Migration motives and integration of international human resources of health in the United Kingdom: systematic review and meta-synthesis of qualitative studies using framework analysis

International migration of human resources for health (HRH) affects individuals themselves and has an impact on both the source and destination countries’ health systems by affecting service provision, health policies [1, 2], workforce planning [3], training and education [4], and the social and economic development of these countries. It is one of the underlying reasons behind the global HRH crisis resulting in global health inequalities [1]. The World Health Organization (WHO), the Health Worker Migration Policy Initiative (HWMPI) and the Global Health Workforce Alliance (GHWA) developed a Global Code of Practice on recruitment of international health personnel, which was adopted by 193 member states in May 2010 [2]. The implementation of the code has remained partially successful both globally and in the United Kingdom [3]. The UK’s historic reliance on international HRH has created established organisational, cultural, professional and social networks that facilitate migration, thereby decreasing the UK’s ability to act on the WHO’s Global strategy on HRH to half the reliance on foreign workforce by 2030. This is despite policies for increasing domestic workforce and better use of skill mix [4]. Therefore, HRH mobility is of high relevance to the UK, whilst it is actively developing policy and regulatory interventions to reduce its reliance on an external workforce [5].

In sharp contrast, NHS England’s (2016) workforce planning, along with other measures, aims to recruit 500 international doctors through an international recruitment campaign to meet the targets of extra 5 000 doctors by 2020 [6]. The National Health Service (NHS) employs more than 1.7 million people across England, Scotland, Wales and Northern Ireland [7]. Data for new registrants to the UK showed that the percentage of internationally trained nurses increased from 11% (n = 2, 121) in 1993 to 53% (n = 16, 155) in 2001/2002 and decreased to 30% (n = 8, 785) in 2016 [8, 9]. International doctors increased from 37% in 1990 to 71% (n = 11, 106) of new registrants in early 2003 and subsequently decreased to 41% (n = 5, 263) in 2016 [7, 10]. Similarly, the proportion of international dentists has increased from 38% (n = 524) in 2001 to 66% (n = 1, 481) in 2005 and then decreased to 35% (n = 795) in 2016 [61]. Retention of these health professionals is important; however, since the UK’s vote on the EU referendum, trends suggest more EU nationals are leaving the NHS [9]. This is compounded by the increase in the ageing domestic workforce leaving the profession, decreased job satisfaction due to decreased staffing, pay freeze, emigration and migration of the workforce into the private sector [11]. The UK’s exit strategy from the European Union ‘Brexit’ may impact further on the retention of European HRH.

The aim of this systematic review was to examine the migration motives, barriers to and facilitators of integration of international nurses, doctors and dentists to the UK, to inform policies on international recruitment, retention of workforce and identify future workforce planning research gaps. Along with retention of this international workforce in the NHS, their integration, training and support are required to maintain patient safety. Understanding barriers to and facilitators of integration for this mobile workforce will help to inform future research into suitable adaption processes.

The number of papers screened, assessed for eligibility and included in the review, together with details of exclusions, is presented in the PRISMA flow diagram (Fig. 1). There were no studies published on the migration motives of dentists to the UK and just one study on a pre-registration training programme relevant to the integration themes [17].

A summary of the study methods, type of participants, methodological approach, sample sizes, sampling process, study settings and the country of primary qualification in the 31 papers selected for this review is presented in Table 3. Reporting qualitative systematic review using PRISMA guidelines showed that some items on the reporting checklist were applicable to quantitative studies and using qualitative reporting tools [18, 19] would have been an alternative approach.

This systematic review highlights the complexity and the differences in health professionals’ motivation to migrate to the UK and their integration [7, 11, 16, 20, 43, 48]. Whilst migrants describe their motivations as mainly driven by micro and meso factors, there are strong established macro factors including active recruitment and bilateral agreements between countries, which facilitates migration.

A key meso driver for HRH migrating to the UK was post graduate training opportunities. For doctors, gaining post graduate qualification was more important than nurses, as this would improve their career progression both in the UK and in the source country should they return. Doctors reportedly earned well in comparison to the rest of source country population and therefore financial gain, although important, was not the main micro driver for migration as compared to the nurses.

Integration studies using cultural frameworks of Pilette’s theory of adjustment (1989) [29], and socio-cultural theories describing phases of acquaintances, indignation, conflict resolution, and acculturation [53], are useful to understand how individuals react when they enter new cultures. Integration experiences of individuals are dependent on the process of learning, developing social and professional identity, understanding the local work place cultures, cross-cultural awareness [38] and improved interpersonal communications. Illing [33] and Hofstede’s model (2001), explains the different distances individuals have to move to make the transition from their training culture to the new work place culture and hence the variations in the adaptation experiences of the doctors and nurses are based on their source country training and personal attributes. Similar to a review conducted in Australia, most international professionals seemed to struggle during the transition from training to work and found it difficult to integrate when they did not have access to adaptation programmes, thus, stressing the importance of investment in such programmes to improve retention and patient safety [54].

The nurses in the UK reported multi-level discrimination, whilst doctors reported less individual and more institutional discrimination resulting in career stagnation. This may be as a result of nurses being in direct contact with patients for longer periods of time and the struggle to control the work environment in hospitals with established hierarchy based on race and gender, whilst doctors had more control on their work environment [27]. Migrant nurses were more likely to set up informal professional and social networks during the transition period, to deal positively with discrimination [46, 52] and get social support, as many lived in the UK without their families, due to immigration restrictions. During integration, whilst there were obstacles in terms of verbal and non-verbal skills, international doctors and dentists felt no knowledge gaps compared to the nurses [17, 30, 52]. That may be explained by the fact that all non-EU doctors and dentists have to take the registration examinations set by the respective registering bodies, which tests their knowledge rigorously. A similar competency test was introduced for nurses in 2014, which may have improved the knowledge gap. Further research is needed into the role of global interconnectedness, social media and virtual networks in the context of HRH migration and integration. More research needs to be done on the effect of migration on migrant nurses and dentists performance, as doctors’ performance was linked to their move to the UK and their experiences of social and cultural isolation, disorientation, financial hardship, language difficulties and their ability to understand multi-disciplinary team working [33], illustrating the need for comparative studies.

It is important that organisations involved in the registration and employment of international HRH, have fair systems in place to recognise HRH international education and training to improve their integration [33, 55]. Retention can be improved through enhancing integration by providing training in equality and diversity [47]. If bespoke support programmes are not put in place to improve integration, dissatisfaction with the system, deskilling, economic and political uncertainties (Brexit) could lead to onward migration of HRH to other English speaking destination countries or repatriation. Emigration of UK-trained doctors and nurses and ageing domestic workforce could further reduce the overall health care workforce in the UK, making international recruitment unsustainable, similar to the situation in South Africa and Republic of Ireland [56].

There have been systematic reviews of international HRH in OECD countries, Australia, Canada and USA but none have focused on qualitative outcomes involving the nurses, doctors and the dentists working in the UK, using formal review criteria for this timeframe. Meta-synthesis of qualitative data using framework synthesis can identify the common recurring themes in a broad context and therefore help policy decisions. This review is limited by the lack of literature on the dental workforce and draws on limited publications in the medical and nursing literature in the UK. It highlights lack of publications, which may be due to publication bias towards workforce research and qualitative research or a lack of research in this area.

Systematic reviews on migration of HRH, in the literature, have focused on trends in workforce migration [57], but not compared the motives across health care professionals. Integration studies have focused on qualitative thematic analyses of lived experiences, particularly in relation to nurses [54, 58, 59] and on doctors [60], but none on dentists. This review is a starting point examining the drivers of migration and integration experiences of the three professions of nursing, medicine and dentistry, which are different in relation to the professional’s control of their work environment, their professional and social identities [17, 20, 27, 28, 36, 38, 59]. Understanding the similarities or variations of migration motives amongst these groups can help in developing bespoke policies for retention, improving job satisfaction and performance, all of which are important to any health system that wants to maximise its HRH potential.

This review is considered timely as the UK prepares to leave the EU, with implications on recruitment of EU health professionals, whilst the NHS is still reliant on international professionals to meet the workforce deficit. There is a lack of qualitative literature on international doctors’ and dentists’ migration and integration compared with nurses, despite their contributions to the UK workforce. Active recruitment, post graduate training and financial gain act as strong common macro, meso and micro drivers that perpetuates migration into the UK, but the extent to which each of these drivers influence nurses and doctors migration is different.

Integration experiences for international nurses and doctors differed as nurses reported a wider knowledge and skills gap, more multi-level discrimination and less career progression compared with doctors. A better understanding of the migration motives and integration experiences of different health care professions will help form policies that are bespoke and therefore more effective in recruitment and retention, which in turn will help reduce UK’s reliance on international workforce. Understanding the barriers to and facilitators of integration for each of these professions is also important for migrants, employers and policy makers to develop a personalised health care system that can meet the sustainable development goals of the WHO Global workforce strategy. Further research into the dental workforce is clearly required.