The survey of several hundred international nurses working in London has provided a detailed picture of their demographic profile, their motivations for working in the UK, their career plans and also some information on their pattern of remittances. The survey provides more insight into these issues than has been available before, and highlights a range of key issues which have implications both for broader-based UK national reliance on international recruitment of nurses and local practice in retaining and motivating these nurses and treating them fairly.
The first point to note is that the sheer diversity of the range of countries from which nurses are being recruited has implications for policy and practice. The broad range of source countries for UK-based international nurses has been obvious in the Nurses and Midwives Council registration data from recent years, but this current survey highlights the extent to which different countries of training can be related to different demographic profiles and reported career intentions. While it can be misleading to generalize based on source country or grouping of source countries, there are marked variations in terms of respondent demographic profile and in terms of responses to some questions from some of the regional subgroupings. To focus policy attention or practice on all internationally recruited nurses as being "the same", but somehow "different" from all UK-educated nurses, is at best an oversimplification of a complex situation and could be a dangerously misleading approach.
While it can be misleading to focus on generalities, it is clear that different types of internationally mobile nurses can be delineated within the survey: the young "backpacker" nurse from Australia or New Zealand who is planning a relatively short stay in the UK has a different range of priorities and objectives than a Filipino nurses remitting money back to her extended family (and perhaps considering a move to the USA); both are different from an older South African nurse taking the opportunity of a few years in the UK for professional development before planning to return home.
Several key themes do emerge, which have implications for policy and practice in the UK. The broad age profiles of nurses, particularly the "older" profile from Africa, counters the assumption often being made that it is only young nurses who are internationally mobile. Some of the mobile nurses are aged in their 40s or 50s and have many years' clinical experience. This reinforces the point that the impact of emigration on sub-Saharan countries is not just about numbers, it is about a loss of experienced staff.
The demographic data also revealed that many nurses have their partner and/or children with them in the UK, which highlights that not all have travelled leaving their spouse and other close relatives "at home": for some, in a sense, home has travelled with them. However, one in three nurses with children reports that they have left children in their home country.
It was also evident from the responses to the survey that financial reasons are not always the reported primary driver for international nurses to be in the UK; many have been attracted to the UK for a variety of other reasons, primarily for professional development reasons or to take the opportunity to travel. These are self reported reasons so must be treated with some caution, but they do highlight a more complex reality than that based on the assumption that money is always the only, or main, driver to migrate.
The central role played by recruitment agencies in both stimulating and facilitating international recruitment was highlighted in the survey. Two thirds of the international nurses working in London reported that a recruitment agency had been involved in their move to the UK – and most had to pay for some of the services provided by the agency. Some of the nurses reported that they had been provided with misleading information by agencies about their pay and working conditions in the UK. Recruitment agencies providing staff to the NHS have recently been brought within the remit of the Department of Health Code practice (discussed below).
The regulatory requirements for nurses entering the UK are stringent and based on an assessment of each applicant. Most international nurses from sub-Saharan Africa, the Philippines and India/Pakistan/Mauritius were required to complete a supervised practice course/or period of adaptation in order to practise in the UK; most had done so in private sector nursing homes, and some nurses from sub-Saharan Africa reported that they had to pay for their adaptation, or received no pay during that period. While these regulatory requirements are in place to maintain standards and for public protection, the response from some of the nurses revealed that they believed they had been exploited during their application and entry process.
The survey evidence on the levels of remittances being sent, although limited, does add new information on this important but under-explored issue. It is important to note that most of the nurses reported that they were the sole or main contributor to family income. More than half of the nurses reported that they regularly remitted money to their home country; nurses from the Philippines and South Africa were more likely to remit a higher proportion of their income – half of each group regularly remitted a quarter or more of their income. This represents a significant flow of money.
The UK policy context in which the survey evidence must be examined is codified within a so-called "ethical" approach. Recruitment of nurses from the developing world has been controversial, and the Department of Health in England has attempted to limit the potential negative impact. It first established guidelines in 1999 [11], which required NHS employers not to target South Africa and the West Indies, and then introduced a Code of practice of international recruitment for NHS employers (in 2001) [12], which was strengthened (in 2004) [13]. This Code requires NHS employers not to actively recruit from developing countries unless there is a government-to-government agreement that active recruitment is acceptable. At the time of writing, such agreements exist only with China, India, and the Philippines – all other developing countries are effectively designated as "no go" areas for NHS recruiters. So far, there has been little active recruitment of nurses from China.
The Code applies to NHS employers, to "preferred provider" recruitment agencies and to private sector employers if they are providing NHS-funded care. The overall impact of the Code is difficult to monitor and assess because of because of an absence of NHS-specific data on numbers of nurses recruited and employed. However, this survey of London-based international nurses clearly demonstrated that many nurses were recruited initially by private sector nursing homes in the UK but moved quickly to the NHS on completion of their adaptation period in the UK. NHS employers in London were the end beneficiaries of private sector "back door" recruitment from countries that were on the NHS "banned " list of developing countries. This does not contravene the NHS Code on international recruitment, but helps explain why there continues to be an annual inflow of several thousand nurses to the UK from developing countries on the list.
The issue of the efficiency and effectiveness of international recruitment rests partially on how long international recruits are retained within the NHS. The survey highlighted that many of the international nurses were thinking about a long-term commitment to the UK (especially those from sub-Saharan Africa and the Indian subcontinent), others were planning to go home (especially nurses from Australia, New Zealand and South Africa); but many were also considering moving on (primary destination the USA), stimulated by recruitment agency contact (this especially the case for nurses from the Philippines).
Limitations of the study
The survey was based only on RCN members, who represent the majority, but not all, working nurses in the UK. Nurses who were in the UK for only a short period may be less likely to join the professional association, so may be underrepresented in the study. Nurses from countries without a culture or tradition of joining a professional association may be underrepresented in the study. The survey had an acceptable response rate, but it was not feasible to identify reasons for non-response. Fewer respondents provided information on remittances than on the other topics covered by the questionnaire; this may reflect a greater reluctance on the part of respondents to provide information on financial details than on other subjects.
NMC data provide information on all nurses accepted onto the UK register, it does not necessarily mean that all these nurses are actually in the UK.
The focus on London provides a detailed insight into the profile and motivations of nurses in the capital; given the relatively higher proportion of international nurses working in London; the results should not be taken to be representative of all international nurses working in other parts of the UK. The sample sizes for some source countries are too small to be taken as representative of all nurses recruited from these countries.
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