miscommunication, isolation and loneliness. It could be argued that isolation and loneliness may be attributed to cultural differences and not associated with language. Feeling alone was an emotion experienced by participants because of leaving their family and friends back in India. A 2012 study conducted in America, which reviewed nurses’ communication in an intensive care unit found that nurses have many interactions with families and patients where they addressed worries and concerns, encouraged questions and listening (Slatore et al., 2012). Interestingly, a study conducted by McCabe (2004) revealed, when nurses were sympathetic, the patients felt that their feelings were justified. It made them feel like the nurses cared about them as a person and were understanding of the patient’s situation. The ONP for these nurses was especially tailored to the needs of critical care nurses. This was experimental, whereby 50% of the study days were delivered by a university senior lecturer and 50% by intensive care educators. The latter delivered core components of the programme but these applied to the specialty of Intensive Care (e.g. pharmacology). The ONP Course Handbook (University of West London, 2013) contained five sections: Key Information, Structure and Content, Learning Teaching and Assessment, Student Support and Guidance, Quality Management and Enhancement. Some of the participants revealed that during the course it was important to be prepared and start writing essays early. One suggestion made was to carry a diary because there was so much to learn when you first start; writing things down would have been helpful. The participants also recognised that it takes time to learn how the systems work and to recognise their limitations. © 2015 British Association of Critical Care Nurses
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The adaptation programme allows time for learning because of the allocation of mentors. According to the NMC, a mentor is defined as ‘A registrant who has met the outcomes of stage 2 and who facilitates learning, and supervises and assesses students in a practice setting’ (2008, p. 45). Some of the participants experienced minimal learning within the first 20-days protected time and found the hands-on approach to be of a greater benefit. The majority of participants had ‘great’ mentors because some mentors were from India and others from the Philippines. This relationship between these mentors and overseas nurses was strengthened because of the mentors’ ability to relate to feelings and language, associated with work and social life. These mentors understood what it was like for the overseas nurses, especially the cultural changes and feelings of insecurity associated with not being home in India. There was also a genuine understanding and recognition of their learning. Many of the mentors had been in similar situations when they relocated to London. Some of the negative comments associated with mentoring focused around mentors not working with the overseas nurses on a consistent basis or mentors leaving the critical care unit when the overseas nurses had not completed the ONP. This was found to be disruptive, and the overseas nurses felt less supported as a result.
Limitations The findings of this study should be interpreted in view of limitations. The sole purpose of the research study was to focus on nurses specifically recruited from India to London to work in Critical Care settings. The results should not be taken to represent all nurses completing the ONP working in other parts of the UK and other specialty areas or wards, although this would not be expected in qualitative research. It must also be recognised that the researcher’s role as a senior nurse may have influenced responses to questions.
CONCLUSION This article has outlined that there should be a degree of expectation of cultural differences with nurses undertaking the ONP and that these differences will impact on their transition. The implications of this study are that managers who are recruiting from overseas need to acknowledge these nurses may require a more extensive period of support. Future studies could review the retention of overseas nurses (compared with UK nurses) as anecdotally it has been noted that overseas nurses may remain working in the critical care environment for longer than UK-trained nurses; thus it could be argued that the initial time investment and support is warranted.
WHAT IS KNOWN ABOUT THE TOPIC •
Previous literature has reviewed the approach of 20 days protected learning time for overseas nurses and the transition of these nurses into the UK. Currently, no research has specifically focused on the transition/experiences of nurses from India into London critical care settings.
WHAT THIS PAPER ADDS • • • •
Expectations of registration should be made clear to nurses who complete the mandatory ONP. Limited information is available on the NMC website indicating timeframes for registration of nurses who are trained outside Europe. The nurses from India would benefit by being mentored by other nurses from a similar culture, with a non-English background. Re-examining education strategies to ensure that essay writing is more familiar to overseas nurses. This may be achieved by providing example essays into their information packs and outlining the marking structure. The results are potentially transferable to any area within the NHS.
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