The NHS People Plan and the NHS Long Term Plan described the ethical recruitment of internationally educated nurses (IENs) as an important part of the workforce supply strategy of NHS organisations for the next 10 years (NHS England/NHS Improvement, 2019; 2020).
The Nursing and Midwifery Council (NMC) (2022) reported that, overall, the number of nursing professionals on the register increased by more than 13 000 between April and September 2022 to a record 771 445. This growth in registered nurses, midwives and nursing associates was driven largely by nurses trained outside the UK.
Having recently submitted a bid to support further recruitment of IENs (the recruitment of IENs continues to be our largest viable pipeline of nurses to join the sector at this time), I have been reviewing our current position. I wanted to look at the overall impact of this increase in IENs and what we need to do to ensure that this strategy remains both a recruitment and a retention success.
The NHS England/NHS Improvement international nurse recruitment programme (2023) has provided a framework for the end-to-end process of recruitment. NHS Employers (2022) has produced a good International Recruitment Toolkit, which is updated quarterly. It is heavily based around the process, in terms of both planning and recruitment. Although there is a ‘recruiting to retain’ section, which includes pastoral care, it currently focuses more on what is practically required, such as a bank account, rather than how it feels to work in the UK. For me, the preparation of existing staff and a focus on understanding the operating model of overseas nursing care to support a more tailored induction and career pathway plan, are the areas I feel are providing the biggest opportunity to learn and share.
What became concerning as I undertook a review of the literature into best practice in these areas, was not only that not much exists, but that what does exist was a range of articles describing issues of racism, exploitation and poor treatment of IENs
Mitchell (2022) reported on the Nursing Narratives project (https://nursingnarratives.com), which was led by Sheffield Hallam University and funded by the Arts and Humanities Research Council. It involved a survey and interviews with health staff from England, Wales and Scotland. Most were either nurses or nursing associates. It gathered the experiences of more than 350 health workers from Black, Asian and Arab ethnic backgrounds. It was found that all had experienced multiple types of racism during their careers. Nineteen participants also spoke about their experiences on film to create a resource of individual testimony videos, as well as a collective documentary entitled Exposed (Sheffield Hallam University, 2022a).
Racism in the health service was described by the researchers as ‘endemic’, ‘cultural’ and existing at all levels. The study concluded:
- 59% of participants had experienced racism at work that was so bad it made it difficult for them to do their job
- 77% of respondents who complained about racism at work felt that they were not treated fairly following that complaint
- Experiences of ‘exclusion and neglect’ were among the most widely recounted from all the participants
- Participants reported being ignored when they walked into a room, conversations stopping, being excluded from meetings, and their contribution to discussions ignored. The researchers concluded that the study clearly showed that, despite initiatives to address inequalities, the culture of the NHS fundamentally remains systemically racist. The nurses who took part in the work created a ‘manifesto for change’ to demand an end to racism in the UK health system, as part of the launch of the Exposed film.
Calls to action in the manifesto include (Sheffield Hallam University, 2022b):
- Stop putting Black and Brown staff in danger of death and psychological harm
- Create clear and real consequences for racist actions, including dismissal and legal action
- Introduce accountability and penalties for trusts that do not comply with a zero tolerance to racism policy
- End the exploitation of Black and Brown staff – delegate work equitably
- Build a more compassionate NHS with respect and equality for Black and Brown healthcare staff.
It is clear from the evidence that racism as it exists in society continues to exist in the NHS. It is clear that, as leaders, we see this, and that in the case of recruiting IENs we must continue to work against racism and support all staff in the recruitment and retention of our IEN colleagues.