Lack of support after arrival

And because they are a more ethnically diverse group than those on the register they are joining, they have contributed to the UK’s nursing workforce becoming more diverse than ever before.

Yet there are serious questions about whether foreign professionals are being adequately supported and given the respect they deserve. The NMC published its inaugural Spotlight on Nursing and Midwifery report to coincide with the publication of its 2022-23 register data, and its conclusions were stark: it found racism is affecting both quality of care and staff retention, and that new arrivals to the UK are often poorly supported.

The result is that internationally educated professionals spend less time on the register than those educated in the UK.

For one nurse, such findings are simultaneously depressing and unsurprising. Obi Amadi, now Unite the Union’s lead professional officer but previously a midwife, health visitor and nurse practitioner, followed her mother into the profession. ‘She used to tell us about the racism she suffered,’ Ms Amadi says. ‘She came over from the Caribbean in the late 1950s and she talks about patients saying things like “Take your dirty black hands off me”.’

Decades on, Ms Amadi is still hearing stories of mistreatment of nurses from overseas, whether in her union capacity or as general secretary of the Nigeria Nurses Charitable Association. ‘None of it is new,’ she says.

Made to feel under-valued

The sense of being unwelcome can begin the moment someone lands in the UK. One nurse, who asked not to be named, tells Nursing Standard how, having taken a long-haul flight, she arrived at her trust-provided accommodation to find no food, no cutlery and no bedding.

‘That first night, we used our bags as a pillow,’ she says. ‘Luckily for me and my partner, we had taken the free blankets from the aeroplane. We had cup noodles with us, which we had to eat using our hands. It was not a good experience.’

The sense of being disrespected continued once she took up her staff nurse role. She had practised for several years in her native country, but discovered this experience seemed to count for little.

‘They treat you like a like a brand new nurse, like you don’t know anything,’ she says. ‘They don’t take into consideration the experience you have back home.’

University College Hospital Foundation NHS Trust senior nurse Bejoy Sebastian, who is general secretary of Alliance of Senior Kerala Nurses says: ‘Someone could have been a nurse educator back in their country, but when they come here they have to start at the bottom. Your experience is not counted.’

Where can a nurse from overseas go to get support?

There are several possible sources of support for any internationally educated nurse who is finding work or life in the UK a challenge.

Growing numbers of employers have international recruitment pastoral support officers, whose focus is helping overseas nurses. Other organisations will offer help via a more general recruitment lead or team.

For worries relating to work on a ward or in a department, the best first contact is typically a line manager. However, it can be challenging to raise concerns, particularly for nurses whose presence in the country is dependent on an employer-sponsored visa. Another option is Freedom to Speak Up guardians, who are in place to help with anything that is stopping someone from doing their job to their best of their ability.

Several internationally educated nurses have gone on to set up support associations designed to assist others coming to the UK.

NHS Employers has a list of these support organisations: tinyurl.com/support-for-nurses

Picture credit: Barney Newman

Pastoral care for overseas staff

Mental health nurse Marimouttou Coumarassamy arrived in the UK 20 years ago, after nine years working in his native India. His first role was staff nurse at Birmingham and Solihull Mental Health Foundation Trust, where he is now deputy chief operating officer.

But he had to change trust three times before ultimately getting to his current role, feeling at points that he had hit a glass ceiling or that he had no further opportunities for progression. It has required an enormous amount of perseverance and determination, he says.

International nurses may find their experience is not taken into account in the UK, or be less familiar with certain aspects of nursing here, such as palliative care

Picture credit: Charles Milligan

‘Wherever I’m working, I work very hard,’ says Mr Coumarassamy. ‘I develop the skills, and then I will try to move on to a new level. If the same trust is going to embrace me and help me, I will stay there. If not, I will move on.’

In August 2020, he co-founded the British Indian Nurses Association (BINA) – in large part to make it easier for UK-based Indian nurses to progress in their careers. The organisation offers informal coaching and mentoring, help with interview skills because UK processes often differ significantly from those in other countries, and the chance to think through career aims.

‘I say to people that the NHS is full of opportunities, and within one or two years or arriving you need to find out where your heart is – we will help you explore,’ says Mr Coumarassamy. ‘I came here 20 years ago and I’m now a deputy chief operating officer, and I have hope that I can progress even further.’

BINA is working with around 40 NHS trusts to support the provision of pastoral care for Indian nurses. This is a focus Mr Coumarassamy believes is crucial. ‘The pastoral support provided to international nurses across this country is patchy. There is nobody checking whether everybody is having the same experience,’ he says.

It is an area where NHS England is seeking to take action. Last year, the NHS Pastoral Care Quality Award for International Nurses and Midwives was established. Trusts in England can apply for the award, based on their recruitment processes for overseas staff, and are required to meet a set of best-practice standards. The aim is to standardise pastoral care across the NHS, while recognising those organisations demonstrating best practice.

‘In one country’s culture, it might be that you focused only on the patient and didn’t speak to the family. These nuances can create problems. It becomes “That nurse doesn’t talk to the family”’

Obi Amadi, pictured left, Unite the Union’s lead professional officer and formerly a midwife, health visitor and nurse practitioner

Prepared to welcome recruits

If overseas nurses are to truly thrive in the UK, preparing them for their new roles will not be enough; homegrown staff will need help too. As Mr Coumarassamy puts it: ‘The NHS is relying much more on internationally educated nurses now, but we haven’t prepared people in the UK to receive them and to embrace their talents.’

Picture credit: iStock

Ms Amadi says: ‘It’s about more than giving international nurses a factsheet and saying that when someone says they’re going to sit on the throne it means they want to go to the toilet. In one country’s culture, it might be that you focused only on the patient and didn’t speak to the family. These nuances can create problems. It becomes: “That nurse doesn’t talk to the family”. It’s not that the nurse is wrong, it’s just a cultural difference.’

Helping recruits to acclimatise: practical and professional support

Maria Sagucio believes many nurses from overseas use their experience of coming to the UK to make it easier for those who arrive after them.

Ms Sagucio, who qualified and practised in the Philippines before moving to the UK, has been international nurse pastoral support facilitator at Northampton General Hospital NHS Trust since March 2022. She has since built a programme to help overseas nurses settle and thrive.

Professional advice and social support

The programme combines professional advice with practical support for living in the UK. A pre-arrival webinar covers everything from advice on how to search for accommodation to determining food preferences and dealing with religious needs.

‘Then when they arrive, they receive a hot meal and at least two days’ worth of groceries,’ explains Ms Sagucio. It’s a small but significant way of demonstrating respect to overseas professionals from the minute they arrive.

After those initial orientation days are over, Ms Sagucio introduces the recruits to the trust practice development team who offer support through the OSCE (objective structured clinical examination). But this does not represent the end of the help provided.

Practical support for new international recruits includes provision of a ‘starter’ groceries box on their arrival

Picture credit: iStock

Career progression to reflect individual competence and experience

Indeed, a levelling-up programme has been launched to help the trust’s nurses from overseas flourish once they have settled. ‘We have a group through which we send adverts for band 6 positions,’ Ms Sagucio says. ‘If they want to apply they can just message us and we can support – practical tips on how to do interviews, using the STAR (situation, task, action, result) method to answer questions, because they may be very experienced but not know about that.’

The support on offer continues to evolve. There are now plans to introduce a seminar on speaking on the phone, and one on end of life care. ‘Answering the phone can be hard for a new international nurse, when they have to update families and so on.

So we’re going to have role-plays to help with that. And because end of life support isn’t common internationally, our palliative care team will do a session that addresses that.’

All of this work has led to national recognition. Earlier this year Ms Sagucio won a chief nursing officer’s silver award, and Northampton General Hospital NHS Trust received an NHS Pastoral Care Quality Award for International Nurses and Midwives.

Mr Sebastian adds: ‘We need to understand that you don’t have to be an active racist to give a discriminatory experience to someone else. You need to understand your own vulnerabilities, your own privileges, and be ready to act as an ally and challenge the norms.’

As he points out, the stakes are high. ‘If we don’t look after internationally educated nurses, if we don’t give them a warm welcome, if we don’t try to solve the issues and help them thrive in their roles, they’re going to leave. All the training we have given will be in vain. So we really need to make people feel at home here.’