The Position of Ethnic Minorities into Nursing and Midwifery NHS Workforce: Using a Systematic Review ApproachNHS Workforce:

University Degree Medicine and Dentistry

Ethnic Minorities

The Position of Ethnic Minorities into Nursing and Midwifery NHS Workforce:

Using a Systematic Review Approach

Acknowledgements

I would like to express my gratitude to my husband, my children and my mother for supporting me towards the completion of my MSc programme.

Table of Contents

Abstract

Gaining new knowledge, understanding a new research tool, observable evidence and the opportunity to investigate the position of ethnic minorities into nursing and midwifery National Health Services (NHS) workforce were the drivers for this dissertation topic.

The focus of this dissertation topic is of a high priority to the NHS. The NHS is struggling to attract and retain staff in nursing and midwifery profession. There is evidence of low representation of ethnic minorities into this profession and a high disparity exists between the subgroups. There are particular low visibilities of all South Asian communities in this workforce.

This dissertation uses the approaches of systematic review as a research tool to investigate the profile of ethnic minorities in particular South Asian groups into nursing and midwifery NHS workforce. Evidence of research and policy based work programmes are used to explore the barriers associated that would signify the low numbers together with the testing and impact of any interventions.

Evidence of information gathered suggest the NHS workforce does not reflect the profile of the community it serves and that position of ethnic minority staff has made little progress since 1960s in spite of race equality legislation. A few numbers of initiatives have been introduced by the government; this dissertation describes these as schemes that can work effectively at an operational level but lack of monitoring and a short time frame of their existence inhibit true measurement of their success. This review maps out the past and the current areas of work on this topic and provides implications for future work.

The Position of Ethnic Minorities into Nursing and Midwifery NHS Workforce

CHAPTER I: INTRODUCTION

1. Executive Summary

Personal curiosity of observed evidence together with national priority to improve the recruitment of ethnic minorities into nursing and midwifery NHS workforce and the opportunity to learn new research tool were the key forces for selecting this dissertation topic.

Exploring the position of ethnic minorities, in particular the South Asian groups, within the NHS nursing and midwifery workforce was the overall aim of this dissertation. I was interested in investigating the trends and characteristics of this group in the past few decades and to explore any possible barriers for this group in accessing the profession. As the topic was of a national policy priority I was also interested in examining interventions that may have been introduced to tackle this issue and whether these had made any differences to the ethnic minority workforce within the nursing and midwifery profession.

Systematic review as the research methodology was used as the dissertation topic required a comprehensive collection of research evidence. The NHS Centre for Reviews and Dissemination for conducting systematic review formed the main source of guideline for conducting this dissertation. The inclusion criteria for the systematic review included published and non-published articles based on United Kingdom (UK) population using either quantitative or qualitative research designs within the time frame from 1966 to 2008.

Of the sixty five studies originally identified as potential relevant citations to include in the systematic review, only seventeen articles were included after screening for their relevance to study inclusion criteria. Of these only six were published articles that used evidence based research work programmes to attract and gain the prospective of South Asian populations into nursing and midwifery profession.

This review provides a clear evidence of under-representation of all South Asian communities into nursing and midwifery profession. Representation is particularly low among Pakistani and Bangladeshi groups. The NHS workforce does not reflect the profile of the community it serves and evidence suggests the position of ethnic minorities in the NHS has made little progress since 1960s in spite of race equality legislation.

Some of the barriers for ethnic minorities accessing this profession lie with the inequalities imposed during recruitment and selection stage of a pre-registration nursing and midwifery course, promotion and continued learning development process, the existence of negative image of the profession by the ethnic minority communities themselves which is stimulated with the existence of discrimination and racism within the NHS itself. Cultural and religious myths deter Asian girls and boys from entering and their parents from encouraging them to choosing nursing and midwifery as a career profession.

It is encouraging to see that the NHS has introduced initiatives and schemes to attract ethnic minority communities in particular South Asian communities into nursing and midwifery workforce. However it is the outcome, rather the results that they achieve that determine their success. With no or little follow up of their progress it is difficult to evaluate the impact these have had to recruitment and on the change management of the perception of the profession by the communities themselves.

There is inadequate data on ethnic minorities into nursing and midwifery workforce. Some NHS trusts are failing to carry out even the basic ethnic monitoring functions required by the NHS Executives. Steps need to be taken to ensure that the recording of ethnic origin data of registered nurses and midwives are adequate, accurate and used in the planning and reflection of trust priorities at local and national level.

This review revealed that the studies conducted on the dissertation topic area used very small sample size and the reason for low recruitment of South Asian groups was not fully discussed. The results from these studies cannot be used as a representation of the views and experiences of the South Asian population in general. There was no detail around how ethical standards were maintained in any of the research based articles. Local action research programmes were encouraging but no details of how these programmes actually work and the success of these from the providers or the receivers prospective.

2. Introduction

A combination of factors influenced my decision on the dissertation subject. Firstly, to explore the lack of presence of certain minority groups registering for nursing and midwifery courses within the NHS, as observed while working in a teaching university for nursing and midwifery students for seven years. This was particularly surprising given that the NHS nursing and midwifery workforce were serving in an area with a large population of ethnic minority community. Secondly, this was an opportunity to plan and develop ideas for future projects that was directly relevant to my occupational field of midwifery research at the time. Thirdly, a personal interest to use the allocated dissertation times to broaden my experiences and knowledge of a research methodology previously unknown to me and finally a topic that is of high priority to the National Health Services (Royal College of Nursing, 2005).

Evidence from literature on this topic suggests that the NHS has been experiencing difficulties in recruiting and retaining nursing and midwifery staff for a while (Finlayson et al, 2002). This has received attention at ethnicity level. As recruiting, attracting and retaining nursing and midwifery staff have been particularly low from ethnic minority groups as described by Parish (2003) and Beishon et al (1995). “About 8% of all nursing and midwifery staff is from minority ethnic groups in the NHS workforce (Beishon, 1995). Culley (2001) in her work reported “There are large differences between the representations of different minority ethnic groups. Black groups (primarily Caribbean and African) are numerically over represented in nursing, while all the South Asian groups (Indian, Pakistani, Bangladeshi and African Asian) are under-represented. Representations are particularly low amongst Pakistani and Bangladeshi group”(Culley, 2001, pp.132). A review of the UK nursing labour market in 2004 to 2005 reported that a “key policy priority for the NHS was to improve the recruitment of minority ethnic groups into nursing and midwifery workforce. However, comparatively little information is available on the ethnic composition of this workforce” (Buchan & Seccombe, 2005, pp. 39).

A diverse nursing and midwifery workforce is essential for the delivery of ethnically, culturally, and linguistically appropriate and sensitive health care. Research on the issues around nursing and midwifery profession for ethnic minority groups exists as independent research work in the UK. However, a more collective approach of all research conducted on the nursing & midwifery ethnic minority NHS workforce will help to show a clearer picture of areas studied and those still remain to be explored in order to assist with the planning and process of recruiting minority groups into this workforce.

The dissertation starts by highlighting and discussing the particular issues surrounding ethnic minorities into nursing and midwifery NHS workforce as reported by other studies . This has assisted me to clarify my dissertation aims, objectives and methods further. In the methods section I have provided details of a robust strategy I have deployed in collecting, organising and analysing secondary qualitative data. This has been followed by the results section where I have presented the collection of data and discuss the results in the light of my review objectives. Finally in the conclusion section, I have summarised the overall findings of my review and provide implications for NHS policy and future research.

3. Background Information and literature Review

3.1 Nursing and Midwifery Profession – brief outlook

In the UK, the definition of nursing and midwifery described by the two professional organizations representing them are as follows:

“The use of clinical judgment in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, what ever their disease or disability, until death.” (Royal College of Nursing, 2003).

“The midwife is recognized as a responsible and answerable professional who works in partnership with women to provide the required support, care and recommendation throughout pregnancy, labor and the postpartum period, to conduct births on the midwife’s own liability and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the discovery of problemS in mother and child, the accessing of medical care or other suitable support and the carrying out of emergency measures.” (International Confederation of Midwives Council meeting, 19th July, 2005)

There exist two groups of staff within the NHS nursing and Midwifery workforce; those that are registered with the nursing and midwifery council who have a diploma or degree, the other not registered with nursing and midwifery council and have national vocational qualifications (Finlayson et al, 2002). For my review, I will not be reporting on the two groups of this workforce separately and instead will focus on looking at issues for nursing and midwifery workforce as a whole.

Nursing and Midwifery is constantly evolving to meet new needs and take account of new knowledge. The literature on the relationship between nursing and midwifery is not extensive. There is very little literature which focuses on the topic of ethnic minorities into nursing and midwifery profession. Too often articles do not clarify nursing and midwifery as two different professions and when reporting often use the term “nursing” when in fact they also mean midwifery, for this reason I have decided to explore my topic area within both nursing and midwifery profession so as that I am not in the danger of missing articles.

3.2 Issues around categorising groups of population (Who do we mean by Ethnic Minorities?)

There has been long debate around correctly describing different groups of people. This is and has been a very sensitive topic and one that continuously creates a challenge particularly in more recent years with the acceptance of and integration of different groups of people. Although accurate monitoring of ethnic data is important in combating disadvantages and discriminations, however, by creating ethnic categories it can discriminate some groups of people; leaving them feeling not being fully represented in the national ethnic categorisation which could have an impact on identity issues.

4. Aim of proposed study

The overall aim of this study is to explore the position of ethnic minorities within the NHS Nursing and Midwifery workforce using a systematic review.

Objectives:

Describe the trends and characteristics of ethnic minority population within the NHS Nursing and Midwifery workforce.
Explore any possible barriers in accessing Nursing and Midwifery workforce by ethnic minority groups.
Investigate any interventions introduced and their effectiveness.
Investigate the need for any future work in this area.

CHAPTER II: LITERATURE REVIEW

5. Review of Literature

Review of literature suggests that allot of research has been conducted on this topic. A number of different research methodologies have been deployed including qualitative, intervention and action research covering various issues such as perceived barriers to nursing and midwifery programs, interventional awareness campaigns and recruitment of minorities into nursing and midwifery programs. However, majority of this literature appears from the United States and the UK.

In America shortage of nursing and midwifery mirror those of the United Kingdom and the reasons for the short falls are similar across. In United States, few students are entering the workforce coupled with the aging of nursing workforce are two reasons for the short fall of this workforce. Under representation of ethnic minority groups is another big issue for the nursing and midwifery workforce and in the United States they often rely on ethnic population to boost their nursing workforce as described in Hinkle and Kopp (2006) and Nugent et al (2002).

A number of initiatives have been used to increase the presence of ethnic minority communities within the nursing and midwifery workforce in the United States. This includes partnership work with community organizations to develop and implement programmes to promote, engage and recruit teenagers from ethnic minority groups into nursing profession and using lessons learnt from these to educate healthcare workers of the needs of the ethnic population in parts of America (Yates et al, 2003).

There are also specific mentoring programmes to encourage and increase the number of ethnic minorities taking up leadership positions within the nursing and midwifery workforce. Washington et al (2001) promote the idea of mentoring through contrasting the differences and benefits of mentoring compared to teaching and advocate mentoring as an additional tool to teaching to encourage minority groups into more senior positions. Other issues identified that impacted the shortage of nursing related to dissatisfaction of working profession; opportunity for promotion, salary, working condition, responsibility, and supervision (Borkowski et al, 2007).

In the United Kingdom the NHS has been experiencing the shortage of nursing and midwifery for some time. A combination of factors contributed to this including financial difficulties leading to recruitment freezes & redundancies (Mulholland 2005) ‘stressful working conditions’ and heavy or increased workloads leading to staff leaving (Office of Manpower Economics 2005). The primary cause of the major nursing shortage was the failure of the NHS to develop effective workforce planning methods earlier in the 1990s. The NHS did not properly take into account the impact of the growth of employment for nurses in the independent sector. Further, there was no effective national assessment of the aggregate effect that the future nurse staffing levels determined by each NHS trust would have (Buchan 1998).

5.1 Challenges and barriers that the profession brings it self

Salary & lack of promotion

Nursing and Midwifery is a profession that has not been receiving high status in terms of a professional workforce. A number of factors contribute to this; the perception that the profession is a dead end job, in the sense that there isn’t opportunity for promotion in the workforce. Salary is another major issue as nurses starting salary and what their potential salary can reach is very small compared to other health care jobs within the NHS. This brings about discussion and decisions around choosing nursing & midwifery as a profession due to the low salaries which isn’t adequate enough to financially support the needs of ones family.

Discrimination

Inequality and discrimination within any profession exists and is not bounded to exist only in relation to race or ethnicity. The low representative of ethnic minorities in the senior jobs within nursing and midwifery perhaps indicates the visibility of discrimination within the nursing and midwifery profession. On the other hand it is possible that the small percentage of ethnic minorities that do exist within this workforce perhaps are not interested or keen to take up these roles as oppose to not doing well than their counterparts as described in (Sadler 1999, p.14). Ethnic minority group’s do less well than their counterparts across a range of indicators such as: opportunity to ‘act up’ to a more senior position; appropriate pay when ‘acting up’ in a more senior position; achievement of promotion. However the report does not indicate what percent of these are home grown staffs as recently more and more nurses and midwives have been attracted to the UK from overseas due to shortages of this workforce in the UK.

A number of studies have investigated discrimination against ethnic minority groups within the NHS (Bharj 1999; Baxter 1988; Torkington 1987; McMillan 1998). Reporting that gender and race discrimination exist and is reflected in salary and promotion. There appear to be clear gender differences where male nurses are better paid than female nurses. There is also race discrimination playing along side where white nurses are better paid and achieve a faster promotion compared to their ethnic minority counter parts. This type of discrimination does not do justice to the NHS nursing and midwifery workforce, as this will discourage people from considering and entering the nursing and midwifery profession. In addition, will contribute to the existing short fall of staff from this profession as more and more staff is likely to look elsewhere for a better deal and leave the profession. As a result the NHS will need to act quickly to investigate this area and come up with plans to resolve some of the gender and race discrimination that has been in existence for some time.

Few studies more recently have focused on the barriers to nursing and midwifery profession by ethnic groups (Storey 2002; Sadler 1999; Royal College of Nursing 2002; Ball & Pike 2002). Insights into the perceptions of problems or barriers by ethnic minorities’ might explain the differences of trends between each ethnic minority groups and the majority population of white nurses & midwives. Ethnically diverse students and staff vary in terms of their needs and problems, the barriers they face, and the amount of assistance they perceive they need. The Royal College of Nursing survey (2002) found that minority ethnic nurses were more likely to change jobs for negative reasons, such as bullying, than white nurses. Ethnic minority participants reported in interviews some negative aspects of nursing; physically demanding, mentally unstimulating, poorly paid, (Bharj 1999). Specific to some ethnic groups on religious or cultural grounds barriers to nursing included; nursing males in bed would not be acceptable, concerns about the appropriateness of nurses’ uniforms- even after modification- on religious grounds (Sadler 1999).

A number of interventional studies looked at factors that contribute to the successful recruitment and retention of South Asian students in health-care education (Darr and Bharj 1999) by using communication strategies involving multi-organisational approaches (Storey 2002). These did attract minority students but this was insignificant in comparison to the local population. Improving nursing & midwifery student recruitment from ethnic minority groups has been reported to require a long-term approach (Storey 2002). Measures should be taken to promote a positive image of nursing and midwifery. This can be achieved through education, lobbying of media, public relations exercises amongst under-represented groups.

Despite considerable effort, the ratio of minority ethnic students registering for nursing & midwifery courses is growing at a very slow rate (Storey 2002). Focus on the different aspects of ethnic minorities into nursing and midwifery NHS workforce has been researched up on in the UK more recently than before. This is partly due to low numbers of ethnic minorities into NHS nursing & midwifery workforce together with more recently government priorities to increase the number of ethnic minorities into the profession. To date, research has been conducted independently by small groups of institutions in geographical areas heavily populated by ethnic minorities. A thorough collection of all work on this topic will inform better of what’s been done on this topic and what is required for future work. To date this has not been done. As a result I have embark on this dissertation to be able to contribute to the working of achieving a more informed overall look at the position of ethnic minorities working within the NHS work force. This will allow NHS policy makers to be in a position to enhance the direction of their nursing and midwifery ethnic working priorities.

However, these are mainly in the USA. As the USA does not have the same health system as the UK and the classification of ethnic minorities are different from those in the UK. Using research data collected in the USA for UK population profile would therefore not present an accurate profile and issues around this topic to the UK population.

The NHS does not reflect the profile of the community it serves and has been coming under criticism for its inability to attract and retain nurses and midwives from the Black and minority ethnic communities (Bharj 1999). There is evidence that people from these communities have unequal access to nursing & midwifery education, promotion and continuing education opportunities in comparison to their White counterparts (Beishon et al., 1995; Gerrish et al., 1996; Iganski et al., 1998). In 2004 the Department of Health in England announced a £9 million funding package for nine projects, one of which would recruit more nurses from black and minority ethnic groups (Duffin 2004).

This dissertation is timely in that it aims to provide an overview of situation in the NHS nursing and midwifery ethnic workforce.

6. Statistics

6.1 Ethnic minority working profile in the UK

The population census of 2001 showed growth in the ethnic population of the United Kingdom (7.9% of the total population). In the ethnic census of 2001 registered at the geographical level and within a particular ethnic classification. This shows that the highest growth of ethnic minorities in Britain, and that half of the total number of ethnic groups are South Asian (Indian, Pakistani, Bangladeshi or other Asian groups). A quarter of the population of ethnic to describe themselves as black (Black Caribbean, Black African or Black).

Ethnic minorities are much younger than the White groups. Ethnic minorities, the proportion of working-age population increased, reaching 3.26 million, or 9.3% of the 35.2 million people of working age in 2004 (1.4% higher than the percentage in the spring of 2001) (Mulholland 2005), and is likely to continue to increase. (Agnew 2005). Office for National Statistics (ONS) describes the working age for men 16-64 and 16-59 years for women. The Department for Work and Pensions (2004) reported that black Africans (39.9%), Black Caribbean (37.1%), and people from the Other Black group (37.1%), most likely, and Pakistanis and Bangladeshis (18% in each case) at least, from all ethnic groups to work in public services (public administration, education, health and social services). Among ethnic minorities, women (42.3%) significantly more often than men (15.5%) in the public service sector.

Ethnic monitoring of patients and staff have been introduced in the National Health Service in April 1995. Nevertheless, it is Culley (2001) shows that the NHS had not been effective ethnic monitoring systems in place and as a result the NHS is unable to provide accurate ethnicity of its nursing and midwifery staff. This, however, as reported by Culley (2001), has recently improved through the United Kingdom Central Council of Nurses, Midwives and Health Visiting (UKCC is now known as the Nursing and Midwifery Council).

The ethnic minority of the workforce for the nursing and midwifery profession in the ...

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The ethnic minority of the workforce for the nursing and midwifery profession in the NHS was 17.8% in England in September 2004 (Buchan and Seccombe, 2005, p. 39.) White (245,000), Black or Black British (21,000), and also Asian and Asian British (19,000), which has three major ethnic categories and ethnic origin, 15% of qualified nurses was "unknown" (Buchan and Seccombe, 2005, pp.40).
The evidence clearly showed that the black minority, that is, black, Black African and Caribbean Black overrepresented and Asians or Bangladesh, India and Pakistan are under-represented in nursing and midwifery (Beishon et al., 1995; Iganski et al., 1998).

NHS is a major employer of nurses and midwives in the UK. Data on employment in other sectors is limited, and poor quality. Since 1997, an increase of 23% in NHS nursing and midwifery in England. However, this growth has not been enough to put an end to all the staffing shortage. International Nurses continue to be an important source of new employees in the UK. Recent data indicate a slowdown in the number of applications and the discharge to pre-registration diploma on the basis of education nurse (Royal College of Nursing 2005).

Given the projected decline in future financial flows, and further restructuring of the NHS could create a mixed economy of health, NHS nurse, planning and policy enters a phase of uncertainty. These uncertainties are compounded by the current problems that exist with the limitations and gaps in the workforce information needed to plan effectively to meet future needs in health care. In this review I have collected data on all nursing and midwifery NHS ethnic workforce. This is partly due to a lack of information about specific ethnic minority groups in nursing and midwifery staff in general, but also because it is difficult to say, one of the articles, the title and abstract of which particular groups they report when they talk about ethnic minorities. For this purpose, my thesis of ethnic minority groups in the South Asian population, for the reasons outlined above. Nevertheless, I will try to collect all the research reports of any ethnic minority in relation to the reasons explained above, but as this would be to compare between different ethnic groups in terms of obstacles and push for the nursing and midwifery profession.

6.2 Discussion of the methodology

Systematic review is the appropriate methodology tool to apply when a comprehensive collection of research evidence of a particular topic is required. The decision on using this method was also a personal one as until now my knowledge about the application of systematic review was very limited. I wanted to use MSc dissertation preparation time to learn about a research tool previously unknown to me in addition to use this time to develop a rigid research proposal and systematic reviews help to establish this. Systematic review approach appears to be the best tool to provide a solution to my objectives as the topic is much broad, and the sources of the literature are not necessarily specified.

A major source in the development of systematic review methodology is the NHS Centre for Reviews and Dissemination (2001). I have been using the theoretical and methodological framework suggested in this report to plan my dissertation. I have used the following websites and found there to be no past or existing systematic review covering my topic area.

NHS Centre for reviews and dissemination (CRD) - The NHS CRD Database of Abstracts of Reviews of Effectiveness (DARE)(ref- www.york.ac.uk/inst/crd)
NICE - National Institute for Health and Clinical Excellence (ref - www.publichealth.nice.org.uk)
Cochrane Database of Systematic Reviews (CDSR) (ref - www.cochrane.org)
UK Centre for Evidence in Ethnicity, Health and Diversity (ref –www.warwick.ac.uk/ceehd)
Research and Development (R&D) Programmes - Academic Organizations traceable via MEDLINE and the NHS Centre for Reviews and Dissemination

Robust systematic reviews of literature are a valuable source of information, as in the search, evaluation and synthesis of evidence from primary studies, they provide empirical answers to the questions focused on health care and related issues. In addition, in determining what we both know, and I do not know, they help in the planning of new studies (CRD 4 2001, Gough and Elbourne 2002). Systematic reviews differ from other types of review that they adhere to strict scientific design, to make them more comprehensive, to minimize the likelihood of diversion and to ensure their reliability. The amount of systematic review methodology is not limited to 'what works on the issues, while focused on efficiency, but also about the process and implementation, methods of assessment and on the experiences and perceptions of consumers of services (CRD Report 4, 2001). Systematic reviews can help inform the current state of knowledge, and any inconsistency in it, but explain that they are not yet known. They are increasingly used to support the practices and policies, and direct new research (Gough and Elbourne 2002). Systematic reviews may include quantitative and qualitative types of data and, in general, the capacity to deal with a determined mainly by the nature of the basic research (CRD 4, 2001).

Systematic reviews have been well developed in the use of quantitative research, largely through the efforts of the international Cochrane Collaboration and the NHS Center for reviews and dissemination. Meta-analysis has been used in systematic reviews of quantitative research to combine the statistical results of various studies into a summary evaluation. Increasingly, such issues are in health services research related to both qualitative and quantitative research, resulting in an increase in concentration in the systematic review of qualitative studies (Khan 2001). Meta-synthesis, as consent to the inclusion of the findings (critical review, analysis, interpretation and comparison of data) of primary qualitative research. (Sandelowski et al., 1997, Sherwood 1999, Paterson et al., 2001, Sandelowski and Barroso, 2002b).

A review of the literature on the topic of my report will provide a study using qualitative research methodology. For this reason, I will discuss and apply the principles of meta-synthesis of qualitative studies in his review. Systematic review and meta-synthesis of qualitative research is a complex activity. They are not as well established and are inevitably longer than a systematic review and meta-analysis of quantitative studies. However, it is also a rewarding process that gives a thorough and thoughtful synthesis. Aspects of the process that much longer than a systematic review and meta-analysis of quantitative research is to find, research and studies, and the inclusion of a study evaluating and analyzing the data (Jones 2004, Evans 2002). Meta-synthesis methods of qualitative research, which will be evaluated and their findings together. Drawing on a wide range of participants and a description, meta-synthesis can be more powerful than any of the results of a study on the same topic (Sherwood 1999)

There were some discussions about meta-synthesis of qualitative research. Some authors believe that, ideally, studies using different qualitative methods should not be combined (Estabrooks et al., 1994, Jensen and Allen 1996). However, others believe that the combination of such research contributes to the depth and width of the description of the research and balances the advantages and disadvantages of certain techniques (Paterson et al. 2001). Excluding studies based on the development alone bears the risk of refusal of valuable information that contributes to the interpretation of a phenomenon (Booth 2001). In addition, the inclusion of studies of any type is also practical. Many articles provide such inadequate information about the selection and application of methodology that, if the methodological supplies have been used as a criterion for inclusion, it would be in danger of including research and inappropriately excluding good (Lemmer et al., 1999). In its review, I will be a combination of different studies using qualitative methods for the same reasons discussed in the above articles.

The decision of whether to include in the meta-synthesis of all studies that meet the criteria for inclusion, or only one sample, is pragmatic, because it depends on the number of relevant studies identified (Evans and Pearson 2001). Inclusion of all studies, after an exhaustive search of literature, helps to prevent exclusion of important information or opinion (Sherwood 1999), and thereby strengthens the findings, because they occur in a broader base. However, this may not always be feasible Paterson et al. (2001) suggest that working with more than 100 studies, may be "too ambitious, and to recommend the study focused more tightly.

6.3 Quality assessment of qualitative research

The quality of any systematic review or meta-synthesis depends on the quality of the studies which it includes. However, there is no absolute list of criteria by which to assess the quality of qualitative research studies (Popay et al., 1998).

A ‘good’ research is one that acknowledges error and has procedures which will minimise the effect such errors may have on what counts as knowledge. In relation to quality assessment some commentators take an extreme view, arguing for example, that quality ‘cannot be determined by following prescribed formulas (Buchanan 1992) or that it is ‘fruitless to try to set standards for qualitative research per se (Howe 1990). Others, accepting the need for structured procedures, argue for more rigorous use and reporting of analytical approaches which improve reliability and validity in qualitative research (Seale 1997). Another suggested approach is to audit the research process from beginning to end, a laborious and impractical process in most situations (Lincoln 1985). Lincoln (1985) has suggested there are general questions that can be asked to judge validity and reliability in qualitative research, but that these are not readily codified. Despite these disagreements, structured approaches to judging validity and reliability in qualitative research are being developed. Problems are likely to arise not simply in relation to which criteria should be included in quality appraisal, but in how they should be applied. It has been noted that most frameworks fail to specify how judgements should be made or whether or not a standard has been reached (Harden et al., 1999).

6.4 Bias and error involved in systematic reviews

Systematic reviews to carry out retrospective and therefore prone to bias and random errors. There are three major forms of bias, publication bias, selection bias and language bias. Including all kinds of documents (for example, in peer-reviewed journals, abstracts, unpublished report) and subjecting them to equally strict critical evaluation of the reviewers to minimize the possibility of publication bias. To avoid excessive overlap of studies in the review, the investigators plan to find and delete duplicate publications, but also because the study may be published in various languages, and because with the exception of studies published in different languages may reject the results of reviews (Gregoire 1995, Egger 1997), articles should be included, as appropriate, regardless of language issues (translation if necessary). Limited time and resources, though, may prevent such an approach. Retrieving data from primary studies is a subjective process and prone to errors. In order to minimize the deviations at all stages of the process, the protocol should contain the sample data extraction form, which lists the items to be received from each of the primary studies. I developed a form of production data for the registration of information relating to a review of my goals. This will minimize errors and re-check the study of law at the time of extraction.

Little has been written about the methodology of systematic review and meta-synthesizing qualitative studies, as well as the practical issues that arise during these processes. Science of qualitative research in systematic reviews of effectiveness is still not enough. My review of studies using high-quality will contribute to the general discussion and refinement with the help of qualitative research in systematic reviews.

CHAPTER III: METHODOLOGY

7. Study selection criteria and procedure

The aim of study selection criteria is to identify articles that help to answer the review question. Those I have based my study inclusion and exclusion criteria based on my review aims and objectives.

7.1 Study selection criteria for the entry in the review:

Inclusion criteria

The review will include both research and non-research evidence published and non-published from 1966 to 2008 using both or either quantitative and qualitative research designs. This period has been selected to ensure that up-to-date and relevant information is collected, and in particular because the shortage of nurses and midwives have been identified since 1990. With an increase in the growing of ethnic minority groups in the same period, this may give opportunity to capture any trends of association between increase in minority groups in the UK and uptake of staff from this group into nursing & midwifery workforce. The other obvious reason is of course most published recorded citations start from 1966; this will hopefully capture all or most studies relating to my topic area. I will also include all studies and reports that discuss both specifically about groups of ethnic minorities and those that do not necessarily define ethnic minorities for the reasons discussed under the background section. Using a rapid review approach due to limited time a full systematic review will not be feasible and will be restricted to studies reporting on the UK population. As the review question is broad I will not restrict my review by selecting specific study design.

Exclusion criteria

The exclusion criteria will include studies that do not incorporate the inclusion criteria and those that are written in any other languages than English. Though there are web-based translators such as Alta Vista’s Babelfish (http://world.altavista.com) I will not be using these due to lack of time, expense and decisions around translating documents have many other issues to consider like measuring its validity. Studies and reports that prove to be difficult to obtain mainly due to time again will be excluded. The review will also attempt to exclude duplicated publication where possible.

7.2 Study selection procedure

The study selection procedure usually consists of several stages (CRD report 4). Initially for this review I will apply the study selection criteria to the citations generated from searching to make a decision about whether to obtain full copies of potentially relevant references. This I will do in three stages; each citation will be reviewed first by title, then by abstract and finally by full text, excluding at each stage citations that do not satisfy the inclusion and exclusion criteria together with duplicates (Meade & Richardson 1997).

There are no hard and fast rules for “stopping rules” for systematic reviews but time is a major factor in my study. I will record the search found and when no more new searches are being found I shall stop there.

Although it is a good practise to have a customised form that contains checklists of the selection criteria, to simplify the selection process, increase reliability and provide a record of the judgements made about each study. I will not develop this due to lack of time and being the only reviewer (Meade & Richardson 1997).

7.3 Development of the search strategy

The construction of the search terms was based on the components of my review aims and objectives. Together with the information that was collected during preliminary search for the background section. This firstly enabled me to explore the extent of material available related to the topic area and secondly ensured that the review was not duplicating work that has already been done.

Appendix 1 shows the search terms and tools used along with the results measured against the inclusion and exclusion criteria. This formed part of the main literature search which was done in two separate stages. The first was done in September 2006 using the search terms against the search tools in appendix 1. As I received an extension for the dissertation due to extenuating circumstances. The second stage was to run the original search terms again as time (two years) had passed by. Few new search items were included which can be viewed in Appendix 2.

Three levels of searches have been deployed to ensure a comprehensive inclusion of literature. Firstly there was a computerised search in literature search engines. Secondly, supplementary searches of key bodies like Royal College of Midwives (RCM), Royal College of Nursing (RCN) and Department of Health websites and Google search engine was checked for relevant papers on this topic. Thirdly, the ‘citation pearl growing’ technique was applied which is a technique in which the reference lists of selected articles is hand searched. This was because of the difficulty of identifying studies relevant to the review question by keyword searching alone.

7.4 Data extraction

Data extraction is the process by which I will obtain the required information I need from each of the primary studies. Data to extract have been based on my review aim and objectives. This process will provide a historical record of the decisions occurring during my review process. The data extraction form has been piloted to ensure I am not collecting too much or too little information about studies. I have recorded the information onto Microsoft word software to allow ease of large data handling and will be the basis by which the analysis will emerge. The form contained some general and specific information about each primary studies together with some outcome measures and results. Appendix 3 provides the data extraction form together with details of citations selected for this review and the details of citations undergoing critical appraisal.

7.5 Study quality assessment

The study appraisal process involves a detailed assessment of the study sample, the study interventions and the outcome measurements in each study. The information gained from quality assessment is crucial in determining the strength of interferences and in rating recommendations generated within a review (CRD report 4, 2001). Many published “critical appraisal checklists” exist for different disciplines and for different study designs. Some checklists are a simple reminder of what one should look for; others attempt to assign a score or grade to a study. Checklists are only an aid to good critical appraisal, not a method in themselves; even the best checklist does not relieve one of the need to make informed and thoughtful judgments. Recently, a number of appraisal criteria have been developed as structured approaches to judging validity and reliability in qualitative research (Oakley 2000; Popay et al., 1998; CASP 2006; Greenhalgh 1997).

However, there is no clear guidance as to which quality appraisal frameworks are best. As a result, for my review I will be using the CASP (2006) quality appraisal framework as I found this to be more user friendly to my needs in terms of the measurements for quality checks but also due to it being less lengthy. This framework describes the scope and purpose of quality assessment, provides a checklist of relevant quality items for measuring the quality of each article. It also allows one to measure the value of each research against other population and settings. I will therefore use the framework to scrutinise the quality of included studies in order to explore quality differences as an explanation for heterogeneity in study results. This will hopefully help the interpretation of the results. I have piloted the appraisal form using two articles.

At the end of the study selection process, the studies that fulfilled the inclusion criteria was subjected to repeated readings during which it was appraised and its findings summarized on the customised form.

7.6 Data synthesis

This process will form the analysis part of the review. Here I will clarify and summarise the results collected using the data extraction form and the appraisal form. There are no formal procedures available to aid narrative synthesis of findings from qualitative studies within the context of a systematic review (CRD report 4, 2001).

Data synthesis is a relatively new technique for examining qualitative research (Jensen & Allen 1996) and has been applied in the past to various health care including midwifery care (Kennedy et al., 2003). The analytic technique of qualitative data synthesis involves a compare and contrast exercise between studies included in the review. The process requires the preservation of meaning from the original text as far as possible. The aim of meta-synthesis is interpretive rather than deductive and seeks to understand and explain phenomena. I will be using the same criteria used to judge the quality of studies included together with my data extraction components to develop the data synthesis of this review and the content of this section will be organised according to my review question.

I will apply thematic analysis to organise the qualitative data according to the review objectives. This method will involve reading the content of each article in my review and categorising these according to the review objectives. Than the content under each of the objectives will be revisited applying the same principles of analysis to extract further issues/themes arising under each objectives. This process will allow for saturation of different themes to emerge under each objective which will form the final data synthesis under each objective.

7.7 Limitation of my review

Conducting the systematic review on my own generates a number of limitations in terms of; bias, multiple perspectives to the various process of study, decision making, lack of debate and discussion and time and resource available.

I have had to compromise on validity and reliability checks around data collection and interpretation particularly during the use of the data extraction process. I have tried to minimise this by using a data extraction form with clear instructions about coding data.

A systematic review should be undertaken by a team of researchers; the application of multiple perspectives to the various process of study appraisal, coding, and interpretation may result in additional insights, and thus in a more complete interpretation of the subject of the review. When screening through articles “tittles and abstracts” for study inclusion criteria it is best that two people do this to check that relevant papers are not missed. Even when explicit inclusion criteria have been specified, decisions concerning the inclusion of individual studies remain relatively subjective. A team of researchers would have allowed for a more debate and discussion as to how broad or narrow the inclusion criteria to be. These are the limitations for working on a systematic review on my own.

Time and resources prevented me from attempting to identify articles from the grey literature and even if I had I would still need author permission to use in my review which would take allot of time. Effective searching is a skill and it is highly desirable to involve an information expert who can design and execute sensitive (and possibly complex) search strategies. Reviewers and librarians should work together to develop the search strategy which my review lacked. There was also no time to supplement missing or unclear data by contacting any researchers from the primary research. The identification of relevant studies in this review has been time-consuming than if it had been a systematic review of randomised control trial. A substantially large proportion of papers had to be retrieved for full reading, as articles with unclear titles, which lacked abstract, could not be dismissed as irrelevant.

7.8 Bibliographic management

Bibliographic software packages like Reference Manager or Endnote are very useful in managing the many references which are assessed and included in a systematic review. Such software can also link into word processors to facilitate the production of reference lists for reports. Although uses of such software would have saved allot of time with regard to organising and managing references, cost of purchasing a product was an issue for me and I had resorted in use of old fashioned copy and past format using Microsoft Word software.

7.9 Dissertation timetable

Although depending on its complexity, a systematic review project should take 9-24 months to complete. My review timetable is below and had I not been interrupted due to childcare issues I would have been able to complete the dissertation within a period of six months, and the timetable below reflects this.

August 2008 to December 2008

Cost

I had allocated £50 for the ordering of the articles from University library and local libraries, photocopying and printing of which none of it was used.

CHAPTER IV: RESULTS & DISCUSSION

8. Results

The results section will be organised in accordance to the evidence gathered for each of the objectives in this study and other key issues/areas commonly arising from the articles reviewed.

8.1 Baseline information of studies included in the review

A total of sixty five studies were identified as potential relevant citations after the first stage of study selection procedure. This was than reduced to thirty nine during the second stages of selection procedure as these did not meet the study inclusion criteria as mentioned in the methods section. The final selection stage yielded twenty six citations of which six were unable to retrieve and eight were duplication. This left seventeen articles to include in the systematic review. Diagram 1 visualises the above information.

Diagram 1: Summary of studies included and excluded from the review.

Due to the small number of research studies conducted on the review topic I had decided to include in the review news articles published in journals to understand a holistic picture of the trends and interventions proposed and applied to progress the recruitment of ethnic minorities into nursing & midwifery NHS workforce.

Table 1: Baseline information of articles included in the review

Table 1 provides the baseline information of articles included in the review. The frequency counts for each section do not add up to 16 as not all the section information for each article were produced. Publications on the review topic have only been produced over the last seven years and the first to be written in 1999. Of course this in no way advocates that the review topic has only been raised since this time period as the literature search for this review did exclude grey literature. It is never the less surprising to find such few research studies have been published on the review topic and more astonishing is that these have been only published in the last seven years given that the presence of South Asian population in the UK goes a long way back.

It is not surprising to see articles on the review topic are largely published in nursing journals. Only one article had been published in the British Medical Journal. This discussed recruitment/retention problems in inner cities and teaching trust and the extent of the NHS nursing shortage in the UK overall and despite mentioning low rates of ethnic minority nursing and midwifery registered failed to provide a breakdown of ethnic minority groups (give BMJ article reference here).

Table 1 also provides the institution affiliation of the articles published. It is not surprising to see academic institutions are the prominent institutions publishing articles on Ethnic minorities and nursing and midwifery NHS workforce. Institutions that did publish were affiliated within areas with a large minority ethnic population. It is surprising that London based institutions have not published on this topic given ethnic minority in particular South Asian populations are larger in numbers in London than elsewhere together with more nursing and midwifery academic institutions in London.

There has been very few (6) published articles that were research based to explore the factors associated together with schemes to enhance the recruitment of South Asian groups into nursing and midwifery profession. Two studies used qualitative research methods applying focus group discussions and one-to-one interviews combined with a moderate sized postal survey which yielded very few response rate. Two articles reported on using Action research to improve the recruitment of ethnic minorities into nursing and midwifery courses and into better employment positions. Large number of articles (9) included in the review were news and descriptive based.

The articles included in the review focused on three areas:

Factors that deter and enhance Asian communities from choosing nursing & midwifery as a career and the experiences of nurses from minority ethnic groups.
Description of leadership programmes, mentorship schemes and initiatives to improve Ethnic minority groups in management positions and the healthcare profession in general.
Examines the evidence of race inequality in access to nursing and midwifery training and tacking racism in the workplace.

As the identified number of published articles are few and the sample of participants are not representative in terms of number or specific South Asian category the issue raised in the above three areas cannot by any means be taken to be the complete picture of issues with regard to South Asian groups and Nursing and midwifery profession.

It is much unforeseen that this systematic review reviled only six published articles from the entire search that used research methodology, to attempt to gain the prospective of South Asian population themselves about nursing and midwifery profession. Not only is this a very low coverage but also the sample size of each of these studies is extremely small to form any real representation of the overall prospective of South Asian population on this topic. One study only reports the sub category of South Asian population they used which was the Pakistani group (7 girls). All other three studies do not reveal the sub groups of the South Asian participants they refer to in their study. This therefore is not a comprehensive prospective of South Asian population on this review topic.

8.2 Trends and characteristics of ethnic minority in nursing and midwifery NHS workforce

8.2.1 BME staff attributes

Britain has a proud tradition of black nurses and midwives; however other BME groups tend to be under-represented. Perhaps because black nurses have been a visible reminder of the ethnic mix in the NHS there have been few attempts to recruit more BME staff until recently.

While more recent data suggest that the recruitment of African-Caribbean’s in some areas has improved, there is evidence of an under-representation of all South Asian (Indian, Pakistani, Bangladeshi & African Asian) recruits in areas where large Asian communities reside (Iganski et al, 1998; English National Board (ENB), 1999; O’Dowd, 2000). Representation is particularly low among Pakistani and Bangladeshi groups.

Evidence suggests that BME staffs are older than their white peers and more likely to be working in mental illness & learning disabilities rather than in more prestigious specialties. Manufacturing Science and Finance (MSF, 1997), shows less than 1% of the under 25 year olds in employment as nurses, midwives or health visitors were from minority ethnic background.

Currently, the NHS workforce does not reflect the profile of the community it serves and is coming under criticism for its inability to attract and retain nurses and midwives from the BME communities (Bharj 1999).

8.2.2 Policies and schemes targeted for ethnic minority communities

The NHS trusts are now required to ensure that their employer profile more accurately reflects the local population (NHSE 2000).

In 1993 the secretary of state for health launched the programme of Action for Ethnic Minority Staff in the NHS, with the overall aim of achieving “the equitable representation of minority ethnic groups at all levels in the NHS, reflecting the ethnic composition of the local population (Department of Health 1993). Government’s various policies and reforms are attempting to respond to the health needs of its BME communities. It advocates that some of the inequalities in access to health services may be reduced by employing health staff who shares the same cultural & linguistics characteristics of the population they serve (DOH 1993, King Edward’s Hospital Fund for London 1990, UKCC 1991)

In the examination of equal opportunities policies & practice in NHS Trusts in a study, Beishon et al. (1995) found very significant gaps between written policies identified by senior managers and the actual practices undertaken in the workplace.

In 2003 the DH launched an initiative called “Access to nurse education for black and minority ethnic communities (Access project)”. This explicitly addressed the issue of the “barriers to access to training places for black and minority ethnic (BME) applicants” (Anon 2003), and set itself the key aim of improving the rates of acceptance of BME nursing students compared with the numbers of applicants (Anon 2003). Health minister John Hutton announced details of nine schemes around the country which aim to help people from disadvantaged backgrounds become doctors, nurses and allied health professionals. The scheme given £9 million funded by department of health and the higher education funding council for England (HEFCE) over five years will look at ways of encouraging a wider range of young people to train in the healthcare professions (website of HEFCE 2004/08). These new schemes are a significant step forward in guarantee that the healthcare professions better replicate the wider population through widening participation.

8.2.3 Inequality

While people from some of the BME communities are coming forward for nursing/midwifery (the Black, Black African & Caribbean) they are all experiencing inequality at recruitment and selection stages (Bharj 1999). Ethnic minorities account more than 30 per cent of applications for pre-registration training courses for nurses and midwives in England, they have less than half the chance of securing a place compared with their white peers (Grainger 2006). In 1987, the CRE published results of a survey of 32 schools of nursing across England and Wales (CRE 1987), black & Asian applicants had half the success rate of their white peers.

The success rates and success ratios for applications to diploma-based, pre-registration nursing and midwifery courses across England between 2001/2 and 2003/4 by ethnic origin showed that the success ratio (obtained by dividing the minority ethnic success rate by the white British success rate) measure falls below 0.8. Commission for Racial Equality (CRE 2002a) suggested that this result should trigger an internal investigation. This survey was followed by other studies, which looked at the statistics on pre-registration nurse training (Gerrish et al 1996, Chevannes 2001, Iganski and Mason 2002) which showed similar patterns of inequality between the main ethnic groups.

Asian ethnic groups are under-represented in applicants to nursing courses, and there is evidence that BME applicants have difficulty in securing course places (Online 2004). There are still very few BME nurses in top jobs and BME nurses are more likely to be asked to act up and not get paid for it than their white colleagues (Nursing Standard news 2005).

In recognition of the inequalities that existed, the former UKCC (1991) (now the Nursing and Midwifery Council) proposed that recruitment and selection to programmes of nursing education should be reflective of the population for which they will be caring.

The NHS and other employers must ensure that their employment practices and provision of career opportunities are non-discriminatory. This process should include facilitating career routes into nursing and other health sector employment, which are more accessible to the minority ethnic communities of inner city London and other urban areas. (Ball & Pike 2002, 2003; Buchan 2003; Duffin 2004)

8.2.4 Data on ethnic minority groups in nursing and midwifery professions

The Labour Force Surveys for 1988 – 1990 estimated about 8% of all nursing & midwifery staff from minority ethnic groups. Nursing and Midwifery Admissions Services (NMAS) statistics show that, from the late 1990’s there has been a steady increase in the recruitment of students from black Caribbean and Asian minority groups into nurse training. An increase of 3% within a decade shows 11% of ethnic nursing & midwifery registered in 2000.

The English National Board showed that of nearly 12,000 students accepted on to nursing courses in 2000, fewer than 200 were Indian or Pakistani (Daniel 2001).

Statistics show that even in areas with a large BME (Black and Minority Ethnic) community, they are under-represented in the nursing & midwifery workforce. For example at the University of Central Lancashire, just 1% of pre-registration nursing students are from a minority ethnic background. Lancashire has large BME communities of South Asian predominantly Pakistani Muslims. These communities are under-represented in the nursing & midwifery workforce in the area. (Storey 2002).

UKCC (now known as the Nursing and Midwifery Council) has only recently (2000-2001) begun to collect data on the ethnic origin of registered nurses. Some NHS trusts are failing to carry out even the basic ethnic monitoring functions required by the NHS Executive (manufacturing science and finance (MSF, 1997).

8.3 Possible Barriers

A number of points have been identified as possible barriers for ethnic minorities entering nursing and midwifery workforce. I have organized these below under three main headings.

8.3.1 Discrimination

A few studies in my review have provided evidence based on information reported by other authors that factors in the selection process of students into pre-registration training courses have the effect of discriminating against some applicants on the basis of their ethnic group (Iganski et al., 1998;Bharj 1999). Similar discrimination has also been noted in the promotion and continuing learning compared to their white counterparts (Iganski et al., 1998). Iganski et al. (1998) looked at the admissions systems of a purposive sample of eight Nursing schools. They concluded that only one had made a serious effort to ensure a bias-free selection process.

BME communities continue to experience discrimination, harassment, and restricted opportunities for professional development (Beishon et al., 1995). Educational institutions are not doing enough to attract minority students or to adequately support them once recruited (Gerrish et al., 1996). NHS staff from BME groups face racism and discrimination at work.

8.3.2 Nursing not seen as an attractive career

The BME groups have a very negative vision of the image of nursing and midwifery profession. The image of this profession is seen as (these are views of mainly South Asian school girls and boys):

Unattractive
Dead end job
Low status profession
Little authority
Unsocial hours with low pay
Physically demanding
Mentally in stimulating
Subservient to doctors
Dirty work
May Catch Something
It’s a girly job, it’s not a profession for boys
career teachers identified cultural & religious myths that deterred Asian girls from entering into nursing
Discrimination and racism within the NHS (There is some evidence that black youngster may be put off nursing because they have a negative perception of the NHS)
Hospitals Are Always In Crisis

Barriers by South Asian Parents:

Money is not very good, long hours, too much hard work, too much stress, not seen as a good profession, fear of catching something. When asked how they would feel about their children following a career in nursing/midwifery response was they would support their children’s choice but would not encourage then in such a choice. Fathers said they would not encourage their sons to become nurses. Mothers said they would support their daughters but not their sons as a career in nursing.

8.3.3 Barriers on religious & cultural grounds:

Nursing male in bed “would not be acceptable”
concerns around the appropriateness of nurses uniform, even after modification on religious grounds

8.4 Interventions to attract ethnic minority groups into nursing & midwifery workforce

A number of different levels of interventions have been taken place to develop the position of ethnic minorities into nursing and midwifery workforce. I have organized these under the following subheadings:

8.4.1 Community briefing events & outreach work

Storey et al. (2002) reported the university had tried to address under-representation by Asian communities by holding meetings with community leaders, attending the local Mela and organizing careers events targeted at minority communities. Although these efforts attracted more minority ethnic students to the University, the increase was insignificant considering that in some areas, more than half the population was of South Asian origin. They planed their future work to include revisiting community groups, colleges and schools because staff turnover is high. Publicize health care as a career option at shopping centres and supermarkets. Presentations in schools & colleges and briefing paper & event for career officers, job centers etc.

8.4.2 Development of targeted PR materials

To redress some of the misconceptions of the South Asian communities about nursing, written and computer-based information was developed in appropriate languages (Storey 2002). The use of multi-language public relations material and video/CD Rom at events. Recruitment campaign included a series of radio advertisements; some of them broadcast directly to Asian communities.

8.4.3 Use of research

Both uses of qualitative and quantitative methods have been deployed as a way of identifying issues and informing others about the realities of nursing. But also as feedback on the progress of the project and to test publicity materials as they were developed. English National Board Commissioned (ENB 2000, 2001) the faculty to audit retrospectively the state of recruitment policies, for the years 1998 to 1990 and 1990 to 2000, with respect to students from BME applying for nursing and midwifery education and training at English Universities (Sadler 1999).

Other interventions took place as a result of recommendations from the research:

Asian nurses were recruited to talk to school leavers about career opportunities in nursing
Competition was held for a girls school to design nurses uniform with a hijab
NHS careers advice “Job Share” desk was set up in a 24-hour health clinic.
Development of new healthcare apprenticeship scheme (14 students (half will make the grade and those who fail will continue to work as care assistants, giving opportunity to men and women from BME communities to see if nursing is the career for them) (Sadler 1999)
Disseminate project outcomes to other higher education institutions and trusts through continued publication of papers and conference presentations.

8.4.4 Mentorship scheme

Storey et al. (2002) reported developing and evaluating the student mentoring scheme, appointing and training student mentors.

8.4.5 Cultural awareness training

Storey et al. (2002) discussed the importance of cultural awareness training to include a greater number of faculty and trust members. Evaluation of these will reflect on its effectiveness and part of this could involve networking with staff at similar projects around the country and look for new ideas.

8.4.6 Initiatives and leadership programmes

In 2000 RCN Connect was set up to increase the representation of BME activists and to improve the image, recruitment and outreach of the RCN within BME communities (Page 2001).

There have been a number of ‘top down’ initiatives to encourage more BME people to join the NHS and ensure they are not then stuck at the bottom of the jobs pile. Some trusts have also pioneered local schemes to boost recruitment. National initiative includes Positive diverse, which 170 NHS organizations have signed up to. This promotes equal treatment and stresses the benefits of a diverse workforce. The Department of Health’s human resources strategy also makes a firm commitment to promoting equality and offers support to trusts.

Chief Nurse Sarah Mullally has an advisory group on BME issues to ensure the perspectives of minority ethnic staff are considered in policy developments (Moore 2004). The under-representation of staff from BME groups in top NHS jobs is also being addressed by a leadership programme called Breaking Through.

8.5 Recommendations from articles included in the review

Recommendations included engagement with BME communities in all aspect of improving/promoting nursing & midwifery workforce using marketing strategy to the multi-ethnic market media, use of role models from BME groups and joint partnership working involving all stakeholders and seek endorsement from key religious leaders for projects (Storey 2002).

Ensure staff undertakes specialist training designed to help them implement equal opportunities policies and procedures in relation to recruitment and selection, career development, education and training, performance appraisals, and grievance and disciplinary hearings. Develop policies on racial harassment and communicate them to all staff.

Regularly and robustly monitor the ethnic composition of the nursing and midwifery workforce. Accurate ethnic data will demonstrate trends & help evaluate the effectiveness of current recruitment & retention strategies & prepare future plans.

8.6 Qualitative Critical Appraisal

Majority of the articles included in my systematic review were well described articles. Although the sample size for all the research based studies were very small and cannot be used to represent the South Asian population. Some articles failed to report on participant numbers and how and why participants were recruited using the methods described. One article included postal survey of parents but did not report on its findings and some failed to identify the specific sub groups of Asian groups used in the study (Sadler 1999).

There was no detail around how ethical standards were maintained in any of the research based articles. One study provided good evidence of race inequality in access to nursing and midwifery training and gave clear arguments for the collection of admissions data into nursing and midwifery educational training. Articles have given good description of initiatives and schemes they have used however, no details on how successful these have been. Local action research programmes were encouraging but no details of how these programmes actually work and the success of these from the providers or the receivers prospective. For example whether by introducing Muslim nurses’ uniform, with full length dress and headscarf has made any difference to improving and attracting nurses & midwives from the Muslim community.

9. Discussion

There is clear evidence of under-representation of all South Asian (Indian, Pakistani, Bangladeshi and African Asian) recruits even in areas where large Asian communities reside (Iganski et al., 1998; English National Board (ENB) 1999; O’Dowd 2000). Representation is particularly low among Pakistani and Bangladeshi groups. Currently, the NHS workforce does not reflect the profile of the community it serves and is coming under criticism for its inability to attract and retain nurses and midwives from the BME communities (Bharj 1999). Evidence suggests position of BME staff in NHS has made little progress since 1960s in spite of race equality legislation.

A few numbers of initiatives have been introduced by the government to address the issues of the barriers to accessing Nursing and Midwifery workforce and the general healthcare profession by ethnic minorities. However, it is difficult to estimate the success of these initiatives as there appear to be no or little follow up or monitoring of their progress by the Department of Health (Culley 2001).

Despite the daring and inclusive approach by the government, one of its initiatives “the Access project” has yet to achieve information on access to anonymous data on applications to each school. (Grainger 2006) most interestingly raised the question of “why deans of the nursing schools have not yet come under greater pressure to release admissions statistics”.

Evidence suggests that all BME groups are experiencing inequality at recruitment and selection stages for pre-registration training courses for nurses and midwives (Grainger 2006). Black & Asian applicants have half the success rate of their white peers. Commission for Racial Equality (CRE 2002a) suggested that the measure of success ratio obtained for applications to pre-registration nursing and midwifery courses across England between 2001/2 and 2003/4 by ethnic origin should trigger an internal investigation. Education institutions perhaps need to be reminded and provided training on bias-free selection process. This discrimination extends to promotion and continued learning development compared to their white counterparts and this has a consequent impact on staff retention. These experiences damage staff moral, waste potential and contribute to difficulties in recruitment and retention. They also reduce the ability of the nursing and midwifery workforce to reflect, and therefore to understand, the breadth and diversity of the communities they serve.

There is inadequate data on ethnic minorities into nursing and midwifery workforce. The existing data suggest the nursing and midwifery workforce compose of a tiny proportion of ethnic minority group’s in particular Bangladeshi and Pakistani groups from the South Asian population. The small data on ethnicity of this workforce that does exist also fails to provide ethnicity data on ethnic sub-group level. Some NHS trusts are failing to carry out even the basic ethnic monitoring functions required by the NHS Executives (Culley 2001). The absence of effective monitoring of ethnic data means it is impossible to give an accurate breakdown of the ethnic origin of nurses and midwives currently employed in the NHS. Steps need to be taken to ensure that the recording of ethnic origin data of registered nurses and midwives by the Nursing and Midwifery Council are adequate, accurate and used in the planning and reflection of trust priorities at local and national level.

BME communities have a very negative image of Nursing and midwifery profession. This is both by 1st and 2nd generation groups (Daly 2003). This negative image is stimulated with the existence of discrimination and racism within the NHS itself together with cultural and religious myths that deter Asian girls and boys from entering the profession. Having Asian role models is likely to encourage recruits from Asian communities and raise general awareness about the diverse career available within nursing.

Studies included in my review suggest there have been a range of interventions applied to improve the position of ethnic minority communities in particular South Asian communities into nursing and midwifery workforce. There is evidence of these working effectively at an operational level. However, these interventions have recently been introduced and applied to very few geographical pockets. Never the less we have seen evidence of very good community briefing events & outreach work resulting from good use of research. These have highlighted the importance of mentorship schemes.

This brings benefits for the mentors too, as the role is a chance to develop, enhance communication skills and improve understanding of how organizations work. The introduction of cultural awareness training and the evaluation of these will reflect on its effectiveness. However, although education may theoretically help in making healthcare professionals more aware of cultural issues, there is little evidence to suggest that such education leads to enduring and consistent levels of culturally or ethnically sensitive care.

It is encouraging to see the NHS has introduced initiatives and schemes to attract and enable BME staff to reach the upper echelons. However it is the outcome, rather the results that they achieve will be the true measure of the NHS’s initiatives and schemes. There is always the danger that some of these schemes can be tokenistic. People can look at the scheme as an end in itself; instead of what comes out of it (Nursing Standard news 2005).

Effective operation of schemes locally can and does work as has been in Bradford Teaching Hospitals Trust. They increased significantly the number of staff from BME groups by raising awareness of job opportunities in the health services and introducing a preparation for nursing programme, which brings school pupils into the hospitals. In addition there is a cadet scheme for those without the usual qualifications and work has been undertaken with Asian parents, who are often influential in their children’s choice of careers (Moore 2004). Barts and the London Trust has introduced a Muslim nurses’ uniform, with full length dress and headscarf, which still satisfies infection control standards (Moore 2004).

The articles included in my review used very small sample size and the reason for low recruitment was not discussed. Therefore, the results cannot be used to represent the views and experiences of the South Asian population in general. There was no detail around how ethical standards were maintained in any of the research based articles. Local action research programmes were encouraging but no details of how these programmes actually work and the success of these from the providers or the receivers prospective. For example whether by introducing Muslim nurses’ uniform, with full length dress and headscarf has made any difference to improving and attracting nurses & midwives from the Muslim community.

CHAPTER V: CONCLUSION

10. Conclusion

My entire search revealed only six evidence based research studies that focused on the position of South Asian ethnic minorities into nursing and midwifery NHS workforce, with only five articles that I was unable to retrieve to assess their relevance of inclusion in my review. This lack of evidence based research work has serious implications to understanding the dynamics of South Asian groups and the nursing and midwifery profession. Together with clear evidence of under-representation of all South Asian in this workforce has serious repercussion as it compromises the NHS in both delivery of equitable health care & in social justice & business efficiency. A representative workforce of it’s client population enables a service to provide a culturally sensitive and appropriate care, as well as acting as a resource or role model for colleagues and the various communities.

The evidence that does exist on this review topic indicates that they can work effectively at an operational level. It is imperative that future research is based on a large sample and should use lessons learnt from existing work to explore the dynamics of South Asian communities and nursing and midwifery workforce to a greater extent.

The NHS is failing to reflect the profile of the communities it serves despite introducing policies, initiatives and schemes. Improving the rate of South Asian in this workforce isn’t just about using tailor made ethnic specific marketing approaches to promote nursing and midwifery profession amongst these communities. It is a lot complex and requires a more holistic approach involving stakeholders at all levels to implement and evaluate planes. Unless policy makers include evaluation and actions to be taken to monitor the success of their initiatives and schemes, the position of South Asian or ethnic minorities in nursing and midwifery workforce will not change. This includes providing training to trust staff on cultural awareness programmes. Specialist training should be designed to help trust staff implement equal opportunities policies and procedures in relation to recruitment, selection and career development. There are no data on the specific effects of racial discrimination on the mental health of the United Kingdom’s multiethnic working force. Racial/ethnic discrimination shows strong associations with common mental disorders (Am J Public Health 2005).

Accurate ethnic data will demonstrate trends & help evaluate the effectiveness of current recruitment & retention strategies & prepare future plans. This is necessary in determining whether policies are being implemented efficiently.

BME communities have a very negative image of Nursing and midwifery profession. This is both by 1st and 2nd generation groups. This negative image is stimulated with the existence of discrimination and racism within the NHS itself together with cultural and religious myths that deter Asian girls and boys from entering the profession.

11. Recommendations

It is imperative that future research on this topic composes of much larger samples than those reported in this review and should use lessons learnt from existing work to explore the dynamics of South Asian communities and nursing and midwifery workforce to a greater extent.

Provide support mechanism for education institutions to be able to implement a bias-free selection process for pre-registration training courses to avoid inequality and discrimination.

Recording of ethnic data for the nursing and midwifery workforce needs to be made compulsory. This will demonstrate trends & help evaluate the effectiveness of current recruitment & retention strategies & prepare future plans. This is essential in determining whether policies are being implemented effectively.

A holistic approach is required to attract, retain and promote the nursing and midwifery NHS workforce to South Asian communities involving stakeholder partnership working at all levels to implement and evaluate planes.

Unless policy makers include evaluation and actions to be taken to monitor the success of their initiatives and schemes, the position of South Asian or ethnic minorities in nursing and midwifery workforce will not change. This includes providing training to trust staff on cultural awareness programmes.

Specialist training should be designed to help trust staff implement equal opportunities policies and procedures in relation to recruitment, selection and career development.

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Appendix

Appendix 1: Search tools and terms used in the review

Appendix 2: Additional new search tools and terms used in the review after two years.

Appendix 3: Data Extraction Form

Key

Bibliographic details: Study Details: Trends and Characteristics: Possible barriers: Intervention:

1. Author 1. Research question 1. Dates 1. What 1. What

2. Article title 2. Study group 2. Ethnicity 2. Why 2. How

3. Source 3. Geographical setting 3. Reasons 3. Which groups 3. Did they work

4. Institutional affiliation 4. Study method/design

5. Key results

6. Conclusion

Finlayson, B., Dixon, J., Meadows, S., Blair, G. 2002, ‘Mind the gap: the extent of the NHS nursing shortage’, British Medical Journal, 325:538-41.
Bharj, K. 1999, ‘Ethnic minority groups in nursing’, Nurse Management, 6(1):11-16.

3. Storey, L., Martin, E., Sawley, L., Brown, C., Rashid, S. 2002, ‘Minority report’, Nursing Management, 8(10):6-9.

4. Sadler, C. 1999, ‘Promoting Diversity’, Nursing standard, 13(39):14-16.

5. Culley, L. 2001, ‘Equal opportunities policies and nursing employment within the British National Health Service’, Advanced Nursing, 33(1):130-137.

6. Parish, C. 2003, ‘Ethnic minorities targeted in leadership programme’, Nursing Standard, 18(6):4.

7. Grainger, K. 2006,’Equal access to training for black and minority ethnic nurses’, Nursing Standard, 20(42):41-49.

8. Allen, D. 2001, ‘Cultural Allies’, Nursing standard, 15(22):18-19.

9. Page, R. 2001, ‘A working strategy for diversity’, Nursing standard 15(34):13-15.

10. Nursing Standard news. 2000, ‘ Recruitment focus for ethnic minority groups’, Nursing Standard, (31):4.

11. Drive for more doctors and nurses from deprived backgrounds (online) 2004, available: http://www.hefce.ac.uk/news/HEFCE/2004/medics.asp

12. Black and minority ethnic leadership & development programme. North East London strategic health authority. Workforce Development Directorate.

13. The Royal College of Midwives (RCM). 2000, ‘Racism and the maternity services.

14. Storey, L., Sawley, L., Rashid, H., Brown, C. 2002, ‘Cultural Shift’, Nursing Standard 16(24):58-59.

15. Moore, A. 2004, ‘Drive for Diversity’, Nursing Standard, 18(39):18-19.

16. Nursing Standard News. 2005, ‘Freedom from racism’, Nursing Standards, 20(4):22-23.

17. Daly, W.M., Swindlehurst, L., Johal, P. 2003, ‘Exploration into the recruitment of South Asian nurses’, British Journal of Nursing 12(11):687-696.