Sally Smith, MSc, RN, is deputy to the assistant director of nursing (education and learning)/nurse trainer, Poole Hospital NHS Trust
VOL: 100, ISSUE: 40, PAGE NO: 40
Sally Smith, MSc, RN, is deputy to the assistant director of nursing (education and learning)/nurse trainer, Poole Hospital NHS Trust
Aim: To explore the perceptions of overseas nurses during their induction programme.
Sample: A pilot cohort of 20 overseas nurses.
Method: A qualitative research approach was used.
Results: The key themes were: communication issues, culture, role definition and feelings of self-worth, which are interrelated and suggest how the experience has influenced each nurse’s professional development and ultimate achievement of ‘competence’ as a registered nurse able to practise in the UK.
Conclusion: These findings confirm there is a need for greater understanding of the ‘adjustment process’ and integration into the workforce. Recommendations are made that for future projects to succeed, comprehensive support frameworks are required to fully support both the overseas nurse and the organisation as a whole.
Nursing is a global profession and the international mobility of nurses is not a new concept. However, the continued growth in demand for health care and the ageing profile of the nursing profession (Buchan, 2002) have required the NHS to explore all the recruitment options available. As a result, recruiting nurses from overseas has become an integral part of the strategy for developing a workforce that is equipped to implement the government’s modernisation agenda for the NHS (Department of Health, 2000). Increasingly, many NHS trusts in the UK are now in the position of having to look abroad for nurses to staff their hospitals and provide care for their patients.
Statistical data suggests that by 2008 there will be 60 per cent more nurses qualifying each year in the UK than at present (DoH, 2000). However, despite an increase in the number of places commissioned for nurse education and training, there will not be enough registered nurses to meet current NHS demands.
Government recruitment and retention incentives, such as offering life-long learning opportunities and ways for ex-nurses to update their skills, will not on their own be sufficient to ameliorate the skill shortage in the UK. To achieve its targets of recruiting large numbers of nurses the government has come to recognise the necessity of international recruitment.
The participants were all recruits on Poole Hospital NHS Trust’s adaptation programme. They were primarily from India and for many it was the first time they had been in the UK, while for some it was their first time away from home. All the recruits had been registered nurses in their home country and their nursing experience ranged from 2-14 years in a wide range of specialties. Some recruits had held senior nursing positions.
As the study was undertaken within the NHS, permission was sought from the local research and ethics committee to carry out the research. Consent for the research was sought from each of the nurses and assurances were given that anonymity and confidentiality would be adhered to - identities would not be revealed and the nurses could withdraw their consent at any time.
The researcher felt that the study required a method that would assist in building a holistic person-centred perspective as described by Leininger (1992). With this in mind, a qualitative research approach was used.
Two questionnaires were developed that used the ‘open’ survey method, to allow the participant flexibility in response and therefore encourage the provision of meaningful data. To minimise misunderstanding in relation to words or to meaning, short, single, unambiguous questions were used and the questionnaires were designed to be completed in about 20 minutes. Care was also taken to avoid using medical jargon and unfamiliar terminology.
In addition, to obtain more meaningful data, face-to-face interviews were then conducted with three participants. The interviews were partly informed by the data that had emerged from the questionnaires, and it was felt that the topics could be enlarged upon and/or confirmed by further discussion and probing.
Semi-structured taped interviews were conducted so the data could be collected in the participant’s own words, allowing for deeper levels of meaning and expression to be ascertained.
One of the major tasks during the interview was to ensure a level of linguistic understanding and an understanding of the cultural milieu from which the participants were drawn. As with the questionnaires, clear, unambiguous and grammatically correct language was used, as the intended participants may vary in their level and experience of communicating in English. To overcome any misunderstandings and to seek clarification, the researcher would explore further by probing or through the use of another, similar question if necessary.
The research’s cost implications were minimal, as the sample size was relatively small and based within the researcher’s own organisation. The interviews were conducted on site in a quiet, private and comfortable lounge, which was free from interruption and could be accessed during working hours, with the nurses being released from the wards at prearranged times.
Results and discussion
The theoretical constructs identified within this study demonstrate the issues and hurdles that the overseas nurses have experienced in order to develop and obtain competence to practise as registered nurses in the UK.
The four theoretical constructs have been entitled:
- Communication issues;
- Role definition;
- Feelings of self-worth.
These theoretical constructs formed dimensions of the core construct, which has been defined as ‘competence’. Each of these constructs is interrelated with the other three and all share an equal relationship with the core variable (Fig 1).
The emerging data began with some of the nurses identifying that they had a need to effectively communicate within their sphere of practice. The ability to understand and respond to colleagues was paramount in building relationships and facilitating learning in relation to their clinical practice. The overseas nurses were struggling with the varying accents, colloquialisms and speed of speech. Employers, managers and mentors need to ensure that their goals are clear and understood by the nurses who do not have English as their first language (Daniel et al, 2001).
The nurses were expected to use computers and to make notes in patients’ care plans. This presented problems for some as they were unfamiliar with IT, medical terminology, hospital abbreviations and associated jargon.
The nurses highlighted the need for improved English language skills in relation to their practice and also for social interaction.
The data reveals that there are significant differences between cultures to which the overseas nurses need to adapt. These have been identified as:
- Professional culture - Adjusting to nursing in a different setting;
- Organisational culture - adapting to a new framework in which to deliver care;
- National culture - learning to live and work in the UK.
An analysis of the data indicated that the areas of culture discussed are interrelated and therefore the issue of culture needs to be viewed holistically in order to effectively understand the perspective and experiences of the overseas nurses.
When asked if the overseas nurses had experienced any significant cultural differences, the responses indicated an overwhelming ethos of being unprepared for the ‘culture shock’ and described some of the fundamental cultural differences experienced in relation to the health service.
Team nursing is an accepted practice in the UK - all staff work and communicate as one team with a common goal, that of caring holistically, effectively and appropriately for the patient. The major differences between the styles of nursing in the UK and India, and the effect this may have, is often referred to as ‘NHS culture shock’. Some nurses found it more difficult to adapt to the new culture than others.
Through these interviews it can be demonstrated that the overseas nurse experiences different stages of ‘culture shock’. The data analysis suggests that the adjustment process involved when adapting to this new culture has been underestimated and that there is a need for greater preparation with regard to culture.
Analysis of the data showed that the role of the registered nurse in India is very different from that of the registered nurse in the UK. For example, in India nurses take instruction from the doctor and are not permitted to make their own decisions.
The culture of nursing dictates that the doctor has overall responsibility and therefore the nurse is seen as being protected. The research suggests that responsibility is a new concept to overseas nurses and many were unaware of the term ‘accountability’ and its importance to the role of the registered nurse in terms of answering for their actions.
All of the nurses interviewed expressed their concern and confusion at one stage or another during the adaptation programme in not having a full and clear understanding of the NMC’s purpose. The data suggests that this confusion and uncertainty influenced their perceptions and understanding of the role and responsibilities and further identified how this role identification has caused problems with integration, relationship-building and with scope of practice.
It became apparent that overseas nurses offer different values and skills from those exhibited by nurses from the UK and that the first few months can be difficult. The nurses expressed feelings of frustration as they experience a drop in status as they change their practice and role from being qualified nurses in their own country to having to be supervised in the UK.
UK nurses do not undertake some clinical tasks. For example, they do not administer intravenous drugs until at least six months postregistration. This is to allow the nurse to fully adapt to her or his new responsibilities and to consolidate learning without additional pressures. Therefore, in some cases the overseas nurses were working on the wards with registered UK nurses who were less skilled. This contributed to the overseas nurses feeling unappreciated and even more confused about their role and the expectations of the trust.
This profound lack of understanding of the scope of practice was not just isolated to the overseas nurses. It also emerged that there were problems relating to role definition by some ward staff and mentors. The overseas nurses expressed a concern over their mentors’ good opinions and wishing to live up to their expectations. They are conscious of how different the NHS working environment is and want more explicit information and training to be able to use their experience and skills effectively.
It is clear from the data analysed that from the commencement of the adaptation programme, accurate role definition and a sound relationship with a mentor are needed. In addition, the data has further informed the researcher of the necessity to create a greater awareness of the issues of culture and diversity relating to UK nursing practices and the role of the nurse in the UK.
Feelings of self-worth
The overseas nurses perceived the adaptation programme to be a means of personal and professional development, in which they would be given the support necessary to improve their clinical confidence and achieve registration in the UK.
The interviews revealed that the overseas nurses know how to nurse in their own culture, but often feel de-skilled when they start work on the wards because they have to be supervised and are unable to undertake the level of clinical responsibility they held in their home country. This was followed by feelings of bewilderment in finding that their skills and considerable experience apparently counted for nothing.
For some overseas nurses, these feelings can lead to confusion over their professional identity, a lack of confidence, frustration and a fear of not completing the competencies.
The data analysis suggests that it is important for overseas nurses to undertake tasks that will reinforce their identity and it is vital to increase understanding for both mentors and overseas nurses in the potential difficulties that may occur during social, work and cultural interactions.
Analysis further demonstrated that once explanations had been given and an understanding established in relation to the role of the NMC, accountability and the subsequent legal parameters that the trust had to work within, the frustration still remained, but to a lesser degree. In addition, feelings of value and self-worth improved through the experience.
Where adequate information, knowledge and support had been given to the overseas nurses, they were able to positively appreciate the wider issues relating to the adaptation programme and period of supervised practice before the final stage of the experience.
The theoretical constructs identified within this study demonstrate that overseas nurses go through an adaptation cycle in order to develop competence. The research indicates that this adaptation cycle is crucial in demonstrating how the overseas nurses are able to take ownership of their development by demonstrating their theoretical understanding, knowledge and clinical ability. Their overall aim is ‘competence’ - the tool used to measure their clinical ability.
Conclusions and recommendations
A great deal has been revealed and suggests that there is much to be learnt from the experiences of overseas nurses. The findings suggest that the ease with which ‘skills transfer’ takes place for overseas nurses has been greatly overestimated. A number of findings need to be addressed and put in place to fully support the overseas nurses and the organisation as a whole. This will enable the overseas nurses to adapt and become fully integrated into the nursing workforce.
The study has suggested that the overseas nurses are undergoing a process of cultural and professional change and would propose the following:
- Supporting methods are used to enhance comprehension and learning, for example visual, demonstration, interactive and written;
- Greater emphasis, identification and understanding are required in relation to the purpose and function of the NMC (NMC, 2002) and to the role of the overseas nurse;
- Cultural issues and awareness sessions should be used;
- Greater emphasis should be given to communication and language sessions within the sphere of practice;
- Overseas nurses should have the opportunity to check concepts, seek clarification and relate the information to ensure effective communication and learning take place;
- Support and increased understanding of the purpose and role of the adaptation programme for interdisciplinary staff to promote effective working relationships, improve morale and a greater understanding and respect for each other’s cultures. It is suggested that this in turn may naturally facilitate a smoother transition of the transfer of skills from one culture to another.
To conclude, the theoretical constructs identified within this study demonstrate the issues and hurdles that the overseas nurses have experienced in order to develop and obtain competence as defined by the NMC.
- This article has been double-blind peer-reviewed.