Since the inception of the NHS, nurses, midwives and health visitors have been a critical part of the workforce. Today, the NHS could be described as ‘one NHS with many nationalities’ (Baker, 2020).
As of June 2020, 169 000 NHS staff in England reported that they were non-British, representing around 200 different nationalities, amounting to 13.8* of all staff (Baker, 2020). Among nursing, 8.7* (27 943) are from an Asian background. Of these, almost 94* are either Indian or Filipino. Some 6* (19 325) of nurses are from countries in the European Union (EU) (of these, 52* are either Irish, Spanish or Portuguese); 2.5* (7938) nurses are from an African country and 559 are from Jamaica (Baker, 2020).
These statistics give a clear picture of the importance of immigrant nurses to the NHS workforce. However, the most important issues worldwide faced by internationally educated nurses when migrating to a new country are discrimination and unequal treatment, especially in countries such as the UK, Canada and the USA (Walani, 2015).
In sharing my experience, I hope to raise awareness of some of the difficulties facing immigrant nurses.
I am one of the 6% (19 325) of nurses from the EU, now working in the NHS. I am a Greek nurse who started her career as a registered nurse working in the cardiac catheter suite and was promoted to a specialist role within a few years of arrival. However, this sounds an easier progression than it has been for an immigrant Greek nurse with Albanian parentage. My devotion and passion for my job as a nurse, and my determination to succeed, has been my guiding light.
Imagine what it is like to begin a new job in a foreign country, full of hope for new career opportunities and new horizons and dreams of the ideal life. There are fears spinning around in your head: will you succeed as a nurse? What will your career look like? Can you cope being away from your family? How will you adjust to a different country? How quickly will you adapt to living in a multicultural society? You do not realise what it will be like until it happens.
Trying to succeed in your NHS career as a foreign registered nurse involves many factors. You have trained, worked and are experienced in a different healthcare setting, and come from a different ethnic and cultural background. There are different policies in the UK that guide UK-registered nurses' practices that must be followed, and this is coupled with trying to fit in and collaborate with colleagues from varied backgrounds and understand cultural differences—all while trying to manage homesickness.
In Greece, a qualified nurse can set up intravenous medication and perform venepuncture, cannulation and catheterisation without separate assessments. These duties are part of gaining your qualification and do not require additional training or supervision once you are qualified. In the UK, however, nurses have to be assessed and signed off for each of these tasks, in accordance with local trust policies. This was a new experience, often leaving me feeling frustrated by having to wait for training and to be signed off. These seemed like obstacles we did not have at home.
Diversity
The first impression of working as a foreign nurse in the NHS was the cultural diversity: I had not imagined that I would come across so many people from so many different ethnicities and nationalities. Shin and Kleiner (2001) and Raver and Nishii (2010) highlighted the importance of having an ethnically friendly workplace, because an ethnically hostile workplace has serious psychological consequences, including creating feelings of anxiety, fear and insecurity. Having experienced some of these effects working in the NHS, I believe the most important way to treat everyone is with respect and as a human being, whatever a person's religion, skin colour or ethnic background, or the institution's prevailing hierarchy.
As an immigrant, the most difficult part of my new life was being away from family and friends. Homesickness is the hardest part of adjusting to a new life and is a major source of stress for migrant workers. This is well documented and reported in a study conducted by Verschuur et al (2004).
There are no words to describe how much you miss family, and how hard you have to try to manage your feelings and emotions so this does not affect your performance as a nurse.
Possibly the biggest obstacle for an immigrant nurse is the language barrier. I thought I knew English and had done well in English classes at school; however, speaking, writing and understanding English cultural nuances has been especially difficult. Not being a native speaker of the language or having the local accent, the different way of thinking and expressing yourself become a communication barrier. No matter how well you think you have been prepared linguistically, you still find yourself unprepared to meet the communication needs of working in a foreign country. You are often afraid to ask questions or express opinions affecting patient care. It is difficult to join in workplace gossip or humour due to the cultural differences.
Language differences are known to create barriers with other healthcare workers and patients, as well as impacting on how you adjust to your new life. A meta-synthesis of qualitative studies explored the language difficulties experienced by immigrant Asian nurses working in Western countries. This was a major obstacle to survival, both at work and in other aspects of their lives, particularly during the initial time after arrival (Xu, 2007).
We have to bear in mind that all of these issues are put into perspective by the outstanding devotion that immigrant nurses have shown towards the care of their patients and the holistic contribution they have made to the healthcare system.
However, the immigrant nurse's desire to deliver good care is often impacted by discrimination in the workplace. The prejudice experienced by internationally educated nurses has been found to have physical and psychological consequences, as well as affecting performance.
This has been emphasised in research conducted by Kulwicki et al (2008). Following the 11 September 2001 terror attacks on New York and Washington DC, there was a dramatic rise in work-related discrimination and unfair treatment that Arab-Americans nurses experienced. A total of 34 nurses participated in the study and approximately half the sample reported being treated suspiciously (47.1%) or being intimidated (52.9%), and 17.6% of encountered a patient or a patient's family who refused to be nursed by them (Kulwicki et al, 2008).
Privilege
Nonetheless, despite the difficulties and obstacles I have faced as an international nurse, it is a privilege to be part of such an amazing organisation as the NHS. I understand why it is a source of national pride. What is impressive about the NHS is not just that it provides a comprehensive service, available to all, regardless of socio-economic status, but that it treats everyone with respect and dignity. Everyone works together to the highest standards of excellence and professionalism to provide high-quality care and improve patients' lives. Compassion, humanity and passion is central to patient care (Department of Health and Social Care, 2021).
The NHS recognises that the treatment of and opportunities for black, Asian and minority ethnic (BAME) staff too often do not correspond to the values and principles that the NHS represents. Hence, the NHS Workforce Race Equality Standard was developed with the aim of addressing this gap (NHS England and NHS Improvement, 2019). There is a commitment to deliver equality within the NHS by 2028, by ensuring the leadership of NHS organisations is representative of the overall BAME workforce.
Last year was the International Year of the Nurse and Midwife. History has shown that, despite their different skin colours, backgrounds and very different experiences, Florence Nightingale and Mary Seacole were both great nurses who made significant contributions to nursing. Today, during the COVID-19 global pandemic, nurses, regardless of ethnic background, religion or professional status, are on the front line fighting against an invisible enemy. As an internationally educated nurse I am honoured to serve the NHS and provide care to our patients.
All of us involved in the health system could do well to remember this quote from the film Patch Adams, based on the life of the doctor Hunter Doherty ‘Patch’ Adams:
‘You treat a disease you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome.’
It reminds us that treating others as we would wish to be treated ourselves is what is important.