Guy's and St Thomas' NHS Foundation Trust (GSTFT) implemented interventions to support their internationally educated nurses (IENs) through the objective structured clinical examinations (OCSE) process.
GSTFT comprises of five hospitals – Guy's and St Thomas', Evelina London Children's Hospital, Royal Brompton, and Harefield – as well as community services in Lambeth and Southwark. They provide specialist care for patients including heart and lung, cancer, and renal services as well as a full range of local hospital and community services for people in Lambeth and Southwark.
GSTFT have around 22,700 staff, 9,000 of which are within nursing and midwifery, making them one of the largest NHS trusts in the country and one of the biggest employers locally.
GSTFT has been recruiting IENs since 2021, and Royal Brompton and Harefield hospitals, which joined the trust that year, have been doing so since 2016. Since January 2022, GSTFT have recruited a total of 538 IENs made up of 26 different nationalities, across three fields of nursing – adult, paediatric and midwifery.
The trust has a well-structured and organised team to support IENs before, during and after their OSCE training, led by their well-established pastoral care team. The nurses are welcomed by their pastoral care team and wellbeing team on arrival to the country. An outline of the programme is below:
- Sending a welcome and safe journey email.
- Organising a pre-departure MS Teams meeting – where the internationally educated workforce (IEW) cohort meet for the first time.
- Providing each IEN with a welcome pack including information about the cost of living, take home salary, reasonable adjustments (if applicable), pension, local community information, maternity benefits, employment contract and the GSTFT equality, diversity and inclusion (EDI) toolkit.
- Ensuring the pastoral care lead welcomes the IENs on arrival.
- Arranging an initial MS Teams meeting to introduce the IENs to their line manager and the OSCE team.
- Giving a tour of the hospital and amenities and providing a welcome lunch.
- Providing an introduction to an IEW WhatsApp group.
- Helping IENs to open a bank account.
- Providing eight weeks' paid accommodation.
- Providing an Oyster card and food vouchers.
- Ensuring IENs attend their corporate induction and complete essential mandatory training.
- Providing a local induction, where IENs meet their managers and familiarise themselves with the clinical area.
- Providing training for the OSCE exam through a structured five-week programme (including sitting the OSCE exam).
- Offering continuous pastoral care support by the OSCE team.
- Empowering IENs to share knowledge and have open conversations, breaking down language barriers around terminology, slang and abbreviations that are used in different countries.
- Delivering professional psychologist-led sessions on managing anxiety during the OSCE examination.
- Ensuring daily face-to-face debriefs with each cohort of IENs to adapt teaching methods that allow for the diversity of the group.
- Supporting IENs to receive their Nursing and Midwifery Council (NMC) registration.
- Providing additional training to prepare for and retake OSCEs if required.
- Providing information and support to find external accommodation ready for when trust accommodation provision ends.
- Ensuring a supernumerary period of a minimum of two weeks following completion of the OSCE, which can be extended as required depending on individual needs.
- Offering a comprehensive and tailored preceptorship to support IENs on the clinical areas, allowing them time to adjust to the demands and differences faced on their healthcare system, as reflected in the national preceptorship/CapitalNurse framework.
- Ongoing focus on career development opportunities and support required to ensure equity, e.g., application writing, interview practice, career development discussions.
- Retention tracker to audit promotion and progression of IENs across the organisation. Since the inception of the retention tracker, for IENs recruited from 2021, over 12 have progressed to band six positions and three to band seven positions (at present this does not include staff recruited to Royal Brompton and Harefield due to different data systems).
The greater support given to IENs to train for their OSCE exam has meant a consistent first-time pass rate of >51% (>78% prior to NMC changes in 2021/22), compared to the national rate of 35% (100% at three attempts). The trust anticipates an improvement in the first-time pass rate following further rollout of the extended OSCE programme, with early impact being seen at Royal Brompton and Harefield sites where IENs have achieved a first-time pass rate of 79% on the five-week training programme.
The pastoral care has proven fundamental to supporting the wellbeing of their IENs. By extending the accommodation provision to eight weeks, IENs can focus on their OSCE training and have longer to look for a permanent residence. The OSCE team have better support and capacity, making them more able to closely monitor the training and provide check-ins with IENs once they start working within their clinical areas.
IENs have contributed to a reduction in vacancies, especially within targeted hard to recruit areas. This has improved the stability and wellbeing of the workforce overall. IENs provide a unique contribution including skills, and experience, across clinical teams. There has also been positive feedback from both clinical areas welcoming IENs, and from IENs themselves on the support they have received.
International Nurses Day 2023. Image supplied by Guy's and St Thomas' NHS Foundation Trust.
Hear from the trust
The Race Equality programme spoke to Gemma Craig, deputy chief nurse, and Sue Cox, deputy director of nursing for workforce and education, at GSTFT about implementation of these interventions, the challenges, learning for the board, and advice for board members looking to support their IEW.
Weekly meetings are held with the OSCE team to provide constant review of the progress that GSTFT IEN OSCE cohorts are making. This allows the trust to keep a structured and updated programme, adjusted to the live needs of IENs.
The trust has established a multidisciplinary international recruitment (IR) programme board, involving key stakeholders to oversee its progress and development. Through this governance, key decisions have been made and implemented - with examples below:
- Extension of the OSCE training programme from four to five weeks.
- Expansion of the OSCE training team to support development of OSCE training and the bespoke preceptorship.
- Extension of paid accommodation provision from four to eight weeks.
- Implementation of processes that recognise prior learning of IENs.
Collaborative work with established IENs and the Kofoworola Abeni Pratt (KAP) fellowship provides continuous feedback on all aspects of the IR programme through focus groups, informal and formal feedback, and representation at the IR programme board. The KAP fellowship was established at GSTFT to support personal and professional development of ethnic minority staff, and to challenge structural barriers and biases which impact the career progression of nurses, midwives and allied healthcare professionals (AHPs) from ethnic minority backgrounds.
An ongoing review of accommodation information and establishment of twice weekly accommodation clinics is held in collaboration with the trust accommodation team.
GSTFT identified some challenges when implementing interventions to support their IEW. Addressing these challenges has helped shape their processes and improve their support offer for future IENs:
- Onboarding and supporting a large group of IENs when the IR programme first started, with a four-week OSCE training schedule (at capacity: 40 nurses to two trainers for four-week OSCE training schedule) - this was a significant challenge that has since been addressed through increased team capacity as well as extending the OSCE training schedule.
- Providing a consistent level of pastoral care. As a pastoral care role was not established at the beginning of the programme, there were some initial challenges in providing support to the initial cohort of nurses who arrived. This has since been addressed through a dedicated IEN pastoral lead establishing the pastoral care team and forming links and supporting interventions within the clinical areas.
- Ensuring there were enough adequately trained practice development nurses (PDNs) to support OSCE provision and cover for holidays and sickness. This initial challenge has been addressed through expansion of the team.
- Ensuring room capacity and availability to accommodate appropriate teaching space within the trust.
- Having accommodation capacity. This continues to be a significant challenge particularly at GSTFT due to central London location and having a large workforce.
Throughout the development of the IR programme, the board has learnt about the importance of actively seeking ongoing feedback through multiple channels and forums, and utilising collaborative working with multi-professional teams (e.g., psychologists, KAP fellows and previous IENs). This has allowed GSTFT to continuously improve all IR processes, including onboarding and OSCE training. It has also supported an increased understanding around the impact of moving to a new country with an unfamiliar culture as well as the need for ongoing support to find accommodation once the trust's provided accommodation ends.
The board also recognised that support needs to go beyond interventions targeted directly at the IENs. For example:
- Consideration needed to be given towards the wellbeing of the OSCE and pastoral care team, and how best to support them to deliver the training and support to IENs.
- All directorate areas needed the IR framework in place to support IENs within their clinical areas, for example dedicated PDNs and a buddy system, with key links to the pastoral care team.
- Awareness around the support required to recruit, onboard and embed IENs within their clinical areas.
Alongside this, the board has also reflected on the importance of establishing an early tracking framework to audit and evaluate the career progression of IENs, and this is being considered as part of future planning.
- Consider the number of IENs per cohort to ensure the right support is available to both deliver and develop OSCE training and support.
- Establish a dedicated lead to oversee recruitment, OSCE and to develop/lead bespoke preceptorship programme.
- Establish a dedicated pastoral care lead, associated team, and clinical area links.
- Create a multi-professional approach to onboarding, training, and evaluation.
- Provide funded accommodation for a minimum of two months with robust support for obtaining ongoing/future accommodation.
- Have a permanent venue to train IENs with the necessary resources.
- Ensure continuous evaluation of the programme, considering pass rates and the wellbeing of IENs.
- Align IR programme with workforce data, identifying any hard to recruit areas.
GSTFT would like to give thanks and recognition for the hard work and dedication of Remah Tabjan, Sian Nobel-Davies, Sakhi Pawar, Desiree Ogle, Jasmin Castillo, and Tania Soares, without whom this programme would have not been possible.