Exploring the perceptions and work experiences of internationally recruited neonatal nurses: a qualitative study

WORKFORCE ISSUES

Exploring the perceptions and work experiences of internationally

recruited neonatal nurses: a qualitative study

Obrey Alexis and Adeline Shillingford

Aim. To explore the perceptions and work experiences of internationally recruited neonatal nurses.

Background. Neonatal nursing and health care are global issues facing developing and developed countries. In the UK, the

recruitment of international nurses to address the labour shortage is not a new phenomenon.

Methods. A purposeful sample was drawn from internationally recruited neonatal nurses, working at two teaching hospitals in

London. Husserl’s phenomenological approach underpins this study. Thirteen nurses, (all female) participated in the study and

semi-structured face-to-face interviews were conducted to capture the unique perceptions and experiences of neonatal nurses at

two hospital sites. A qualitative approach was adopted and this study used Colaizzi’s analytical framework to analyse the data.

Results. The analysis of the data resulted in four themes namely the support mechanisms, unfamiliarity with family centred care,

feelings of being treated like a child and coping strategies.

Conclusion. It can be concluded that in recruiting internationally recruited neonatal nurses to work in the NHS, there is a need

to support them, encourage them to become familiar with family centred care and they should be treated as qualified nurses.

Therefore, there is a need to consider these findings in any recruitment process involving neonatal nurses.

Relevance to clinical practice. Internationally recruited neonatal nurses play an important role in caring for neonates in the NHS

in the UK however meeting their needs have not always been addressed in the health care setting.

Key words: Coliazzi, international nurses, phenomenology, neonatal, nursing, recruitment

Accepted for publication: 30 July 2011

Introduction

For several decades there has been a steady recruitment of

qualified internationally recruited nurses (IRNs) for hard-to-

fill vacancies in the UK’s NHS. Widespread nursing shortages

have meant that managers in the UK and other countries such

as America, Canada and Australia have actively recruited

trained nurses from both developed and developing countries

(Buchan & Calman 2004, Cameron et al. 2004). This has

resulted in particular, in a reduction in trained nurses in many

developing countries. In view of the detrimental impact that

recruiting trained nurses from developing countries has on

developing countries’ economies, the World Health

Organisation (WHO) (WHO 2010) has drafted a global

code on the recruitment of all health care workers including

nurses with its aim to promote ethical practice in relation to

international recruitment.

Background

It is estimated that there are over 80,000 IRNs who have

registered with the Nursing and Midwifery Council (NMC)

(NMC 2009) since the middle of the 1990s to end of March

2009. According to Buchan and Sercombe (2005) these nurses

Authors: Obrey Alexis, BSc, MSc, PhD, RN, FAETC, Senior Lecturer,

School of Health & Social Care, Oxford Brookes University,

Swindon; Adeline Shillingford, Dip. Health Studies, BSc, MSc, RN,

RM, Senior Sister, Neonatal Unit, Queen Charlotte’s and Chelsea

Hospitals, Imperial College Healthcare NHS Trust, London, UK

Correspondence: Obrey Alexis, Senior Lecturer, School of Health &

Social Care, Oxford Brookes University, Ferndale Road, Swindon

SN2 1HL, UK. Telephone: 01793 437432.

E-mail: [email protected]

� 2011 Blackwell Publishing Ltd

Journal of Clinical Nursing, 21, 1435–1442, doi: 10.1111/j.1365-2702.2011.03922.x 1435

currently form a major part of the nursing workforce in the

UK. Of these it is difficult to estimate how many are

internationally recruited neonatal nurses, however in London

in particular there are problems with the recruitment and

retention of IRNNs. It has been stated that the demand for

neonatal nurses far outstrips supply (Green 2005). According

to the National Intensive Care Review – Strategy for

Improvement document (Department of Health [DH] 2003)

and the National Service Framework (NSF) for Children

Standards for Hospital Services (DH 2004) the demand for

neonatal care has increased dramatically over the last

two decades particularly with the advancement in obstetrics

and neonatal technology and treatment. More recently a

report by the NHS Neonatal Taskforce titled, Toolkit for

High-Quality Neonatal Services (DH 2004) highlights the

serious shortages of neonatal nurses and draws on the care

that is required for neonates and their families in the NHS. As

a result of the recruitment crisis facing many neonatal units,

many hospitals have focused on recruiting international

nurses to fill those vacancies.

For the past few years, research in the UK has

concentrated in general on the experiences of internation-

ally recruited nurses in the NHS (Daniel et al. 2001, Allan

& Larsen 2003, Withers & Snowball 2003, Alexis &

Vydelingum 2004, 2005, Allan et al. 2004, Magnusdottir

2005, Matiti & Taylor 2005, Taylor 2005, Winkelmann-

Gleed & Seeley 2005, Likupe 2006, Smith et al. 2006,

Alexis et al. 2007, Okougha & Tilki 2010). Others have

also focused on the experiences for example in the USA

(Lopez 1990, Yi & Jezewski 2000, Ea et al. 2008),

Australia (Omeri & Atkins 2002, Witchell & Ousch

2002, Brunero et al. 2008), Canada (Sochan & Singh

2007) and Europe (De-Veer et al. 2004, Humphries et al.

2009). Although these studies have focused on the expe-

riences of IRNs in different clinical settings none has

specifically concentrated on the experiences of IRNNs in a

neonatal environment in London. Therefore, if IRNNs are

to be part of the workforce in London there is a need to

find out how they have fared in their work settings.

Therefore this study will seek to address this issue by

examining the experiences of IRNNs using Husserl’s

phenomenological approach.

Methods

Aim of the study

The aim of the study was to explore the experiences of

internationally recruited neonatal nurses in the NHS in the

UK.

Sample

A purposeful sample (Silverman 2005) was drawn from

internationally recruited neonatal nurses who were working

at two neonatal units in two separate NHS Trusts in London.

In this study, participants were recruited on the basis of their

experience as IRNNs. To be included in this study, the

participants were required to be IRNNs working in a

neonatal unit and were required to have a minimum of

one year but no more than 10 years of experience in a

neonatal unit in London. These criteria were used because of

the need to focus the study on this particular group of nurses.

Thirteen nurses (all females) participated in the study and

they originated from either Jamaica or the Philippines.

Participants were aged between 24–55 years.

Research design

A qualitative design was adopted for this study using

Husserl’s phenomenology philosophy. It is beyond the scope

of this paper to offer a detailed critique of this approach.

However, Husserl’s (1965) framework emphasises the impor-

tance of ‘bracketing’ as a method for suspending precon-

ceived notions (Koch 1995, Crotty 1998). Phenomenology

recognises the complexity of humans and seeks to understand

their experiences from their perspective and how it is actually

lived (Bowling 2002). According to Polit and Beck (2004)

and Flick (2006), phenomenology research is an important

method with which to begin accumulating evidence when

little is known about a particularly topic, or when studying a

topic from a fresh perspective. The aim of phenomenology is

to produce a description of the phenomenon of everyday

experience; to determine what an experience means for the

person experiencing it and to provide a comprehensive

description of it (Priest 2002). In this study the researcher

wrote down what was known about the topic and what the

issues were as this process allowed the researcher to bring

these issues into consciousness. A reflective diary was used to

document the researcher’s thoughts, feelings and perceptions

throughout the research process.

Data collection

To minimise the potential for either bias or prejudice during

the data collection, the researcher reflected on their own

experiences and documented the information prior to inter-

viewing the participants. This process is termed ‘bracketing’

and is known as the epoche principle (Hamill & Sinclair

2010). Bracketing is a mathematical metaphor originally

coined by Husserl to mean suspending one’s beliefs,

O Alexis and A Shillingford


1436 Journal of Clinical Nursing, 21, 1435–1442

assumptions and prejudices to extract the ‘truth’ about the

participants’ experiences (LeVasseur 2003). It allows the

researcher to analyse the data supplied by the participants in

a pure form by setting aside the researcher’s own precon-

ceived ideas and notions surrounding the phenomenon. This

process makes it possible to focus only on the participant’s

experience by keeping the meaning of the researcher’s

personal experience separate from that of the participants.

In-depth open ended interviews were conducted during

the months of August to October 2007 by the researcher.

Each participant was asked: Can you tell me about your

experience of working in your neonatal unit? How did you

feel? Can you give me an example? Each participant was

provided with an interview number to assist the researcher

in identifying their voice on the audio-tape. A demographic

sheet was also obtained prior to the audio-taping to assist

in identifying and contacting the nurses so that validation

of the transcribed information could be obtained. The

interviews lasted for approximately 30–60 minutes. All

participants were interviewed in a communication room, in

a quiet area on each neonatal unit, as this was convenient

for them. Tapes were transcribed verbatim and processed

into a hard copy and each participant had their transcript

returned to them by hand delivery so that they could

review, comment and validate the data. This process was

carried out so as to ensure that the data reflected their

views and to establish credibility of the study (Guba &

Lincoln 1994). The methodology adopted is that of

Husserl’s approach and the researcher was able to answer

the research question because the approach was thoroughly

followed as evidenced in this study.

Ethical considerations

As part of the NHS Research Governance Framework (DH

2005), ethical approval was granted by the Central Office of

Research Ethics Committee (COREC) and the Research and

Development Department at each hospital site. Informed

consent was obtained by provision of an information/invita-

tion letter and consent form. The researcher gave the

assurance that confidentiality and anonymity would be

adhered to. All participants were aware that they could stop

the interview and withdraw from the study at any time.

Data analysis

The data from the interviews were tape-recorded and

transcribed verbatim. They were analysed using Colaizzi’s

(1978) analytical framework (Table 1). The tape was played

and replayed and the content was carefully listened to. Field

notes were read repeatedly to acquire a feeling for them and

to make sense of the participants’ experiences (Priest 2002).

Following reading of the whole interview material, state-

ments were extracted from the raw data. These were analysed

to identify the meanings contained in these statements.

During the process, the researcher entered into a dialogue

with the material, aiming to gain an understanding of the

meaning attached to these statements. These meanings were

then combined into groups of themes which were gradually

formulated into main themes.

Results

The themes are presented below with quotations from the

interview texts. Four main themes emerged following data

analysis namely: the support mechanisms, unfamiliarity with

family centred care, feelings of being treated like a child and

coping strategies.

The support mechanisms

The participants expressed both negative and positive feelings

about the support they received. Some participants spoke of

regaining confidence and were offered support when needed.

They stated that they did not have to struggle whilst working

in the neonatal unit:

My confidence came back again because here at this unit they are

supportive. (Interviewee 5A)

They made it easier. We didn’t have to go through a lot of struggle

compared to others. (Interviewee 5B)

On other hand, some participants expressed that they were

not informed of what to expect. Others stated that some of

their UK counterparts were not prepared for them so there

was not much information by way of what needed to be

done. They stated that they found the experience to be

stressful:

Table 1 Colaizzi’s phenomenological analytical framework

1. Reading through the entire interview transcript to form a general

picture.

2. Extracting statements relevant to the research topic from the raw

data.

3. Extracting meanings out of statements.

4. Repeat steps 1–3 with each interview.

5. Formulating themes out of meanings.

6. Combining themes into descriptions of the topic.

7. Reflecting the themes back onto the data so as to ensure that the

analysis has produced a description of the experiences concerned.

Workforce issues Exploring the perceptions and work experiences of internationally recruited neonatal nurses


Journal of Clinical Nursing, 21, 1435–1442 1437

People used to watch you. No one came up to say, I am your mentor/

preceptor for the day, this is what we do. No one did that.

(Interviewee 1B)

I think they didn’t know what to do with us when we came. They

didn’t know where to start with us, what to tell us. They had

absolutely nothing planned for us. So it was a stressful situation for

all of us. (Interviewee 3B)

Although there was mixed support from their UK counter-

parts, support came from other IRNNs who were able to

guide them and provide them with the much needed

information for practice:

I think it was made easier, by the fact that there was five of us and

four of us started together, so that made it easier to have people with

you, as opposed to you being by yourself. (Interviewee 3B)

Unfamiliarity with family centred care

Communication is undoubtedly fundamental in health care

and for some participants in this study as English was not

their spoken language in their country of origin. It would

appear that working in the NHS created some communi-

cation difficulties for these participants. They described

how they needed to communicate and provide parents with

information. This they found to be difficult as they were

not prepared:

You need to involve the parents, giving them all these information.

This was new to me when I came here, very difficult, especially giving

all this explanation and all, involving the family. (Interviewee 4A)

The first part is really to deal with the parents because I’ve never had to

deal with parents before... so I’m not used to dealing with the family

and that makes the work, I mean hard for me. (Interviewee 6A)

The IRNNs also voiced their concerns about the organisation

and delivery of neonatal care and how they were being forced

to work in situations where they were overstretched and

understaffed as illustrated in the following quotations:

There is some shortage of staff or even the staff ratio to patient

workload is very low. We are trying, you know, to cope with these

situations, but sometimes it makes you feel very stressful and very tired

at the end of the day. The number of staff is not enough for the number

of patients. Sometimes you care for two very sick babies and still having

to admit a baby or two to the unit. (Interviewee 1A)

Some said that the workload was heavy and that the staff to

babies ratio was too low:

The workload can be quite heavy, not enough staff to care for sick

babies. (Interviewee 3B)

The workload is a big issue. The ratio of babies to nurses is too low.

(Interviewee 3A)

Feelings of being treated like a child

Participants described many situations when they felt that

they were treated differently to that of their UK counterparts:

The first clinical experience I had I was practically in tears. I

remembered this experience where this couple, they were Caucasians

and they didn’t want me to look after their baby, not because they

think I didn’t know what I was doing, but because I was black. So

they went and complain to the nurse in charge at the time and instead

of pacifying the situation, she played into it by assigning me to

another baby and assigns another white nurse to the baby. I felt that

humiliated and felt thought that this could have been handled

differently. I am not a child here, I am a grown up and if the family

feels that I am not caring appropriately for their child then I expect

my manager to approach me to discuss the issue not to behave the

way that she did. (Interviewee 5B)

Participants felt that because they came from a developing

country their knowledge and skills were questioned. They felt

that they were compared with countries such as Australia and

New Zealand:

They felt that because we came from a Third World country, they felt

our experience was not up to par or in comparable to persons from the

UK or Australia or New Zealand. You were being questioned. After

doing something, instead of a person criticising you in a constructive

way, they criticised you in a destructive way. (Interviewee 4B)

Another participant said that she was accused of not providing

appropriate care which she felt was unfounded. In handing

over, the baby condition was stable and all observations were

within the normal ranges however, the participant was blamed

for the deterioration in the baby’s condition:

I remember having a patient once and the baby was fine on my shift,

but went off on the night shift. I was on an early shift and another

nurse took over the late shift, but she said that the reason why the

baby went off was because I cared for the baby on the early shift. I

found the experience to be humiliating. (Interviewee 1B)

One IRNN described her experience as going ‘back to square

one’ and ‘back to zero’ as well as being treated like a student,

instead of being seen as a qualified nurse:

It was a bit frustrating to start with. There was even a point that

we really wanted to quit. You can’t really suggest because they

will tell you forget about your past experience, this is a different

place, this is UK. I mean it was quite frustrating because they

don’t give you the independence that you are used to. You don’t




have the liberty to do most of the stuff that you were doing back

home, but to be treated like students. (Interviewee 3A)

It was more like starting from square one, not practising as a

professional nurse but going back to zero and this became frustrated

for me. (Interviewee 5A)

Coping strategies

The IRNNs expressed various methods of coping whilst

employed in the NHS. They stated that their UK counterparts

undermined thembutdespite this theyneeded toprove that they

could cope despite being treated differently. They also stated

thattheycopedbygettingonwiththejobinhand.Moreover, the

findings revealed that they were in the UK to provide care of the

highest standard but at the same time to gain more skills and

qualifications:

Persons undermine your experiences initially, because they didn’t

know you. They didn’t know you. They didn’t know what your

capabilities are, so we had to really work our way up and prove

ourselves, prove our capabilities. (Interviewee 4B)

I came with a goal in mind to get my degree that was what drove me

to understand the system, to work with it as best as I could.

(Interviewee 3B)

For some participants, to cope with the challenges of the NHS

and that of being a new comer to a different environment, the

watching of black films was a regular occurrence. For others,

being open minded and assertive helped them to cope with the

challenges that they faced:

What kept me going; I watched a lot of black movies, empowering

movies, movies where black people really stand out. I used the words

of these people to really motivate myself. (Interviewee 1B)

I try to overcome the difficulties by being open-minded, at the same

time being vocal, telling them what you feel, so they know, so they

could do something about it. (Interviewee 2B)

In addition, participants revealed that they stuck together and

this enabled them to cope. They stated that, had they been in

the UK alone, they did not think that they would have been

able to overcome some of the obstacles and challenges of

working in the NHS:

I was not alone and we stuck together. I think that was what made

the difference. If I had come alone and just in this environment, I

don’t think I would have stayed. (Interviewee 1B)

Discussion

The aim of this study was to describe the lived experiences of

IRNNs in the NHS in London. The use of phenomenological

approach resulted in rich descriptions of their experiences of

working in the NHS. The study was based on a sample of

only 13 participants from two different hospitals and the

findings offered a greater insight into their experiences.

This study highlighted the inconsistencies in the nature of

support for IRNNs in that some participants received support

from colleagues as well as from their managers and this

enabled them to become much more confident in their

working environment. This finding is consistent with other

studies (Gerrish & Griffith 2004, Matiti & Taylor 2005,

Cummins 2009). On the other hand some participants

received minimal support. Such finding is similar to that of

previous studies (Allan & Larsen 2003, Alexis & Vydelingum

2005). In any working environment it is necessary to have

support (Piko 2003). This is important because it may enable

individuals to carry out their duties with ease and to a greater

extent allows them to function much more effectively.

The findings of this study also revealed that IRNNs were

unfamiliar with family centred care in the UK. Giving

information and involving the family in the care of neonates

were areas that IRNNs were not accustomed to doing.

According to the Institute for Family Centred Care (2005),

family centred care is a way of caring for children and

families in health services which ensures that the care is

planned around the family not just the child but also in

providing care information giving and sharing should be

paramount. This notion is further echoed by Shields et al.

(2006) who stated that family centred care should involve the

family as well as the child but there should also be an

exchange of information between health care professionals

and that of the family.

Family centred care is an important aspect that IRNNs

ought to consider when caring for neonates however in this

study such activity may have been affected due to a stressful

working environment. As highlighted in this study some

IRNNs stated that they were overstretched and were working

in some stressful conditions thus negating the need for

involving family members in the sharing of information. The

National Service Framework for Children (Department of

Health 2004) advocates that family centred care should be

paramount in the delivery of health care and therefore

IRNNs should align their care in accordance with this

framework. This is also supported by Shield (2010).

It could be argued that some IRNNs experienced some

interactions with their UK counterparts that could be

described as maternalistic. Their testimonies of feelings of

being treated like a child in the clinical environment may

have had an impact on their self-esteem and confidence which

have been alluded to in Oeye et al.’s (2009) study. The

findings of this study also support that of Riikonen’s (1999)




description of disempowering and non-inspiring practices

that health care practitioners must move away from.

Generally, some participants felt that their knowledge

and skills were questioned. Others felt that they were

treated like students and in some respects felt devalued.

Drawing on Walker’s (1994) model which states that,

people work best when they feel valued and when their

individual and group characteristics are different. Indivi-

duals who feel valued and empowered are more likely to

build relationships with others and are able to work

synergistically. However, it would appear that this was not

the case for IRNNs. They felt devalued and appeared to be

treated like children.

Lazarus and Folkman (1984) defined coping as ‘constantly

changing cognitive and behavioural efforts to manage specific

external and internal demands that are appraised as taxing or

exceeding the resources of the person’ (p. 141). The range of

cognitive and behavioural strategies people use to manage

internal and/or external demands in stressful encounters have

been classified as confrontation, distancing, self-control,

seeking social support, accepting responsibility, escape-

avoidance and positive reappraisal (Lazarus & Folkman

1984). There are two main forms of coping such as problem-

focused and emotional. In problem focused, attempts will be

made to manage or change the environment that causes

stress. This approach is used when the environment is

appraised as amenable to changes. In contrast emotional

coping which involves handling the emotional response to the

problem and reducing the stress by attempting to maintain

optimism as well as hope and by denying to acknowledge the

worst (Lazarus 1999). In this study, the problem focused

approach that some IRNNs used were that of setting

themselves goals and attempting to prove to themselves as

well as to their UK counterparts that they were just as capable

as their colleagues. Similarly, emotional coping as seen in this

study involved IRNNs watching black humorous films and

being open-minded as these gave them some sense of strength

to deal with the challenges of working in the NHS in

particular in the neonatal clinical settings.

Limitations

The perspectives of IRNNs in this study may not be

reflective of other IRNNs in other settings in the UK or

internationally. In addition, the small sample size used is

another limitation of this study. However, the rich and

clear views that IRNNs provided are hopefully informative

and insightful and consideration should be given to these

findings when recruiting IRNNs to work in the NHS in

the UK.

Conclusion

Recruiting IRNNs to work in the NHS in the UK can be a

challenge for any hospital. Given that IRNNs are part of the

workforce, it is therefore important to offer them support as

this could enable them to provide high quality care. Not only

should IRNNs be supported but this also should be extended

to all staff as equity in treatment should be part of the ethos

in the working environment.

This study however reveals a number of challenges that

IRNNs experienced whilst working and these could have

been minimised by introducing a well-structured induction

and mentor programme tailored to meet their needs. This

perhaps could have made their experiences much more

positive and to a greater extent enjoyable. There is a

pressing need however for IRNNs to focus their care and

information around the family as this would help them to

create an environment where the family feels included as

well as part of the team. Although IRNNs come with

different skills and knowledge base to that of their UK

counterparts, their treatment should be no different to that

of any other UK trained nurses. Accepting, valuing and

supporting of IRNNs can create a much more satisfying

workforce ultimately improving the standard of care for

patients. With this in mind, it is hoped that the findings of

this study will be considered when recruiting IRNNs to

work in any neonatal settings in the NHS in the UK.

Relevance to clinical practice

IRNNs play an important role in caring for neonates in the

NHS in the UK however, their needs have not always been

met in the working environment. Addressing their needs in

the health care sector in the UK could contribute to a better

workforce of IRNNs who could have the much needed skills

to provide family centred care and they could be in a much

better position to cope with the challenges that they may

encounter in the NHS. Policy makers are key drivers to

ensuring that policies are instituted for the benefit of IRNNs

and for the sustainability of the workforce. A failure to

ensuring that IRNNS needs are met could jeopardise the

care provision for patients and their families with the

ultimate effect on the standard of care in the NHS.

Acknowledgement

The authors would like to thank the participants for

divulging their experiences of working in the NHS in

London.




Contributions

Study design: OA, AS; data collection and analysis: AS and

manuscript preparation: OA, AS.

Conflict of interest

The authors have no conflict of interest

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Exploring the perceptions and work experiences of internationally recruited neonatal nurses: a qualitative study