Engaging with a new reality: experiences of ... - Wiley Online Library

MIGRANT LABOUR

Engaging with a new reality: experiences of overseas minority ethnic nurses in the NHS Obrey Alexis

PhD, BSc, MSc, RNT, RN, FAETC

Senior Lecturer, School of Health and Social Care, Oxford Brookes University, Oxford, UK

Vasso Vydelingum

BSc, PhD, PG Dip Ed., RN, SCPHN, DN

Senior Lecturer, European Institute of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK

Ian Robbins

BSc, MSc, PsychD, RGN, RMN, CPsychol, AFBPsS

Professor of Mental Health Practice, European Institute of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK

Submitted for publication: 10 July 2006 Accepted for publication: 09 May 2007

Correspondence: Obrey Alexis School of Health and Social Care Oxford Brookes University Oxford UK Telephone: þ44(0)1793 437 432 E-mail: [email protected]

A L E X I S O , V Y D E L I N G U M V & R O B B I N S I ( 2 0 0 7 ) Journal of Clinical Nursing, 16, 2221–2228 Engaging with a new reality: experiences of overseas minority ethnic nurses in the NHS Aim and objective. The purpose of this study was to explore, describe and develop a greater understanding of the experiences of overseas black and minority ethnic nurses in the National Health Service (NHS) in the south of England. Background. For the past five decades, the NHS has been recruiting overseas black and minority ethnic nurses from several former British colonies to alleviate the manpower shortages. More recently there has been a shortage of nurses in the labour force and as a result the NHS has once again recruited overseas nurses. Despite this recruitment drive there are limited studies outlining how overseas black and minority nurses have fared in the NHS. Methods. This qualitative phenomenological study used four purposeful focus groups and all participants involved were interviewed at a place convenient for them. These all non-white participants originated from Asia, Africa and the Caribbean. Each focus group contained six participants with an overall total of 24 participants involved in the study. Results. Following thematic analysis, the findings revealed six themes such as, the devaluation process, concept of self-blame, discrimination/lack of equal opportunity, concept of invisibility, experiencing fear and benefits of being here. Several overseas nurses felt devalued and indicated that white UK nurses appeared to have placed little trust in them. They stated that both discrimination and lack of equal opportunity were present in the workplace and they also revealed that some white UK nurses were sometimes abusive. As a result they tolerated such behaviour for fear of being thrown out with their families. Despite such negative experiences participants indicated that the experiences gained whilst working in the NHS were useful.

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd doi: 10.1111/j.1365-2702.2007.02080.x

2221

O Alexis et al.

Conclusions. There is a need for overseas nurses to be treated fairly and with respect particularly in the light of an acute labour shortage of nurses in the NHS. The findings suggest that overseas minority ethnic nurses’ experiences have been mixed, with some positive as well as negative experiences, within a process that devalues them as workers. Relevance to clinical practice. This paper highlights a need for a re-evaluation of equal opportunity policies and proposes more diversity training so as to prepare nurses to cope with an increasingly complex and diverse workforce. Key words: black and minority ethnic, migration, nurses, nursing, overseas nurses, phenomenology

relationships particularly between overseas black and minority ethnic nurses and their UK counterparts.

Introduction For the past six decades the National Health Service (NHS) in the United Kingdom had relied on overseas nurses particularly from developing countries to alleviate the skills deficit inherent within its system (Beishon et al. 1995). Several reasons have been suggested as contributory factors affecting an acute shortage of nurses in the NHS. Such factors include low pay, poor working conditions, insufficient family friendly policies, discrimination and a lack of training opportunities (Meadows et al. 2000). In 1997 there were over 648,000 nurses, midwives and health visitors registered with the Nursing and Midwifery Council (NMC), decreasing to 634,000 by March 2000. However, 2002 saw a major increase, with over 644,000 nurses, midwives and health visitors registering with the NMC (Nursing and Midwifery Council 2002). Despite the rise in the number of health care professionals registered with the NMC, the underlying demographic trend is towards an ageing population of nurses in the UK. Today only 13% of the nurses are under 30 and 58% are over 40 (Couch 2003) and, because of this demographic trend, there have been increasing difficulties experienced with nursing shortages in both the NHS and the private sector (Warner 1999, Ball & Pike 2004). Given that there has been a shortage of nurses in the NHS for a considerable time, the evidence suggests (Beishon et al. 1995) that UK-trained nurses are ill-equipped to cater for the diverse needs of such a complex workforce. Several studies (Akinsanya 1988, Baxter 1988) have drawn attention to the diverse needs of black and minority ethnic nurses suggesting that their needs should be considered in the NHS, and they advocated that one of the ways of addressing such need is promoting diversity training for all staff. Although this may not be the panacea for dealing with such a diverse workforce at least, it could contribute to our understanding of other cultures. The lack of diversity training for all NHS staff continues to be a potential contributory factor affecting the 2222

Literature review In the UK several studies have explored the experiences of overseas nurses in the NHS (Daniel et al. 2001, Allan & Larsen 2003, Withers & Snowball 2003, Alexis & Vydelingum 2004, Allan et al. 2004). For example, Daniel et al.’s (2001) qualitative study used two focus groups to elicit information from overseas nurses. The findings revealed that white UK-based nurses were helpful and supportive of Filipino nurses, unlike Alexis and Vydelingum’s (2004) study that utilized 12 face-to-face interviews and found a different picture where overseas nurses received limited support from their UK counterparts, and this is consistent with the findings from a similar study undertaken by Matiti and Taylor (2005). Similarly, the lack of support and problems of adjustment to a new environment were found in an American study by Yi and Jezewski (2000) that aimed to understand how Korean nurses adjust to the USA hospital settings. This grounded theory study used a purposive sample of 12 Korean nurses and the findings revealed many factors that Korean nurses encountered such as adjusting to a new environment, a lack of support, differences in treatment and attitudes of staff. The study highlighted that, although racism was not overtly explicit, it was inherent in the structures of the organization. Similarly, in a UK qualitative study Allan et al. (2004) utilized 11 focus groups and interviewed a total of 67 overseas nurses in three sites in the UK. Data analysis revealed that racism and institutional racism were understood in more complex ways and that institutional racism manifested through negative stereotypes and organizational hierarchies. These results are consistent with those of Yi and Jezewski (2000). More recently, a UK study by Taylor (2005) sought to examine the experiences of nurses recruited from overseas.

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

Migrant labour

This qualitative study consisted of both participant observations and focus group interviews with 11 overseas nurses who participated. Factors identified were differences in nurses’ role, the deskilling of overseas nurses and status of overseas nurses, racial discrimination and lack of pastoral support. Although this study offered much insight into the experiences of overseas nurses and extended the understanding derived from earlier studies, it was difficult to assess how the themes emerged particularly from the focus group interviews. In attempting to address the deficiencies in previous studies, a qualitative UK research by Gerrish and Griffith (2004) sought to evaluate an adaptation programme for overseas registered nurses. Data were collected from 17 female nurses who originated from China, the Philippines, India and sub-Sahara Africa. They were interviewed in a group 12 weeks after the start of the programme. Fourteen overseas nurses were interviewed face-to-face six months after registration. Clinical mentors, managers, recruitment manager, promoting diversity officer, three educationalists from the trust and local university and the assistant chief nurse were interviewed face-to-face. The findings revealed five ways in which success of the adaptation programme was given meaning. These are as follows: gaining professional registration, fitness for practice, reducing the nurse vacancy, equality of opportunity and promoting organizational culture that values diversity. One of the limitations identified with this study is the use of a quasi-experimental approach to evaluate the adaptation programme. Quasi-experimental approaches normally use both a control and experimental groups. However, this study made little attempt to clarify this within the methodology and, therefore, it was difficult to assess whether the approach was appropriate. Despite this limitation, the study provides important insights into another aspect of the experiences of overseas nurses in the NHS. Although these studies have highlighted the experiences of overseas nurses, few studies have specifically examined the experiences of overseas black and minority ethnic nurses recently recruited to the NHS. In seeking to address this limitation, this paper will report on a phenomenological study, using focus groups to explore the experiences of recently recruited overseas black and minority ethnic nurses in the NHS in the south of England.

The study Aim The aim of the study was to explore, describe and develop a greater understanding of the experiences of overseas black

Experiences of overseas minority ethnic nurses

and minority ethnic nurses who are working in the NHS in the south of England.

Focus groups This qualitative study used a focus group approach to collect qualitative data to learn more about the phenomenon under investigation (Morgan 1997). Few studies have used a focus group methodology specifically to explore the experiences of overseas black and minority ethnic nurses. Focus group interviews were chosen for the study as it was intended to seek information from participants that would potentially be sensitive (Kitzinger 1994), and to elicit participants’ beliefs, attitudes and feelings through group processes (Freeman 2006).

Sample A purposive sample was sought amongst overseas nurses in the NHS in the south of England as a large number of overseas nurses were employed in this region in comparison to any other regions in England as noted by Buchan (2003). Four focus group interviews were used to elicit information from the participants. Each focus group consisted of six participants and they were recruited from a hospital in the south of England. These participants originated from Africa, Asia and the Caribbean. In total there were eight different countries represented. The term ‘black’ is a political category commonly used to describe people’s ‘race’, colour or ethnic origins to differentiate them from the majority white population, although it is recognized that colour categorizations do not describe the actual colour of people. Similarly, minority ethnic groups refer to people who belong to minority groups with a distinct culturally and historically shared identity (Mason 2000) with a clear recognition that there is also a majority ethnic group. For the purpose of this study, participants were referred to as black if they came from Africa and the Caribbean and minority ethnic for those nurses who came from South Asia. All the participants involved in this study were non-white.

Data collection Owing to the nature of focus group discussions, personal and sensitive information may be disclosed, therefore all participants involved were informed at the outset of the ground rules and that sensitive material may be shared and each participant had a responsibility to keep in confidence such information and not to share this with others outside of the group.


2223

O Alexis et al.

The focus group interviews lasted for approximately 90 minutes. In-depth semi-structured interviews were conducted at a place convenient for all participants. The discussions were audio-taped to facilitate recall and analysis. Participants were included in this study if they had worked in the NHS for a minimum of one year. On average participants had worked in the NHS for at least three years. Some participants held senior positions in their own countries such as nurse lecturer, head nurse and assistant chief nurse. For all four focus group interviews there was a facilitator and an observer who recorded the discussion and took notes about non-verbal cues. The interview questions were based on the findings from the face-to-face interviews, reported elsewhere. The same questions were asked of the four groups. These sample questions were: • How important is migrating to the UK for you? • What factors might impact on your working lives in the NHS? • How important to you is preparation for a new culture and why?

Ethical considerations Both the health service and the university research ethics committees approved this study. Permission was sought from service managers to approach overseas nurses within their wards. Permission was also obtained from these managers to leave a number of information sheets about the study on their wards. Within a few days several nurses contacted the researcher to express their interest in the study. Arrangements were made to meet and at each session the study was explained again and participants signed a consent form to give their consent to participate in the study. Permission to use a tape recorder was also obtained at each focus group interview. They were assured of their right to refuse to answer questions and they could withdraw from the study at any time without any consequences. Participants were assured of confidentiality and that the study would be reported in such a way that they would not be recognized by others reading the report. They were also encouraged to contact the researcher should any concerns arise following the focus group interview.

an understanding of the participants’ stories were reached. Such a framework enabled the researcher to make sense of the participants’ experiences. Following each focus group interview, the taped data were transcribed verbatim. The transcribed data were managed and analysed using qualitative data analysis software NUD*IST QSR (N6) and Van Manen (1990) analytical framework was utilized to guide the study. The tapes were listened to so as to gain a sense of the group’s whole story. Themes were developed through a process of coding, reflection and balancing each descriptive statement by considering the context in which it was said and the relationship with the content of the group stories. The quotes obtained were views expressed by two or more participants. Deviant case analysis was conducted to ensure that minority perspectives were considered. As the main focus was on capturing the essences of the group experiences, differences in reality were noted and taken into account throughout the analysis.

Findings This study identified six themes such as the devaluation process, concept of self-blame, discrimination/lack of equal opportunity, concept of invisibility, experiencing fear and benefits of being here.

The devaluation process The key principles advocated by the DH (2001) centre on maximising the contribution to all staff in improving patient care, reducing barriers, developing new and more flexible careers for staff. In nursing, valuing other colleagues is fundamental for effective team work and patient care, however failure for this to be part of the nursing ethos could jeopardize the harmonious environment and this could lead to nurses feeling disenfranchised. Several overseas nurses expressed some concerns about the lack of opportunities to exercise their ability to demonstrate their managerial skills because some managers did not trust them: We are not given the opportunity to run the ward and demonstrate our leadership and management abilities because they do not trust us (FG: 1: Female Filipino nurse).

Analysis Phenomenological research is more a philosophical perspective rather than a rigid method in understanding human experience, the hermeneutic circle was pivotal in the analytic process. This analytic process involved the researcher moving back and forth within the textual data until an awareness and 2224

Similarly, in describing their experiences, participants revealed that the lack of trust coupled with a feeling of being watched at all times alongside being made to feel awful following mistakes contributed to their feelings of low self-esteem and loss in confidence, as exemplified in the following extract:


Migrant labour In this country you are followed so much you are looked at so much, you are watched so much and you are put down so much and you are not allowed to do anything. Whenever you make mistakes you are made to feel awful. This made me lose my confidence and I felt so low that I was on the verge of going back because I never thought I would be able to live up to their expectations. The way things are done, the way I was followed, the way I was watched it’s like I had no rights. I sometimes feel it’s difficult to be honest to be comfortable here. I think if you are a softie and don’t have enough strength to survive it can be quite difficult here (FG: 2: Female Indian nurse).

Concept of self-blame Many overseas nurses perceived that being of the wrong colour was a contributory factor in the way they were treated and wondered whether their treatment would have been any different had they been of similar racial features to that of their white UK counterparts. The data also revealed that overseas nurses were internalising their experiences and appeared to be blaming their skin colour for the difference in treatment: It’s because our skin colour is different and I suppose our hair as well and there is nothing I can do about this (FG: 1: Female Filipino nurse).

Similarly, such internalization meant that participants were blaming themselves to a certain extent for what they had experienced. They also attributed their racial features as being contributory factors in the way in which they were perceived and experienced differences in treatment from their white British counterparts:


Despite the exhortation of equal opportunity policies, participants revealed that these were not reflected in practice. They commented that their chances of promotion were limited and that managers would offer many reasons why they could not be promoted: This particular hospital will give you a lot of reasons why they are not going to promote you and I think this is unfair. Other staff will be recruited from outside and they will be promoted very quickly (FG: 1: Female Filipino nurse).

In these examples as identified above overseas nurses indicated what they had experienced as overseas black and minority ethnic nurses in the NHS in the south of England.

Concept of invisibility Participants also referred to their experiences of working in the NHS as being different in comparison to their white UK counterparts. They reported that there were times when their managers or health care professionals would ignore them by speaking to the sister or the charge nurse about the patient even though the patient was in their care. The following extract illuminates this vividly: I sometimes feel that when orders are given, these should be given to nurses and not through the ward manager or a white nurse. I feel that the manager’s role should be to confront the doctor and tell them that this nurse is qualified to carry out orders. They are as capable as we are to do the things that you want done for the patient. I mean to care for the patients so don’t talk to me you should speak to the nurse who is

Well, I sometimes feel it’s my fault for the way I am treated but I just

looking after the patient. Most times the manager and the consultants

can’t change my skin colour. I am from overseas and there is nothing

would discuss those patients and I will be ignored even though the

I can do about the colour of my skin (FG: 2: Male Filipino nurse).

patients are cared for by me (FG: 1: Male Caribbean nurse).

Discrimination/lack of equal opportunity Discrimination can be either overt or covert and overseas nurses in this study experienced either one form or the other and sometimes both. Several participants revealed that promotion was given to nurses who appeared less deserving: People less deserving get higher post than us for example a new white

Similarly, the data indicated that relatives would sometimes bypass overseas nurses and seek information from UK nurses about the progress of their ill relatives even though overseas nurses were caring for their sick relatives: Some relatives would by-pass me and look for a white nurse to enquire about their family member although I am the one caring for that patient (FG: 4: Female Ghanaian nurse).

staff nurse was promoted within a month of being here (FG: 4: Female Filipino nurse).

Experiencing fear

For another nurse, discrimination was in the form of exclusionary practices as exemplified in the following verbatim statement:

Participants described their account of working in the NHS and stated that to survive in their everyday world, experiencing fear was a regular occurrence. All revealed that being temporary residents in the UK meant that they needed to be cautious of what they could say or do because they were scared of being asked to return to their country of origin:

Since I came here I have never experienced such open discrimination. White nurses have treated me as stupid and they will not include me as part of the nursing team (FG: 3: Female Filipino nurse).


2225

O Alexis et al. Because number one we are just temporarily here. They are here no matter what happen to them they won’t lose anything. But for us we would be thrown out with our families and we would have to start all over again. So we have to consider this at times (FG: 1: Female Filipino nurse).

In a similar vein, the views expressed by this overseas nurse were representative of how some overseas nurses felt: We are just careful of what we have to say you know what I mean. They are permanent here and no matter what happens they can stay here but we are temporary nurses here and if we say something that they don’t like we could be thrown out of the country (FG: 2: Male South African nurse).

Another stated that: They can sometimes be abusive to you and can make your life a living hell (FG: 1: Female Filipino nurse).

Benefits of being here Overseas nurses in the study stated that they came to the UK for personal reasons such as having the ability to support their immediate and extended families: Came here to help my immediate and extended family (FG: 4: Female Filipino nurse)

For others, they were appreciative of the opportunity to gain experience in a different culture, particularly the British culture. They stated that such experience could be neither bought nor taken away from them: Getting the experience…you cannot buy this experience…. and they cannot take it away from you (FG: 2: Male Malawi nurse).

In addition, some overseas nurses revealed that some patients appreciated the care they received and as a token of good gesture, they would sometimes receive cards and chocolates: Some patients appreciate our care and we get cards and chocolate from them (FG: 4: Female Jamaican nurse).

In summary, these six themes characterized the experiences of overseas nurses in the NHS in the south of England.

Discussion The findings from the focus group discussions provide an insider insight into the lives of recently recruited nurses. A picture emerges of a process in their workplace that devalues them as individuals and as professionals. The devaluation process consists of perceptions of people as being negative in social roles with negative consequences 2226

to the person (Williams 2003). The response of an individual to this devaluation process may reinforce the negative social perception of them in a highly negative and damaging feedback loop, according to Williams (2003). However, in this study, the devaluation process is linked to nurses’ lack of recognition of their professional values and attributes through a stigmatising process, which could lead to feelings of self-blame. Similar lack of recognition and loss of status have been found by Aboderin, in this issue. There is very little literature on the concept of self-blame, especially in relation to black and minority ethnic nurses, however there is a related study of depression and rape victims’ classifications, which may have relevance here (Janoff-Bulman’s 1979). Just like rape victims, who are often made to feel as if they were the cause of their predicaments, similarly overseas nurses perceived themselves to be victims of their experiences, hence they blamed themselves for their situations. Janoff-Bulman (1979) suggests that there are two types of self-blame: behavioural and characterological. Behavioural self-blame relates to attributions to a modifiable source, such as a person’s behaviour is associated with a belief in the future of avoidability of a negative outcome. Whilst behavioural self-blame is control related, characterological self-blame is esteem related and involves attributions to a relatively nonmodifiable source such as one’s character (Janoff-Bulman 1979). Findings from this study would suggest that nurses’ expression of self-blame would be more characterological, mostly attributed to being from overseas, and being of the ‘wrong’ colour or culture, which in themselves could result in discrimination. Lack of promotion, exclusionary practices and limited chances of promotion are all examples of discrimination revealed in this study though workplace discriminatory practices can sometimes be difficult to prove or disprove. Henry (2007) as discussed elsewhere in this issue, found a process of promotion rooted in patronage which facilitated inequity, characterized by a lack of transparency. According to Boulding (1989) prejudice and discrimination are negative manifestations of integrative power and is suggestive of some sort of hierarchial relationship between employee and employer relationships. It has been argued that integrative power is the power that binds humans together unlike disintegrative power which causes conflict and a breakdown in the integrative system (Boulding 1989) and the latter has been the case involving overseas nurses and their UK counterparts. In this study, several overseas nurses felt unfairly treated and they perceived this to be happening to them because of their racial features which were different to


Migrant labour

that of the white dominant group. Whilst open discrimination is illegal, covert discriminatory practices might be endemic within the organization and this can be difficult to determine. Larsen (2007), as articulated elsewhere in this issue, revealed that discrimination not only worked at interpersonal and institutional levels, but also as a form of ‘symbolic violence’ that can be internalized to affect the individual negatively. The concept of invisibility in relation to nurses is unreported. Bjorklund’s (2004) discussion of the concept of invisibility relates much more to the unseen work of nurses, rather than nurses themselves feeling invisible. Parallels can be drawn here in that overseas nurses were perceived as being invisible and to a certain extent it could be argued that their input in the labour market, though significant could be seen as being less significant or even invisible to that of their UK counterparts. Much of the literature on the concept of invisibility emanates from the USA and relates to black peoples’ experiences and the way in which the white dominant group express their social superiority by perceiving those they dominate as being unequal and this is illustrated in Ellison’s (1952) work, Invisible Man. Invisibility involved not only a physical nonpresence, but also a rather non-existence in a social context. What many of the nurses in this study described were how doctors, managers and relatives were ‘looking through’ them, an active form of intentional invisibility, which demonstrated the capacity of the other agent to disregard the nurses’ presence. Such intentional practices that ‘looks through’ the black and minority ethnic nurses, not only shows dominance and power, but also simultaneously reinforcing a form of invisibility that emphasizes humiliation by the white dominant group. Symptoms of fear in the workplace have been studied as part of organizational behaviour, but there is no evidence of any work related specifically to minority ethnic nurses. The experiences of fear reported by nurses in this study appear to be perceptions of a personal threat of their employment, status and a fear of ‘being thrown out’. Austin (2000) suggests that employers and employees may see each other as having a great deal of power to control outcomes and employees’ fear may have something to do with loss, fear of the loss of inclusion, role, the job itself, future opportunities and one’s destiny, as revealed in this study. However, despite what would seem as negative experiences, overseas nurses did find value and satisfaction in their working experiences in the NHS. They felt that the care they had provided for patients had been valued and greatly


appreciated, especially by both patients and relatives. Similar experiences about the positive value and the possibility for further studies and professional development have been confirmed by Larsen et al. (2005).

Implications for practice The findings from this study have implications for practice. The fact that overseas nurses perceived that opportunities were given to the dominant culture is an indication that equal opportunity policies are not working effectively and therefore should be reviewed. In addition, to retain and recruit staff there must be opportunities for advancement irrespective of staff’s ethnic backgrounds. Valuing overseas nurses’ contribution in the NHS is important as this creates a sense of belonging and this could improve team work and ultimately patient care. The experiences identified in this study would seem to suggest that a culture of friendliness and acceptance should be created as these could contribute to retaining staff in the NHS. In general, there is a need for more diversity training in the service sector to prepare nurses to cope with an increasingly complex and diverse workforce.

Conclusion This paper has explored the experiences of overseas black and minority ethnic nurses and has presented data from four focus group interviews. While the majority of the experiences appear to be reflective of a process of adjustment to a new environment, such negative feelings have also been confirmed by both Allan et al. (2004), Larsen et al. (2005) and other papers in this issue (see Aboderin (2007), Henry (2007) and Larsen (2007)). However, the types of feelings expressed, such as devaluation, self-blame, invisibility and fear, have not been found by any other similar studies. The evidence presented in this paper suggests that despite the negative experiences, overseas black and minority ethnic nurses are hopeful that things would change and that they are gaining valuable experience of care in the NHS.

Contributions Study design: OA; data collection and analysis: OA, VV and manuscript preparation: OA, VV, IR

References Aboderin I (2007) Contexts, motives and experiences of Nigerian overseas nurses – understanding links to globalization. Journal of Clinical Nursing 16, 2237–2245.


2227

O Alexis et al. Akinsanya J (1988) Ethnic minority nurses, midwives and health visitors: what role for them in the National Health Service. New Community 14, 444–450. Alexis O & Vydelingum V (2004) The lived experience of overseas black and minority ethnic nurses in the NHS in the south of England. Diversity in Health and Social Care 1, 13–20. Allan H & Larsen JA (2003) We Need Respect: Experiences of Internationally Recruited Nurses in the UK. Royal College of Nursing, London. Allan H, Larsen JA, Bryan K & Smith PA (2004) The social reproduction of institutional racism: internationally recruited nurses’ experiences of the British health services. Diversity in Health and Social Care 1, 117–125. Austin J (2000) Fear in the Workplace. Available at www. potentialatwork.com/articles/fear.html [accessed 21 September 05]. Ball J & Pike G (2004) Stepping Stones: Results from the RCN Membership Survey 2003. RCN, London. Baxter C (1988) The Black Nurse: An Endangered Species. Training in Health and Race, Cambridge. Beishon S, Virdee S & Hagell A (1995) Nursing in a Multi-Ethnic NHS. Policy Studies Institute, London. Bjorklund P (2004) Invisibility, moral knowledge and nursing work in the writings of John Liaschenko & Patricia Rodney. Nursing Ethics 11, 110–121. Boulding K (1989) Prejudice, Discrimination. Available at http:// www.colorado.edu/conflict/peacve/problem/prejdisc.htm [accessed 26 September 2005].. Buchan J (2003) Here to Stay? International Nurses in the UK. Royal College of Nursing, London. Couch D (2003) As if by magic. Nursing Times 99, 21–23. Daniel P, Chamberlain A & Gordon F (2001) Expectations and experiences of newly recruited Filipino nurses. British Journal of Nursing 10, 254–265. Department of Health (2001) A Health Service for all Talents: Developing the NHS Workforce. Department of Health, London. Ellison R (1952) Invisible Man. Randon House, New York. Freeman T (2006) Best practice in focus group research: making sense of different views. Journal of Advanced Nursing 56, 491–497. Gerrish K & Griffith V (2004) Integration of overseas registered nurses: evaluation of an adaptation programme. Journal of Advanced Nursing 45, 579–587. Henry L (2007) Institutionalised disadvantage: older Ghanian nurses and midwives reflections on career progression and stagnation in the NHS. Journal of Clinical Nursing 16, 2196–2203.

2228

Janoff-Bulman R (1979) Characterological versus behavioural selfblame: inquiries into depression and rape. Journal of Personal Social Psychology 37, 1798–1809. Kitzinger J (1994) The methodology of focus groups: the importance if interaction between participants. Sociology of Health and Illness 16, 103–121. Larsen J (2007) Embodiment of discrimination and overseas nurses’ career progression. Journal of Clinical Nursing 16, 2187–2195. Larsen JH, Allen HT, Bryan K & Smith P (2005) Overseas nurses’ motivations for working in the UK: globalisation and life politics. Work, Employment and Society 19, 349–368. Mason D (2000) Race and Ethnicity in Modern Britain, 2nd edn. Oxford University Press, Oxford. Matiti RM & Taylor D (2005) The cultural lived experience of internationally recruited nurses: a phenomenological study. Diversity in Health and Social Care 2, 7–15. Meadows S, Levenson R & Baeza J (2000) The Last Straw: Explaining the Nursing Shortage. King’s Fund, London. Morgan DL( ed) (1997) Successful Focus Groups. Advancing the State of Art. Sage Publications, Newbury Park. Nursing and Midwifery Council (2002) Statistical Analysis of the Register: 1 April 2001 to 31 March 2002. Nursing and Midwifery Council, London. Taylor B (2005) The experiences of overseas nurses working in the NHS: results of a qualitative study. Diversity in Health and Social Care 2, 17–27. Van Manen M (1990) Researching Lived Experience: Human Science for an Action Sensitive Pedagogy. The Althouse Press, Ontario. Warner M (1999) Healthcare Futures 2010. Report Commissioned by the UKCC from the Institute of Health and Social Care, University of Glamorgan. UKCC, London. Williams P (2003) Incorporating social role valorisation onto other contexts of needs assessment, anti-oppressive practice. International Journal of Disability, Community & Rehabilitation 3, 1–8. Withers J & Snowball J (2003) Adapting to a new culture: a study of the expectations and experiences of Filipino nurses in the Oxford Radcliffe Hospitals NHS Trust. NT Research 8, 278–290. Yi M & Jezewski MA (2000) Korean nurses’ adjustment to hospitals in the United States of America. Journal of Advanced Nursing 32, 721–729.
