A qualitative study of nurse participation in global health in the English NHS: participation, interest, and barriers to participation

Abstract

Background

Nurses contribute to the largest demographic of the healthcare workforce. However, given current global shortages of workforce capacity, this often leads to limited capacity to engage in extracurricular educational developments beyond their immediate role. Consequently, this significantly limits the range of workforce training and development opportunities that are available to them, which could enhance the variety of skills that are brought to the National Health Service (NHS).

Objective

We aimed to understand prior, current, and future participation in global health activities such as global health conferences, networks, and placements, among National Health Service (NHS) staff. Furthermore, we investigated the barriers and facilitators to participation in global health activities for nurses in our sample.

Method

Qualitative and quantitative data was gathered from an online survey conducted in England from July to November 2021. Thematic analysis was used to examine the qualitative data collected from one open-ended question, whereas statistical analysis was used to examine the remaining quantitative data.

Results

Most (84%) nurses in our sample had not participated in a global health activity. Our results highlighted three barriers to participation, including insufficient communication, a lack of awareness, and capacity issues.

Conclusion

This study showed that, despite low levels of prior participation, there is a strong desire among surveyed nurses to be involved in global health activities and education. Our findings also suggest that enhanced communication of opportunities available is needed, in addition to organisational support which incorporates strategies to overcome capacity constraints.

Background

Global health is identified as a field of study, research, and practice [1] highlighting the need for equity in health systems globally. Ensuring such equity allows inclusive and diverse perspectives and experiences to be included in the education provided to healthcare professionals, particularly nurses, better preparing nurses to address the varied healthcare needs of different populations. Over recent decades, global health has increasingly recognised as relevant to local and regional health systems which has prompted the development of global health education and training, predominantly in high-income countries [2,3,4]. In the United Kingdom, inclusion of voluntary global health curricula in university courses and individual volunteering programmes have been in existence for many decades [2]. Over the past decade, engagement in global health among UK health professionals and students has grown, with almost all medical schools now offering elective global health modules [3] and many National Health Service (NHS) organisations now supporting participation in global health activities among staff [4]. Global health activities are activities such as global health conferences, networks, and placements which provide healthcare staff and students with opportunities to enhance their learning and skills of improving health on a global scale. Such opportunities enable learning opportunities that enhance clinical and non-clinical skills among health professionals with reported benefits including leadership development [5,6,7,8], intercultural communication [9] and cultural competence [10, 11], and exposure to a disparate health system [12]. At a system level, global health engagement has also been argued to enhance the productivity of health workers [13].

However, global health has historically attracted particular groups of health professionals, most notably medical professionals. Meanwhile, there has been more limited engagement by the nursing and allied health professions. While global health modules are available to medical students in most universities in the United Kingdom, for instance, there remains a scarcity of provision for nurses [14,15,16,−17]. Consistent with this, the only study of participation and interest in global health in the NHS included a survey sample of 400 medical professionals, which showed broad interest in engaging with global health [18]. There is still limited research on global health participation among NHS staff, especially among nursing professionals, and what the barriers and enablers to participation are [19]. The growing interest in global health engagement [7, 20] and importance of global health competencies to the education of nurses worldwide [21] thus requires further research on existing patterns of participation and future interest, as well as how to facilitate global health engagement.

This study aims to contribute to understanding the participation and barriers to participation in global health activities among nurses currently working in the NHS. We will do this by analysing rich quantitative and qualitative data providing data collected from 907 nurses working in the NHS. This article will address the following research questions:

• 1. What is the prior and current global health participation of participating NHS nurses?

• 2. Is there interest to participate in global health activities among participating NHS nurses?

• 3. What are the perceived barriers to participating in global health activities among participating NHS nurses?

The remainder of this article is as follows. First, the methods used in this study are outlined. Next, the results are discussed with three sections focused on prior and current participation, interest in participation, and barriers to participation. Finally, the significance of the results will be considered, which will also include reflections on the study’s limitations and policy relevance. Concluding remarks are then offered.

Methods

Survey design

In partnership with Yorkshire and Humber Academic Health Science Network (AHSN) and Sheffield Hallam University, Health Education England (now NHS England) conducted an online survey of NHS secondary care staff in England. The aim of the survey was to understand interest and engagement in global health, as well as the facilitators and barriers to participation. The survey was comprised of several open and closed questions to generate quantitative and qualitative data on several topic areas (Appendix 1).

The survey was conducted using the Key Survey online survey platform between 29 July – 29 November 2021. The survey could be completed using a computer or a mobile phone. All English NHS secondary care organisations were contacted to facilitate the dissemination of the online survey to staff via internal communication platforms (i.e., intranet). Contact was made with senior leadership or organisational and professional development (OD) staff. However, this approach varied by organisation due to differences organisational structures. The survey was also shared using several media platforms, including the Health Education England and Yorkshire and Humber AHSN social media accounts (Twitter, LinkedIn, Facebook), the Health Service Journal (HSJ) and Nursing Times.

All respondents were incentivised to participate in this research via receipt of a free coffee or cinema voucher. Sample characteristics are displayed in Table 1.

Table 1 Sample Summary

Survey analysis

The approach to analysis differed according to data type. Post-hoc descriptive statistical analysis was conducted on quantitative data on respondents’ prior, current and prospective participation in global health activities. Qualitative data analysis was conducted using Braun and Clarke’s [22, 23] thematic data analysis approach. The data was reviewed several times to aid familiarisation. Repeated familiarisation aided the identification of 10 codes, which after further analysis were subsumed into three themes. Each step of the analysis involved a review element with another member of the research team assessing and discussing the analysis process and themes produced.

Results

Prior and current participation in global health activities

Most nurses (84%, N = 764) indicated they had never taken part in global health activities. The most common reason chosen for not participating in global health is limited knowledge of opportunities (68%, N = 614).

Table 2 Global health activities respondents indicated they had taken part in (n = 37)

Among those who had taken part, the types of activities engaged in are summarised in Table 2. Self-funding was common among this group (46%, N = 17 of previous participants) and the main reasons for participating was for personal development (65%, N = 24) and to develop their knowledge of a new culture (49%, N = 18).

Future interest in global health activities

Over half (56%, n = 512) of respondents stated they are interested in taking part in global health activities in the future. Only 5% (N = 48) stated they were not interested, with the remaining 39% unsure. Survey respondents expressed most interest in participating in global health events (e.g., conferences, lectures, webinars, seminars) (31% of respondents, N = 280), mentoring (27%, N = 246), and overseas health service programmes (24%, N = 216).

Barriers to participation in global health activities

Respondents were also asked what would enable them to participate in global health activities. Responses generated 576 qualitative open text comments, which were arranged into 10 codes and three overarching themes. The three themes were: communication, awareness, and capacity (Table 3). Each theme is elaborated on further below.

Table 3 Thematic analysis summary

Communication

Communication was referenced by a large number (N = 198) of respondents as one of the barriers for participation in global health activities. Respondents indicated that there was a need for more communication of available global health activities so they could engage, as currently communication was labelled as “limited” (Nurse, Northeast and Yorkshire). When communicating global health activities to nurses, respondents emphasised the need for it to be communicated to all professional and demographic groups. Furthermore, some stressed the importance of showing the relevance of opportunities to their roles in communications:

“…for these to be widely advertised to individuals so that this can then be discussed as a learning opportunity but also to see how relevant it would be for the areas that we cover (Nurse, Northeast and Yorkshire).”

Avenues through which opportunities could be communicated were suggested by many respondents. Ideas included sharing opportunities via news bulletins, staff networks, staff intranet, trust communication networks and/or newsletters. Local management were identified as important institutional gatekeepers to facilitate communication of global health opportunities to nurses, especially among less senior staff members. For example, one respondent stated that there needed to be “greater advertisement and support from management to allow engagement in the activities” (Nurse, Northeast and Yorkshire).

Awareness

Relatedly, a lack of awareness of global health activities was cited as another key enabler or disabler to participating in global health activities. Respondents indicated they needed to know what the actual process of engaging in global health activities involved to be able to commit to such opportunities (see Table 3). For example, one respondent explained that “I can easily participate with this one as long that I know what the step-by-step procedures are” (Nurse, Midlands). Moreover, awareness was desired on the practicalities of the opportunity, requisite skills and knowledge, whether support was provided locally (i.e., funding for backfill, ability to return to a permanent role) and how this relates to their career progression:

“More awareness of the opportunity to engage, i.e., on trusts internet, awareness of the progression. Management supporting staff to facilitate engagement (Nurse, East of England).”

By enhancing awareness of global health activities among nurses, it would enable them to make more informed decisions regarding whether to participate or not. However, many respondents highlighted how their limited knowledge of global health functioned as a barrier to getting involved, with “a better understanding of global health” (Nurse, Midlands) felt to be needed to make an informed decision.

Capacity

The third theme identified as a facilitator/barrier to global health activity participation is capacity. This was raised by many as a significant issue generally within the nursing profession as respondents frequently stated the need for “more staffing” (Nurse, Northeast and Yorkshire), “staff backfill” (Nurse, Midlands), and “more time and protected breaks” (Nurse, London). This was articulated in terms of how current workloads already limit their capacity to engage in additional activities and thus any additional education and training would need some form of staff backfill to ensure wards were adequately staffed. For example, one respondent explained:

“For staff who work predominately 8 − 6 with timed clinic appointments… there isn’t usually time to go to do the activities on offer and they aren’t available when we are more likely to be free (Nurse, Midlands).”

Consistent with this sentiment, another referred to the commonly expressed view that activities needed to be designed based on the workforce’s availability:

“Buddying shouldn’t impinge on work time and space. Implementing a quality improvement project would prove very fulfilling, alongside research. Attending seminars at weekends or in the week would be feasible (Nurse, Southwest).”

Buddying programmes are opportunities where NHS healthcare staff or students can work with a partner country or organisation to take part in knowledge or skill exchange, in areas such as research, policy, or learning from healthcare professionals from different health systems.

Furthermore, as well as work-related capacity barriers, some respondents referred to other capacity issues that prevent them from participating in global health activities, such as those with children or on short term contracts:

“I’m not aware of any opportunities. I have issues with childcare when trying to access training (Nurse, Northeast and Yorkshire).”

“If I were on a permanent contract, I would find it easier (Nurse, Midlands).”

These sentiments reiterated the combination of heavy workloads the capacity of nursing staff to engage in additional activities. Any additional training undertaken could further reduce the time nurses have outside of work, which may explain why those with extra commitments may not participate.

Discussion

This study has demonstrated that global health is a desired area of personal and professional development for participating NHS nurses. Our findings show that only 5% (45) of participating nurses indicated a lack of interest in future global health participation. Yet, there are barriers to participation which, if addressed, could facilitate future participation. These are: insufficient communication of opportunities, associated lack of awareness among NHS nursing professionals, and capacity issues. These findings are consistent with existing research on global health engagement in the NHS. Particularly, it lends further support to research conducted by the Tropical Health Education Trust [17], which showed high levels of interest among a sample of NHS doctors. Our research is also consistent with the recent trend seeing developments in opportunities to engage with global health in the English NHS. Prior research studies have examined the competencies and productivity improvements to be obtained through global health education and training [6, 7].

Yet, our findings suggest that the NHS is currently failing to capitalise on these benefits. In a health system with a diverse workforce [22] which delivers services to an increasingly diverse patient population, this would suggest that further work is necessary in this area [22]. Likewise, there are increasing calls for the NHS workforce to enhance its productivity [23]. Our findings would suggest that supporting increasing numbers of nursing professionals to be exposed to global health learning opportunities would contribute to addressing reducing productivity [24,25,26], given that research has shown the productivity gains from global health activity engagement [6, 8]. Therefore, this would suggest that policymakers should ensure that sufficient opportunities to participate in global health activities are available to NHS staff. When doing so, our findings on the facilitators and barriers to participation are instructive. Opportunities must be effectively communicated across the NHS system, with information on what participation entails for the individual and, importantly, what support is available to facilitate participation. Where not already available, this also points to the need to provide funding to cover backfill if participation necessitates time away from NHS clinical practice. This is one way through which capacity barriers to participation can be addressed. Yet, providing diversity in the types of opportunity available – in terms of type of activity, mode of participation, and required time commitment – may enable global health engagement while remaining in one’s current role. Our survey indicates that global health events, mentoring and overseas health programmes are of interest to nurse respondents; the first and second of which can be combined with working in the NHS.

Further research exploring nurses’ experiences who have participated in global health activities soliciting views on increasing access to participation in global health activities would help to elaborate our results. Future research could also contrast any findings related to nurses with those of medical graduates and allied health professionals (AHP) to understand differences between different groups. Lastly, our analysis of gender and ethnic inequalities is limited. Therefore, future research should seek to investigate whether inequities exist across different demographic variables, including but not limited to ethnicity. Lastly, it is important to ensure that the perspectives of partner countries – the NHS’s global partners – in any future global health participation involving NHS staff, especially where this involves working in overseas health systems.

This research has three key limitations. Firstly, survey distribution took place during the coronavirus pandemic which is likely to have impacted on the level of response to the survey, potentially skewing our findings based on those with the capacity to participate. Due to the heightened demands on healthcare professionals during the coronavirus pandemic, there was a reduction in healthcare professionals specifically nurses’ availability and willingness to take part in a survey. Secondly, non-probability sampling was used, limiting the external validity of this study. The research team faced challenges compiling a complete sampling frame for NHS secondary care staff to enable random sampling. Therefore, the sample may be biased to those who were more aware of the organisations conducting the survey or with an interest in global health hence affecting the representativeness and generalisability of the study outcomes. This methodological constraint means that the sample collected may not reflect the wider population of NHS secondary care staff. Thirdly, qualitative data analysed was collected via an online survey, which hindered the ability of the research team to solicit further information on responses provided. The lack of face to face or online interaction for the collection of qualitative data restricted the research team’s ability to probe deeper into any ambiguities or limited answers respondents gave. This limitation may have resulted in a limited understanding of respondents’ perspectives and experiences which could mean valuable insights were unexamined.

Conclusion

Currently, there is limited participation from nurses in the NHS with global health activities. However, nurses stated they want to engage with global health activities if they are presented as short-term commitment options such as seminars or conferences. However, factors such as communication, awareness and capacity are barriers that have prevented NHS nurses from engaging in the full range of global health opportunities and learning that are present in the NHS. In order to encourage and maximise on increasing the participation of nurses in global health activities, it is critical to increase the awareness of the opportunities available to NHS staff with realistic strategic support, both financially and logistically. By directly addressing these barriers, it will help to increase participation and bring considerable benefits to the individual and in turn the NHS health system. As we recognise the relevance of global health to national health systems, and the value of global health competencies to the education and training of nurses, increased opportunities for nursing professionals to engage in global health are needed. Nurses play a critical role in addressing health disparities on the front line and can bring significant insights and skills from global health experiences back to their local practice, improving patient care and outcomes. Furthermore, nurses’ involvement in global health activities promotes cultural competence and leadership skills which are vital for providing effective healthcare in progressively diverse societies.