The 'structural empowerment' and 'speaking up' against unsafe practice, among overseas trained nurses working in NHS hospitals

Background: The United Kingdom recruits overseas trained nurses from several countries to deal with the shortages in National Health services (NHS). These nurses face several challenges in a new health care system. The organisations that employ overseas trained nurses play crucial role in ensuring patient safety culture. Aim: To explore the perceived levels of ‘structural empowerment’ and ‘speaking up’ among overseas trained nurses working in NHS hospitals in the United Kingdom. Methods: A sequential explanatory mixed-method study was applied to achieve the aim and objectives of the research study. The Phase one (quantitative) involved questionnaire completion by 144 overseas trained nurses. Non-probability, convenience sampling was used. Snowball technique was employed to recruit staffs from all shifts. The questionnaire included validated tools comprising CWEQ 2 with five-point Semantic differential scale, hypothetical speaking up scenarios with five-point Likert scale, open-ended questions on role of education and training and demographic profile section. The Phase two (qualitative) involved semi-structured interview of 21 study participants who also participated in phase one. Thematic analysis by Braun and Clarke (2006) was used to analyse interview data. Therefore, first quantitative, then followed by qualitative method was used in this study. The theoretical framework applied to this research is based on Kanter’s theory (1977;1993) and existing theories on assertiveness. Findings: Overseas trained nurses perceived very low levels of access to resources compared to, low to moderate levels of access to support, information and opportunity. Levels of access to information, opportunity and informal power affected speaking up. Perceived levels of access to informal power was better than formal power. The participants reported high levels of willingness to speaking up. Type of ward, country of origin, age and length of experience influenced speaking up. The qualitative findings showed that lack of support and trust from ward managers, blame culture in workplaces, staffing shortages, communication challenges, professional practice differences, fear and anxiety related to speaking up and lack of cultural awareness in workplace influenced the willingness of the overseas trained nurses’ speaking up. The interview participants emphasised that they benefitted from inclusion of practical scenarios and use of trainers of overseas origin in trust induction and training. Conclusion: The findings support Kanter’s theory. This research study offers valuable contribution to understanding of overseas trained nurses’ levels of access to empowering structures and willingness to speaking up, and the factors that act as barriers to doing so in the work environment. The findings provide cultural context to existing understanding of structural empowerment and speaking up, which is an unique contribution. Implications: Improving access to workplace empowerment structures enhances overseas trained nurses’ speaking up, therefore patient safety culture and positive patient outcomes. Particularly, low level of access to resources required to do the job effectively affects safe nursing practice. Organisations and its leaders should consider the impact of cultural differences on speaking up and empowerment, and improve formal and informal systems within work environments that contribute to overseas trained nurses’ empowerment. Investing in relevant robust support systems and policies provide empowered work environments that enhance the overseas trained nurses’ levels of willingness to speak up against unsafe practice.