1

What are the professional experiences of foreign formed nurses working in

the UK? Protocol for a systematic review.

Student: Guerard Marie-Laure (Marie-Laure.Guerard@city.ac.uk)

Supervisor: Coutts Alison (A.M.Coutts@city.ac.uk)

Content:

- Background page 1

- Objective page 3

- Inclusion criteria page 3

- Methodology page 5

- References page 8

- Appendixes page 9

- Time table page 15

-

Background

Nurses formed overseas represent an important and historical part of the nursing workforce in the UK. Few

statistics data are available on the actual percentage of foreign-born nurses working in the UK. According to

NMC data on registered nurses and midwives, 10% were initially registered outside of the EU and 4% within

Europe (MAC, 2016). The shortage of nurses in the UK is a chronic issue and has been addressed through

overseas recruitment over decades.

The first part of this background section will report on the history of nurses’ migration in the UK. The second

part will report on the current situation of overseas workforce and related governmental policies.

History of nurse migration.

Nursing shortage is not a new phenomenon in the UK. A historical trend of health staff shortage and of

consequent international recruitment even predates the creation of the NHS in 1948. Since the 1930s, Britain

recruited doctors, nurses and other health workers from abroad. The first mass recruitment of nurses

occurred in 1930 from the Caribbean. The creation of the NHS and the development of technologies and

specialists increased the need for workforce in the health sector. For two decades after World War II the

needs of nurses was supplied by British colonies and former colonies. (Snow and Jones, 2011)

By the late 1980s, the NHS again faced serious problems in the retention and recruitment of nursing staff,

chronic shortages of trainees and qualified nurses. According to Snow and Jones several factors influenced

this critical situation: inflows were shrinking due to nursing's diminished popularity as a career choice, to the

tightening of working permits for overseas staff, and to the repercussions on recruitment of a second

generation of overseas health workers because of the discrimination of the previous generation in relation to

training and career opportunities. Outflows of overall nurses were high partly because of low salary levels

and because of the pressures of the job (Snow and Jones, 2011).

Over the last two decades, the main factors leading to an increase in demand for nurses have been: changes

in the needs of an aging population with more Long Term Conditions; necessity of rising the quality of care

2

with highly educated nurses taking more responsibility and staffing guidelines dictating an increase in the

nurse-to-patient ratios, in response to the 2013 Francis report into events at Mid-Staffordshire NHS trust

(MAC, 2016).

Reflecting the increases in demand together with the chronic lack of nurses, a severe nurse shortage

occurred in the late 1990 and early 2000s. Measures taken by the governments at that time consisted in

increasing the workforce recruited internationally (mainly from outside the EEA), in increasing student

commissions and in substantial pay increases (MAC, 2016). More recently, tighter immigration rules and the

effects of economic crisis on some European countries determined for the first time a rise in the recruitment

of nurses from within the European Union (RCN, 2015.

Current situation

In October 2015, the Department of Health added nurses to the shortage occupation list (SOL) on an interim

basis, meaning that nurses from outside EEA who apply for nursing posts will be prioritised in getting the Tier

2 visa, giving them a right to stay for up to six years. (DH, 2015). Health Education England, the body

responsible for workforce planning for the NHS, estimates the current nurse vacancy rate in England at 9.4%.

In London, the RCN put the rate at 17% (MAC, 2016). In February 2016, the independent Migration Advisory

Committee reviewed the situation and recommended the DH to keep nurses on the SOL (MAC, 2016).

Should the emergency shortage be covered, to be eligible for an indefinite right to stay overseas nurses from

outside Europe would have to earn £35.000 yearly, corresponding to a middle-upper Band 7 on the Agenda

for Change pay scale. As acknowledged by the Impact Assessment conducted by the Home Office in January

2012, it is very likely that many foreign nurses will not be able to reach such a level of salary in that lapse of

time (RCN, 2015). The more realistic scenario is that these nurses would have to leave the country after a

maximum six years of permit. Fear of losing legal status probably exerts strong personal and professional

pressure on migrant nurses presently working with a Tier 2 visa.

According to a report on “Growing nursing numbers”, retaining existing staff is cheaper than training new

staff and that option should be prioritised and strategies to prevent nurses from leaving are highly

recommended (NAO, 2016; HEE, 2014). In fact 10% of nurses intend to leave their work, leading to high

turnover if nothing is done to prevent it (Health Education England, 2014).

For nurses in general, intention to leave may depend on several factors, such as the work environment,

demographic variables and the individual’s personal response to situations. The emotional strain inherent to

the nursing profession, together with stress linked to the working environment, represent very high risk

factors of burnout. It is however possible to efficiently prevent this losses especially be improving nurses

work environments (HHE, 2014).

In 2015, Nursing Times reported that some trusts have lost more than half of their overseas nursing recruits,

suggesting that overseas nurses turnover is high (Nursing times, 2015). The origin of the overseas nurses is

however not specified in the article. MAC reports that European nurses tend to return earlier to their country

of origin, while extra EEA nurses offered a better return on investment because they tended to complete a

minimum 3-year contract, are usually more experienced and have better English skills. This return on

investment is also determined by the fact that nursing is an occupation in which migrants earn, on average,

less than UK workers doing the same job as “employers often looked to recruit non-EEA nurses with specific

skill sets but that the pay on offer was nearly always the bottom of band 5” (MAC, 2016).

3

A report on diversity and inclusion in the NHS showed that: “The work life experiences of non-White,

disabled, Muslim and non-heterosexual staff (among others) within the NHS are clearly much worse than

their comparator groups and this experience of discrimination profoundly and pervasively damages the

health, well-being and quality of work life of the many staff affected in the NHS.” (West, 2015)

To conclude, foreign nurses are an important and historical contributor, but also a vulnerable layer of the

British healthcare workforce, deserving research attention as a contribution leading to improve their

professional experience.

A systematic review of the lived experience of overseas nurses would increase the understanding of the

nature of their professional experience. It would provide evidence on the quality of their working

satisfaction, the barriers they encounter in their integration into the working teams or in relating to patients,

the distance between their expectations and their actual experience, the main factors of stress and burnout.

It may highlight areas in need of further research, opportunities for future practice and need for policy

changes.

Objective

The primary objective of this systematic review will be to synthesize and report the professional experiences

of overseas nurses working in the UK, their satisfaction at work, the barriers they encounter, their opinion on

what can improve their working conditions.

The secondary objective will be to deliver evidence-informed recommendations for what can improve the

professional experience of overseas nurses in the UK.

Inclusion criteria for the present review

Articles about nurses educated abroad will be included, from European and non-European origin.

Studies on health care professionals will be included when nurses are explicitly considered an important part

of the study. Nurses registered and formed abroad but working as health care assistants in the UK will be

included in the review if their previous formation is clearly reported. Studies including foreign formed

midwives will be only included if the population studied also includes nurses.

Studies exploring the social or daily life experience and integration of nurses as foreigners in the British

society will not be included. Nurses’ relations with their professional organisations and with their

communities do influence each other and can play a role in job retention or turnover (HEE, 2014), but they

are not the focus of the present study. However, nurses’ opinions and findings of studies on the repercussion

of nurses’ professional experience on their quality of life will be taken into consideration.

Context

The context is the health-care sector in the UK (including England, Northern Ireland, Wales and Scotland).

The considered health-care sector will include working experience of nurses in health-care institutions within

the NHS or the independent sector, but excluding other sectors (commercial activities, etc.). Working

experience in other countries will not be included.

Studies exploring the experience of overseas nurses in Britain together or in comparison with other countries

will be included, providing they are extensive enough on the experience in the UK.

4

Outcomes

The outcome is a review of the type of professional experiences of overseas nurses. It will focus on the

barriers they encountered, how these influenced the quality of their work; their expectations, satisfaction

and opinions, and how they conditioned their eventual decisions on employment.

Types of studies to be included

The review will be mainly based on published results of research, mainly qualitative phenomenological

studies, through interviews or focus groups, or case studies on specific settings, as the most appropriate

methodology to explore experiences and perceptions.

Literature reviews analysing studies related to the question should be included and analysed to provide

stronger evidence to the research.

In the event of an existing systematic review answering the same question, it will be appraised to determine

its quality. If such review will be found to be of high quality, the proposed review would include studies post-

dating it. If such a review is recent, the proposed question will be changed in order to preserve originality.

Quantitative or mixed methods studies (for instance reporting statistics on overseas nurses) will not be

considered of high priority for inclusion but may be considered in the absence or dearth of more suitable

studies.

A search to identify grey literature (non-peer-reviewed works) will be undertaken in order to find published

accounts or letters from foreign nurses to editors, Doctoral dissertations or reports of conferences.

Guidelines, political decisions or protocols issued by professional bodies directly reporting or influencing the

working experience of overseas nurses will be taken into consideration in an introduction or discussion, but

not included in the review. The references used to produce these policy literature or guidelines will be hand

searched and considered for inclusion when relevant to the study.

This literature review will be based on published literature only. Unpublished literature will not be searched.

The reason for this being held in the difficulty to identify this kind of literature, while being aware it is

inherently at risk of bias, as discrimination are sensitive topics that may be judged inconvenient for

publication.

Only studies published in English will be considered for inclusion, which may result in the exclusion of some

data but, given the selected UK context, should not introduce a significant bias.

Studies published after 1996 will be considered for inclusion. This twenty years period is selected to ensure

that up-to-date and relevant information are included. While the recruitment of overseas nurses predates

1996, the selected range covers a period with peak immigration waves in late 1999 and early 2000s. The

period also overlaps with the introduction of changes in the provision of care (with nurses taking more

responsibility) and of staffing guidelines increasing the nurse-to-patient ratios for safety and quality (MAC,

2016). However, the experience of overseas nurses may have seen substantial changes in different historical

periods. In order to address this latter concern, predated major contributing research articles maybe included

if they significantly enrich the review.

5

Methodology

Search strategy for identification of studies

Main computerised Databases search

A first limited search of CINAHL will be undertaken using the initial keywords, followed by a search of the

words contained in the title and abstract, and of the subject heading terms used to describe the article. A list

of synonyms and final keyword will be reported in a table. Initial keywords to be used will be:

Overseas nurses; professional experience; United Kingdom

A second search using the identified keywords will then be undertaken using the following databases.

CINAHL Plus with Full Text (core research tool for all areas of nursing and allied health literature from

America and Europe)

Medline (extensive medical and nursing Database),

Health Policy Reference Center (full-text database designed to support the informational needs of

corporations, medical institutions, government agencies, and other entities relative to health policy),

Soc Index, (comprehensive and highest-quality sociology research database)

HMIC (non-clinical topics including inequality in health and user involvement),

Embase (Covers all aspects of care, including literature about all aspects of psychology and psychiatry)

Cochrane database of Systematic Reviews

Open Grey and BASE databases will be searched for Grey literature like Doctoral dissertations, reports of research or conferences reports.

Each term/synonyms and subject headed word will be entered into the database and will be truncated where

appropriate and combined using the “OR” Boolean operator and searched in the abstract. Each group of

keyword will then be combined using the “AND” function to produce a list of citations. Records of all

searches in each database will be maintained. Citations will be saved into Refworks, and screened for

duplicates.

The search strategy will be reported using a PRISMA flow Chart (Moher et al, 2009).

Supplementary searching

Other search strategies will consist in a search of the references of the identified studies; author searching (in

the eventuality that a particular author has specialised in the topic) and a manual search of the relevant

journals that may publish interesting studies on the topic:

Journal of Transcultural Nursing (TCN): (peer-reviewed journal that offers theoretical approaches and current

research findings for the delivery of culturally congruent health care)

From Royal College of Nursing connected journals (RCNi): Nursing Standard; Nursing Management and

Nursing Research. These journals may report articles, letters to the editor, or research reporting experiences

of overseas nurses living in the UK.

6

Journal of Nursing Management: (international vehicle for scholarly debate embracing the many facets of

nursing management in modern international healthcare)

International Nursing Review (INR) is the official journal of the International Council of Nurses (ICN). It is a

peer-reviewed journal that focuses on nursing and health policy issues of relevance to nurses.

Before the research proposal is concluded, the Prospero, Cochrane Library and NICE evidence search

databases will be searched in order to make sure that no systematic review is currently registered with the

same question and objective than the present one, and the present protocol will be registered in Prospero.

Reviewing the literature

All potential articles will undergo a screening process based on title and abstract according to the inclusion

criteria. Reviewers will discuss results. Full text of each included citation will be obtained. Each study will be

read in full and assessed for inclusion. Any discrepancies will be resolved through discussion. (Butler et al,

2016)

Critical appraisal of the studies

The following framework structure for appraisal of papers, data extraction and data analysis is based on a

Guide from The Joanna Briggs Institute (2015) joined in Appendix.

Qualitative papers selected will be assessed by two independent reviewers for methodological validity prior

to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute

Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I).

Textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to

inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute

Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix II).

In the case where systematic review is selected, will be assessed by two independent reviewers for

methodological validity prior to inclusion in the review using standardized critical appraisal instruments from

the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews (Appendix III)

In the case where a decision is taken to include quantitative papers, the studies will be evaluated for

methodological validity using standardised critical appraisal instruments from the Joanna Briggs Institute

Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).

During this process, any disagreements that arise between the reviewers will be resolved through discussion,

or with a third reviewer.

Data extraction

Qualitative data will be extracted from papers included in the review using the standardized data extraction

tool from JBI-QARI (Appendix IV).

Textual data will be extracted from papers included in the review using the standardized data extraction tool

from JBI-NOTARI

Quantitative data will be extracted from papers included in the review using the standardized data extraction

tool from JBI-MAStARI.

7

The data extracted will include specific details about the interventions, populations, study methods and

outcomes of significance to the review question and specific objectives.

Data analysis

Qualitative research findings will be pooled using JBI-QARI (Appendix V). This will involve the aggregation or

synthesis of findings to generate a set of statements that represent that aggregation, through assembling the

findings rated according to their quality, and categorising these findings on the basis of similarity in meaning.

These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of

synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not

possible the findings will be presented in narrative form. Textual papers will, where possible be pooled using

JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that

represent that aggregation, through assembling and categorising these conclusions on the basis of similarity

in meaning. These categories are then subjected to a meta-synthesis in order to produce a single

comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where

textual pooling is not possible the conclusions will be presented in narrative form (JBI, 2015).

Quantitative papers will, where possible be pooled in statistical meta-analysis using JBI- MAStARI. All results

will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted

mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis

#modify text as appropriate. Heterogeneity will be assessed statistically using the standard Chi-square and

also explored using subgroup analyses based on the different quantitative study designs included in this

review. Where statistical pooling is not possible the findings will be presented in narrative form including

tables and figures to aid in data presentation where appropriate (JBI, 2015).

Acknowledgement

This systematic review protocol, as well as the systematic review, will contribute to a Master of Nursing

degree for the student. The student has been an overseas nurse in Britain, from within the EU, but has not

been working in the UK during her permanence in the country. This may be reducing the potential bias of

being influenced by her own experience, but is limiting her knowledge of the working context and practice in

the UK.

8

References

Aveyard, H. (2014). Doing a literature review in health and social care: A practical guide. McGraw-Hill

Education (UK).

Butler, A., Hall, H., & Copnell, B. (2016). A Guide to Writing a Qualitative Systematic Review Protocol to

Enhance Evidence‐Based Practice in Nursing and Health Care. Worldviews on Evidence‐Based Nursing.

Department of Health (2015) Restrictions on nurse recruitment from overseas changed. Available at:

https://www.gov.uk/government/news/restrictions-on-nurse-recruitment-from-overseas-changed

Health Education England, NHS, July 2014, Growing nursing numbers, Literature review on nurses leaving the

NHS, Available at:

https://www.hee.nhs.uk/sites/default/files/documents/Growing%20nursing%20numbers%20%E2%80%93%2

0Literature%20Review.pdf

Hoffmann, T., Bennett, S., & Del Mar, C. (2013). Evidence-based practice across the health professions.

Elsevier Health Sciences.

Merrifield N (10 Feb 2015) “Some trusts have lost more than half of overseas nursing recruits”. Nursing Times

Vol 111 No. 7 pages 2-3. Available at: http://www.nursingtimes.net/roles/nurse-managers/exclusive-trusts-

hit-by-high-turnover-of-nurses-recruited-from-abroad/5081928.fullarticle

Migration Advisory Committee. (March 2016). Partial review of the Shortage Occupation Lists. Review of

Nursing. MAC, London. http://tinyurl.com/qdaqbbl (last accessed 23/6/2016)

Moher D, Liberati A, Tetzlaff J, Altman D, (2009) The PRISMA Group: Preferred reporting items for systematic

reviews and meta-analyses: The PRISMA Statement. PLOS Med. 6 (7): e1000097-

National Audit Office, Department of Health (2016) Managing the supply of NHS clinical staff in England. HC

736 SESSION 2015-16 5 FEBRUARY 2016. Available at: https://www.nao.org.uk/report/managing-the-supply-

of-nhs-clinical-staff-in-england/

RCN (2015) International recruitment 2015. RCN Online. Available at:

https://www2.rcn.org.uk/__data/assets/pdf_file/0007/629530/International-Recruitment-2015.pdf.

Snow, S., & Jones, E. (2011). Immigration and the National Health Service: Putting history to the forefront.

History and Policy, http://www. historyandpolicy.org/papers/authors. html.

The Joanna Briggs Institute, Christina M. Godfrey and Margaret B. Harrison, (January 26, 2015) CAN-

SYNTHESIZE, Queen’s Joanna Briggs Collaboration Version 4.0 (see appendix)

West, M., Dawson, J., & Kaur, M. (2015). Making the difference: Diversity and inclusion in the NHS. Report by

The Kings Fund, commissioned by NHS England.

https://www.england.nhs.uk/wpcontent/uploads/2015/11/making-the-difference. pdf

9

Appendix I: JBI QARI Critical Appraisal Checklist for Interpretive

& Critical Research

Reviewer Date

Author Year Record Number

Yes No Unclear 1. Is there a congruity between the stated philosophical

perspective and the research methodology?

2. Is there a congruity between the research methodology and the research question or objectives?

3. Is there a congruity between the research methodology and the methods used to collect the data?

4. Is there a congruity between the research methodology and the representation and analysis of data?

5. Is there a congruity between the research methodology and the interpretation of results?

6. Is there a statement locating the researcher culturally or theoretically?

7. Is the influence of the researcher on the research, and vice versa addressed?

8. Are participants, and their voices, adequately represented?

9. Is the research ethical according to current criteria or, for recent studies, is there evidence of ethical approval by an appropriate body?

10. Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?

Overall appraisal: Include Exclude Seek further info

Comments (including reasons for exclusion):

© Christina M. Godfrey and Margaret B. Harrison

© Joanna Briggs Institute

11

Appendix II: JBI Critical Appraisal Checklist for Narrative, Expert Opinion & Text

Reviewer Date

Author Year Record Number

Yes No Unclear

1. Is the source of the opinion clearly identified?

2. Does the source of the opinion have standing in the field of expertise?

3. Are the interests of patients/clients the central focus of the opinion?

4. Is the opinion's basis in logic/experience clearly argued?

5. Is the argument developed analytical?

6. Is there reference to the extant literature/evidence and any incongruence with it logically defended?

7. Is the opinion supported by peers?

Overall appraisal: Include Exclude Seek further info

Comments (including reasons for exclusion):

© Christina M. Godfrey and Margaret B. Harrison

© Joanna Briggs Institute

12

Appendix III: JBI Critical Appraisal Checklist for Systematic Reviews

Reviewer Date

Author Year Record Number

Yes No Unclear

1. Is the review question clearly and explicitly stated?

2. Was the search strategy appropriate?

3. Were the sources of studies adequate?

4. Were the inclusion criteria appropriate for the review question?

5. Were the criteria for appraising studies appropriate?

6. Was critical appraisal conducted by two or more reviewers independently?

7. Were there methods used to minimise error in data extraction?

8. Were the methods used to combine studies appropriate?

9. Were the recommendations supported by the reported data?

10. Were the specific directives for new research appropriate?

Overall appraisal: Include Exclude Seek further info

Comments (Including reasons for exclusion)

© Christina M. Godfrey and Margaret B. Harrison

© Joanna Briggs Institute

13

Appendix IV: Data Extraction Template for Qualitative Evidence

Method

Methodology

Interventions

Setting

Geographical

Cultural

Participants

Data analysis

Author’s conclusions

Reviewer’s conclusions

© Christina M. Godfrey and Margaret B. Harrison

© Joanna Briggs Institute

14

Appendix V: Extraction of Study Findings Template – for Qualitative Evidence

Finding

Illustration from publication (including page number)

Evidence Unequivocal Plausible Unsupported

Category

15