Experience of mobile nursing workforce from Portugal to the NHS in UK: influence of institutions and actors at the system, organization and individual levels

Abstract

In UK, since 2010 shortages of nurses and policy changes led many health service providers to become more active in recruiting nurses from the European Union Member States. This article analyses the experience of Portuguese nurses working in the English NHS considering the individual and organizational factors that affect the quality and duration of nurses’ migration experience, future career plans and expectations. Twenty-seven semi-structured interviews were conducted at the individual, organizational and policy levels in UK with Portuguese nurses and NHS healthcare staff in 2015–16. The results demonstrate that organizational settings, conditions, actors’ attitudes and level of support influence nurses’ level of commitment to their employer and their overall mobility experience. Professional achievements, professional and personal sources of support made these nurses evaluate their overall mobility experience as positive, even overcoming personal challenges such as homesickness. The results reveal that migration is accomplished through constant interaction between institutions and individual actors at different levels. Understanding the influencing factors as well as the complex and dynamic nature of a professional’s decision-making can design more effective retention responses.

Introduction

In UK, vacant nursing and midwifery posts in the NHS are around 40 000.^1,2 Based on current trends, that shortfall could increase beyond 100 000 full-time equivalent nurses within a decade.³ International recruitment has long been used as a strategy to address nursing shortages.^4–6 However, the decreasing number of nurses from the European Union (EU) and European Economic Area (EEA) coming to the UK combined with the increasing number of EU/EEA nurses leaving the Nursing and Midwifery Council (NMC) register since the vote in favour of Brexit in 2016⁷ indicate, that these countries are now a less important source of supply.⁸

We need to better understand how nurses’ mobility decisions are made. There are studies on the reasons underpinning mobility patterns of nurses within the EU,⁹ on nurses’ intentions to leave their country, on turnover rates and on retention strategies.^10,11 However, less research has focused on the experiences of EU/EEA nurses in UK, compared with the experiences of overseas (non-EU/EEA) nurses and on the influence of the organizations that recruit and employ them.

The high demand for foreign-trained health professionals in a context of changing labour market conditions makes the NHS in UK an interesting case for exploring the mobility flows. We used Portugal as a case study to analyze the interplay between changing labour market conditions and the ‘human face’ of the workforce, such as motivation to move and experience of individual professionals. Portugal provides a unique test bed for an in-depth analysis, because of its large emigration flow of nurses to UK^11–13 during a period of austerity measures, deteriorating working conditions and unemployment.

The aim of this article is to present and analyze the individual and organizational factors that affect the quality and duration of Portuguese nurses’ migration experience, future career plans and expectations. An in-depth exploration of how these nurses relate to recruiting and employing organizations and experience the different challenges and facilitators during their recruitment, arrival into the new organization and overall integration may allow to better understand how of nurses’ individual stories, preferences and expectations can be integrated in long term more effective workforce planning.

Methods

The present article uses material collected between November 2015 and July 2016 in UK. A total of 27 semi-structured interviews were conducted face-to-face, using Skype and telephone, including 11 Portuguese nurses, 9 NHS staff members (e.g. Nursing Directors, Clinical Practice Facilitator, Associate Director of human resources) in 5 NHS Trusts and 8 key informants representing the views of Portugal, UK and the EU, ranging from policy to general matters such as advocacy, education and regulatory issues. Nursing respondents were invited to participate through networks of Portuguese migrants (e.g. website Além Fronteiras). Data were analyzed through thematic analysis using the framework approach.¹⁴ For the purpose of this article, the focus was placed on the factors, actors and relationships that shape the experience of mobile nurses and determine the balance between the perceived costs and benefits of their move.

Results

Context of nursing mobility

In 2016, there were 69 682 nurses on the Portuguese register, a number that has been increasing over the years, but that has remained at around 6.7 nurses per 1000 population.¹⁵ The ratio of nurses per doctor declined from 1.5 in 2008 to 1.3 in 2017. OECD averages are of 8.8 for nurses and 2.7 for the ratio of nurses per doctors.¹⁶ Portugal is among the European countries that suffered the most severe austerity measures in response to the economic and financial crisis of 2008, including salary cuts of health workers in the National Health Service, non-replacement of leavers and promotion freezes.¹⁷ During the crisis, there has been an emigration flow of nurses, and mostly to UK.^5,13

Since 2015, some aspects of the working conditions such as weekly workloads have improved in Portugal and more recently, the career structure has been revised to recognize the status of specialist nurse and nurse manager.¹⁸ However, overall working conditions, remuneration and broader opportunities for career development remain largely unchanged. Recent figures of new registrations and total numbers of Portuguese nurses in the NMC (figure 1) suggest that nurses continue to leave Portugal, but not on the same scale to UK. The decreasing value of the pound, a sense that the UK is less welcoming of migrant workers and a post-Brexit environment with a potentially more onerous migration system¹⁹ are all negative factors influencing the decision of whether to go and stay in UK.

Figure 1.

Number of new registrations of Portuguese and other EU/EEA nurses in NMC against number of Declaration of Professional Qualifications requests (2014–19). Source: NMC, 2020¹⁹; PNC, 2017, 2019, 2020^20–22. Note: the number of requests for the ‘Declaration of Professional Qualifications’ made to the PNC refers to the recognition of professional qualifications by the official Nurse regulator in a country and it is a necessary requirement to be qualified to work as a nurse in another Member State. This document only reflects intention to move abroad. No data is presented for the number of new registrations of all EEA/EU nurses in the NMC in 2014

Motivations and activating factors to move

Motivations to move provide information for a better understanding of nurses’ subsequent experiences, as they set the expectations and goals for their future in UK. The main reason to leave Portugal was the lack of opportunities for career progression. The most experienced nurses in the sample described feeling ‘frustrated’, ‘stagnant’ or that they had ‘nowhere to continue growing to’, voicing low expectations of career growth in Portugal. The more recently qualified nurses referred to the low attractiveness of employment in the public sector. All interviewees expressed concerns that the prospects of working in Portugal did not match what they had envisioned.

Previous knowledge of English seemed to make UK a desirable migration choice. Similarly, the ease and the low cost of travel, including to return home when necessary, provided a sense of ‘closeness to home’. But the factors that prompted the decision to leave their home country were related to the information and assistance they were able to acquire from different sources.

Recruitment process

The group of nurses who arrived in UK between 2005 and 2009, mentioned that their decision to move was encouraged by personal circumstances and the availability of sources of support. As nursing mobility from Portugal to UK was not common at that time, access to recruitment agencies (RAs) and to information about the logistics of the move was more limited. In fact, three out of four early migrants came to UK without a job offer or were recruited into a new job without intermediaries. These nurses reported the importance of having family or friends already established in UK, or the assurance of migrating together with a friend or a partner who had also found a job in the country. Six out of eleven nurses also indicated that they had visited or lived in England before, which made the project of migrating there more familiar.

For nurses who came to UK more recently, positive accounts shared in social media and the press of the many job opportunities and the working conditions in UK were the main activating factors. Social media, in particular, made the idea of moving abroad more accessible and less daunting. One respondent said that these accounts gave her the stimulus and confidence to make the decision, prompting the question ‘if everybody can do it, why wouldn’t I?’ [Nurse 2]. These positive stories were disseminated by the several RAs, that began to be active throughout the country, organizing recruitment fairs in the main cities and highlighting the overall benefits of working in UK, such as mobility within the NHS to look for promotions or a post in the preferred region and specialty.

This group of nurses, who were in most cases recruited through an agency, reported an easier recruitment process, which they attributed to the assistance provided with paperwork and to benefits such as accommodation and flights. This helped focus on adapting to a new environment, new ways of practice and using a different language. An added benefit of this recruitment route was cohort flights with other nurses, coordinated arrivals at the same organization and joint briefings and induction, which helped develop friendships. Nurses recruited through agencies were known to undertake longer and more thorough induction programmes in comparison with those recruited independently.

The only perceived challenge or ‘disadvantage’ of the RA route was the tendency to place new recruits in rural locations or in clinical areas or regions with greater staff shortages, and not necessarily in the area or region of their choice. Despite the preference of most nurses to work in hospitals in London, most of them were initially deployed to regional hospitals. According to these nurses, this resulted in later movements within and between NHS trusts to secure better positions and apply for promotions, and to finally be able to choose where and in which specialty to work.

Networks and support systems at arrival in employing organization

Access to support within the work environment, in the form of establishing good relationships and even friendships with colleagues, mentors or chief nurses, was one of the aspects most frequently highlighted as the ‘best’ or ‘worst’ experience in participants’ mobility trajectory. Most nurses described their experience as positive, sharing many happy stories related to the way they were welcomed in the organization and to their relationships with supportive mentors, preceptors and teams. These positive experiences created a sense of loyalty and gratitude towards the organization, factors that carried weight in the decision to stay or leave; feeling valued was an incentive to remain in the organization as a way of showing appreciation. ‘They invest in us in here and this is our way to say, “thank you for everything that you’ve done for us, we’re not going anywhere after”’ [Nurse 11].

However, some nurses faced challenges associated with the attitudes of specific individuals in more senior positions. Three nurses described several situations in which they felt unsupported by their superiors and deliberately held back from accessing opportunities to progress professionally:

‘The lead nurse for education told me that if I wanted to do a masters I had to do my training all over again as my Portuguese diploma was not going to be accepted in any UK university’ [Nurse 5].

As regards to personal sources of support, having friends or family already in UK and having moved with a partner eased the transition into a new culture and environment. Also important was having come together with a group of Portuguese nurses, or having met another Portuguese among the staff of the organization. One nurse stated: ‘when someone asks me in Portugal about the recruitment process, I always say, “If you can, always go with a group” ’ [Nurse 2]. Sharing accommodation with other nurses during the first weeks created further opportunities to make new friends, share experiences and develop an overall sense of belonging and community. Even being among other foreigners from different nationalities made them feel less like foreigners themselves, highlighting the relevance of networks and communities in general.

Homesickness and the general difficulties of having left family and friends behind were common shared experiences during the settling phase into the new organization. However, in most cases, these were regarded as an inevitable consequence of the decision to leave their home country to look for better opportunities abroad. All nurses, however, reported staying in close contact with their loved ones, in some cases even more often than when they were living in Portugal.

According to NHS organizations interviewees, making sure these nurses had a community to rely on was crucial for successful adaptation and overall integration, reducing the time and resources needed for their induction, integration and continuous retention. They also mentioned that the involvement of human resources staff in agency recruitment processes provided new recruits with points of reference within the organization from the outset, facilitating communication between the employer and new employees and providing routes for resolving any issues that these new nurses may later encounter.

Balance between perceived costs and benefits of the move to UK

All nurses in the sample left their home country without having a firm end date for their stay abroad. They said that a particular event might trigger a decision to return (e.g. a family problem), but generally they indicated that the decision to stay or return home was part of a continuous and ongoing assessment of the ‘pluses’ and ‘minuses’ in their mobility trajectory. The fulfilment of professional aspirations was one of the principal factors involved in their decision to emigrate, and it remained the most significant ‘plus’ for staying in UK. Overall, professional gains seemed to compensate for personal costs. In all but one case, nurses had no plans to return and the difficulties of being away from their families were the price to pay for their decision.

Discussion

The present study relates to a time and context when these nurses felt that the only way to progress professionally was to leave their country. The combination of perceived blocked professional progression and willingness to advance in their careers was strong and led to also look for better opportunities once in UK, within the NHS. Professional achievements, professional and personal sources of support made these nurses evaluate their overall mobility experience as positive, despite personal challenges such as homesickness or feelings of guilt or remorse for having taken the ‘selfish’ decision of leaving. These findings are well aligned with the literature, which notes that career growth not only increases nurses’ job satisfaction but also enhances their sense of commitment, loyalty and gratitude towards their employer, which can be manifested in greater engagement, better performance and longer retention rates.^11,23–25

Interviews showed that recruitment practices driven only by nursing shortages, but neglecting nurses’ professional aspirations, preferences of area of work, location of organizations or years of experience, led many nurses to move internally after a couple of months, to more technical areas of practice, a better paying job or to a reference hospital in a different region. This suggests that the placement in the destination organization should try to respond to migrant’s preferred specialty, location and aspirations to grow professionally. From the RAs and NHS organizations point of view, considering migrants’ preferences and profile might help increase the chances of finding the right professional, with the appropriate skills and values for the post and the organization. Similarly, considering these nurses’ need for professional fulfilment after recruitment, might increase the chances of more effective and longer retention. Another significant point is that organizational settings, conditions and, most importantly, organizational agents’ attitudes and level of support also influence nurses’ level of commitment to their employer and their overall mobility experience. The observation of the impact that the role and influence of members of staff in leading positions (e.g. chief nurses, ‘leads of education’ nurses, managers) can have on the career progression, well-being and overall retention of newly arrived foreign professionals is consistent with the literature.^24,26,27

Finally, the findings also demonstrated the importance of the networks that nurses are able to access before and after they come to a foreign country. Social media communities, nurses of the same nationality in the recruiting hospital,²⁸ communities of people from similar nationalities nearby, and even the experience of being part of a cohort, were found to provide various resources as well as an identity that made newly recruited nurses feel less isolated. These networks operated as crucial sources of support, providing knowledge and confidence, as well as emotional, material, practical, financial, intellectual and professional resources in order to better deal with the effects of the continuous tension between the personal and professionals ‘pluses’ and ‘minuses’ of mobility.

Limitations

The context and policy landscape in UK have changed since the time data were collected. Brexit has potentially added new obstacles and reinforced previous challenges for international recruitment and retention that need to be considered in future analysis. However, the focus on migrant nurses’ personal and professional support systems as well as on their interactions with health organizations can provide valuable insights into how best to align nurse and organizational needs to continue recruiting while maximizing the benefits of the move for all parties involved, regardless of the context and time period.

Conclusion

This study approaches EU nurse mobility by considering the influence of multiple factors in nurses’ decision to move and throughout their recruitment, arrival and integration in the destination organization. We argue for the need to move beyond labour market analyses focusing on economic factors to better understand the ‘human’ aspect of mobility. Results reveal that migration is neither an isolated nor a static experience. Rather, it is accomplished through constant interaction and adjustment between institutions and agents at the policy, organizational and individual levels. Understanding the set of influencing factors as well as the complex and dynamic nature of a professional’s decision to come and stay can better help design more effective retention responses for both sending and receiving countries.

The current context represents a period of unprecedented political, social and economic volatility and of an English NHS in need of qualified health professionals from abroad to run their services safely. The results of this study remind us that these decisions to move are more complex than what we tend to acknowledge, and that these professionals also need to be more than mere numbers and figures. As highly qualified professionals aware of their value, their experiences, preferences and need for strong systems of support at the professional and personal levels throughout their mobility experience need to be integrated in long term more effective workforce planning.

Conflicts of interest: None declared.

Key points

• Mobility of nurses is accomplished through constant interaction and adjustment between institutions and actors at different levels.

• Career growth manifests in longer retention rates and helps overcome personal challenges of mobility.

• Organizational settings and conditions as well as actors’ attitudes and support influence nurses’ overall mobility experience.

• Migrant nurses’ experiences, preferences and support needs should be integrated in long-term workforce planning and governance.