Diversity & Equality in Health and Care Open Access

Keywords

Scoping Review; Widening Participation; Black, Asian and Minority Ethnic Groups; Male Nurses

List of Abbreviations

National Health Service - (NHS)

Black, Asian and minority ethnic - (BAME)

Health Education England - (HEE)

United Kingdom - (UK)

Migration Advisory Committee - (MAC)

Shortage Occupation List - (SOL)

Black and Minority Ethnic - (BME)

Population, Intervention, Comparison, and Outcomes - (PICO)

Introduction

Nursing faces a global crisis. There is a significant shortage of qualified nurses [1,2] which has been variously explained as being due to an ageing population and increasing demand [3] alongside a decreasing supply of nurses including the underrepresentation of specific groups such as men in the nursing workforce.

In England only 11% of the nursing workforce is made up of men. The underrepresentation of men in the nursing workforce is not specific to England and data from other countries shows a similar picture. The available evidence shows that different countries have historically reported varying proportions of male nurses within their respective workforces. There is no contemporary evidence showing international improvements in the number of men in nursing. However some comparisons can be made with Turkey having no male nurses until 2007 [6]; A 2016 study reported on Denmark having 3.5%; Canada 6%; Israel 16.5% and Italy with 20% [7]. The United States of America (USA) is reported to have 9.6% registered male nurses [8]; and the National Health Service (NHS) (which is the largest employer of nurses in England) put the male contingent of the NHS nursing workforce at 11% in 2018 [9]. This figure is low and does not reflect the overall representation of males and females in England and the United Kingdom (UK) as a whole [10].

A closer look at the ethnicity of the NHS workforce highlights that, like the USA, Black and Asian minority ethnic (BAME) men are underrepresented in nursing [11-14]. In other words gender and ethnicity intersect when considering the underrepresentation of BAME men in nursing. Increasing the diversity of the nursing workforce is currently a priority in the UK because evidence shows that increasing workforce diversity in organisations contributes towards cultural competency [15] leading to increased quality of care for patients, better adherence to treatment advice/regimes and improved health outcomes [16] and subsequently, more efficient cost management [17,18].

Recognising the merits of diversifying the workforce, Health Education England (HEE) [32] launched a national framework ‘Widening Participation-it matters!’, in order to help the NHS better represent the cultural needs of the community it serves. Furthermore this strategy acknowledged that diversifying the workforce can have additional benefits such as enabling social mobility by engaging underrepresented groups in higher education and the nursing workforce. However, at present, it is unclear what recruitment strategies or initiatives may be in operation to increase the number of BAME men in nursing education, to meet the future workforce needs of the UK, which has residents from diverse ethnicities; which includes heterogeneric language and cultural needs [10].

The lack of male BAME NHS nurses

Male underrepresentation in nursing is not specific to the UK. There is an extensive international literature highlighting how cultural notions of masculinity, femininity, and sexuality may influence men’s professional career choices in relation to nursing [19-21]. Zamanzadeh et al., [42] in their study on factors influencing men entering the nursing profession concluded that societal stereotypes, feminisation of the nursing profession and in-service prejudice has contributed to lower numbers of men entering nursing careers. Similarly Rajacich et al. [20] quote several Canadian-based studies reporting that male nurses identified sexual stereotypes, lack of recruitment strategies, nursing as a female-oriented profession, and a lack of male role models in the media as the most commonly perceived deterrent to entering the profession.

Alongside the longstanding need to recruit more male nurses, the public debate on racism and the inequality of opportunity within the NHS has been well documented [22-24]. There is a recognised need to challenge unequal service provision, and eliminate inequality of opportunity for the potential public sector workforce, which remains at the heart of the relevant legislation such as the Equality Act 2010 and its previous constituent parts such as the Race Relations Amendment Act 2001.

As well as legislative requirements around providers having to have equality policies in place, the government has in the past devised national initiatives to widen participation for underrepresented groups, specifically in Higher Education [25]. This concept of widening participation is not unique to the UK, as in Australia the term ‘equity’ is more commonly used, yet the principle behind these concepts is fundamentally the same; that being to increase the opportunities for traditionally underrepresented groups to access and benefit from Higher Education [26]. In ‘Widening Participation-it matters! Our Strategy and Initial Action Plan’ (HEE, [32]), HEE do not commit to an agreed overarching definition of precisely what ‘widening participation’ means. However, they do acknowledge that the current understanding of widening participation includes “targeting the increase in education and employment opportunities, especially for under-represented groups, such that representation in education and the workforce is representative of the broader population” (page 7) Focusing on interventions that help introduce more diversity to the workforce may aid the development of a more culturally competent service and more transcultural care.

The NHS is still one of the largest employers of people belonging to an ethnic minority in the UK [27]. Furthermore, nurses represent the largest single occupational group within the NHS. The first major study of nursing employment in the UK found that those from BAME backgrounds reported racism and prejudice. Black and Minority Ethnic (The term BAME is used as opposed to Black and minority ethnic (BME) as it signifies the differences within minority ethnic communities, specifically differentiating between a homogenous political ‘Black’ and Asian group [14,43]) nursing staff not only routinely faced racism from patients but also felt that they could not progress within their careers due to prejudicial attitudes amongst white NHS managers and staff. BAME staff were poorly represented in senior roles within nursing according to the report, a trend which has continued [28]. The NHS workforce statistics consistently show not just a male underrepresentation in nursing, but also an underrepresentation of men from certain ethnic groups. For example, analysis of national census and workforce statistics has shown that British South Asian men make up close to 3% of the overall population, yet account for only 0.5% of the overall NHS nursing workforce. Therefore it would appear that despite legislation and policy initiatives underrepresentation and inequality of opportunity still exist for some groups (including BAME men) in the NHS and its nursing workforce.

To the best of our knowledge this is the first scoping review identifying specific interventions for BAME men in the NHS nursing workforce in the UK. Although there is increasing evidence highlighting that diversifying the NHS workforce leads to a range of benefits there is a dearth of evidence synthesising current interventions for BAME men in the nursing workforce. The findings from this scoping review will inform nursing educators, service commissioners and support providers to identify specific interventions to widen participation for BAME men into the nursing profession. Put simply, in order to know how to address the underrepresentation of BAME men in the nursing workforce, we need to know what has been done to widen participation for this underrepresented group. This learning is essential for policy makers, commissioners of interventions and nurse recruitment and those committed todiversifying the nursing workforce, especially those who are targeting minority ethnic groups and men.

Review

Aim

The aim of this scoping review was to identify specific interventions to widen participation for BAME men into the nursing profession in the UK.

Design

This review uses scoping methods. Arksey and O’Malley [29] highlighted the lack of research on conducting scoping studies but then went on to use systematic reviews as a counterpoint to reference the relative advantages and disadvantages of different types of scoping studies. They identified that different scoping studies will need to focus more on either the breadth of results, or the depth of results as an outcome of the study. It became clear from the outset that this scoping review would need to focus on the breadth of relevant results. As following an initial search of the literature, it became evident that there was a deficit of empirically evaluated interventions addressing widening participation for BAME men to inform policy in this area. Consequently, the methodologies for the final included studies were expected to be heterogeneous, and it was anticipated that the final output of the review would be small. Therefore satisfying the criteria for using a scoping review [29,30].

Search methods

Because of the nature of the subject matter and heterogeneous intervention approaches creating difficulties in standard comparison, construction of the search string used Boolean operators to combine search terms. Consequently a keyword strategy was used (Table 2) categorising search terms by a) population; b) profession; c) intention of intervention and d) region. The population search term categories included words which identified the targeted population by labels such as their ethnic group and gender. The profession search term category included words relating to the targeted profession, that being nursing. The intention search term category contained words describing the intention of the intervention such as recruitment, diversification and widening participation. The final search term category was for the region, which included words relating to the geographic scope of the review which was the UK.

Table 1: Introduction for the study.

Table 2: Keyword search string listed by component search term category.

After an iterative process involving the research team and the expansion and reduction of the number of words within each search term category, the search string listed in Table 2 was agreed upon as most appropriate. Following agreement on the search string, a systematic identification of relevant databases was carried out using the University of Bedfordshire Library Services website, listed by Health related databases, subject related databases and suggested general databases https://lrweb. beds.ac.uk/health/Databases. The final list of databases searched is set out in Table 3. In addition a wider article search and grey literature search was conducted utilising Google, Google Scholar, reviewing reference lists of relevant articles and visiting national widening participation and nursing websites [31] .

Table 3: Individual databases searched with search tool and initial result.

The inclusion criteria applied was; Interventions specifically targeted at BAME men; interventions carried out in the UK; papers written in the English language; papers published from the year 2000 onwards and grey literature including reports and theses.

The exclusion criteria applied was: Interventions not specifically targeted at BAME men; interventions not carried out in the UK; papers in languages other than English; papers published pre-2000 and papers that were a review of the literature. Initial screening of the first identified papers checked the suitability of the identified papers, before a more detailed review of the content of the paper using a predetermined strategy (Figure 1).This strategy included an iterative process of consulting on search results between the research team, to identify studies of interest and worthy of further exploration. This iterative process was carried out by IQ in consultation with RG, with further checking and agreement on suitable studies for further exploration by NA and GR.

Figure 1: Study selection flow diagram.

After identification of the initial studies, duplicates were manually removed. This was followed by an initial screening of identified papers by title and abstract, following the inclusion and exclusion criteria. This resulted in the removal of further papers. In addition, manual searches identified further items of potentially relevant grey literature [32-34] and one agency was contacted for details of service evaluations (see discussion section). Following the identification of potentially relevant papers and further potential items of grey literature, a more detailed extraction of information pertaining to each paper/item was sought. Incorporating established data extraction methods (i.e. Cochrane data extraction template) a more refined data extraction record was developed to include the information pertaining to the current scoping review research questions. Therefore, providing a comprehensive extraction record of information [35]. Furthermore, it was considered that a data extraction of this kind could help assist in completing an intervention mapping process when undertaking the synthesis of data/findings attempting to allow heterogeneous interventions to be evaluated more clearly [29,36]. The full data extraction template was based on Cochrane data extraction [37]. Two reviewers (IQ and RG) reviewed the identified papers according to the inclusion/exclusion criteria and agreed that no studies fully met the inclusion criteria. However a summary data extraction exercise was carried out on the items of interest following the iterative approach in scoping review methods [29]. A summary table drawn from the data abstraction exercise is shown as Table 4 for information.

Table 4: Summary table of data extraction.

Results

No studies were identified as adhering to the inclusion criteria. However, five items (including two studies and three items of grey literature) were identified as of interest and worthy of further exploration.

The initial search yielded 1919 studies, 4 duplicates were manually removed. Applying the inclusion and exclusion criteria resulted in the removal of 1913 papers, many of which were not workforce, widening participation intervention focused-rather papers focussing on improving health care access, efficacy and experience for ethnic minority groups. A smaller set of papers considered some aspect of widening participation but did not concentrate on the population of interest and many of those considered interventions carried out outside of the UK. This process resulted in the identification of two potentially relevant papers [38,39] but no specific papers adhering to the inclusion/ exclusion criteria. In addition, manual searches identified a further three items of potentially relevant grey literature [32-34] and one agency was contacted for details of service evaluations (see discussion section). However, again the grey literature search yielded no specific paper adhering to the inclusion/exclusion criteria.

Discussion

Treating all underrepresented groups as one The aim of this scoping review was to identify specific interventions to widen participation for BAME men into the nursing profession in the UK.

This scoping review did not identify any specific interventions aimed at increasing the number of BAME men in the nursing workforce. However, the five studies which were identified, were more broadly directed at underrepresented groups who do not traditionally join the nursing profession (e.g. younger people; people with disabilities and men). Following extraction of the data within these five studies, it was determined that underrepresented groups in nursing (or other health professions) are likely to be grouped together/categorised together thus homogenising characteristics that may provide explanations for their underrepresentation within the healthcare workforce. Categorising underrepresented groups in this way conceal the nuances that contribute to the barriers (and facilitators) which prevent these underrepresented groups accessing student nurse courses are diverse and specific to the needs of specific groups of underrepresented people such as older students [40], disabled students [41] and others such as male nursing students [42].

There was some interesting material found in the grey literature. However, this was of limited value because while it documented some interventions to help widen participation it did not specifically target BAME men and not limited to nursing. A good example of such grey material can be found in HEE’s comprehensive ‘Widening Participation Directory; A Directory of Best Practice’ [32]. The directory is a compilation of examples received in response to a call for best practice which resulted in over 80 submissions. The interventions cover the range of widening participation initiatives that various organisations had engaged in across healthcare professions, and are therefore not specifically limited to nursing interventions. The directory is set out under the themes of: Health Careers Advice and Information and Guidance; Pre-employment Programmes; Apprentices; Bands 1-4 Workforce Development; Foundation Degree Development; Career Pathway Development; Access to Professions.

Lack of rigour in evaluating interventions

Particular references to nursing related interventions can be found under various themes. Examples include: a scheme of work experience placements (including nursing) put in place by North Bristol NHS Trust; a specialist recruitment panel and exercise for Adult Mental Health Nursing degree applicants at the University of Lincoln and various transition modules/foundation degrees facilitating pathways for healthcare assistants and others to access higher education with a view to completing pre-registration degrees at a number of universities across the country.

One of the interventions listed did state a rise in BAME nursing students as an outcome (although the rise was stated as BAME and not specifically male BAME). This intervention included a range of taster days and recruitment events by the outreach and access team at Anglia Ruskin University. The university did respond to further enquiries and confirmed that they felt several factors had led to the increase of BAME nursing students including the work of the outreach team, the changing demographic of the catchment and their use of BAME nursing students as role models for any potential new students.

As useful and interesting as this example of documenting widening interventions is, it did not fit to the inclusion criteria for the scoping review. It did not state specifically who was being targeted (BAME men were never the only targeted group). Examples also often did not identify predefined measurable outcomes and hardly ever stated how, if ever, the intervention was evaluated (although, there was a notable exception to this in an example from St Georges University carrying out a ten year evaluation of its summer school intervention). Overall however, this is understandable as the directory was not devised as an academic exercise intended on adding to an empirical evidence base, rather it was to be a practical summary document for practitioners to use as a reference point to then follow up examples with other practitioners.

Study strengths and limitations

Due to the dearth of relevant papers, this was a scoping review, whereas a systemic review of a larger evidence base may have been more comprehensive. Furthermore, whilst the focus on identifying interventions for BAME men into nursing helped focus the review, this specificity may have led to overlooking interventions aimed more generally at underrepresented groups. The further consideration of the five items of interest identified during the review is an attempt at countering this limitation.

Conclusion

BAME men are underrepresented in the NHS nursing workforce. This scoping review did not identify any specific interventions aimed at increasing the number of BAME men into NHS nursing careers in England. Therefore it was not possible to record any outcomes or map emerging themes and narratives. However, the review did identify five studies that addressed broader research into interventions aimed at widening participation into healthcare professions, including underrepresented groups, such as BAME groups. According to HEE populations included in underrepresented groups are likely to be disengaged young people, those without qualification, low-skilled, part-time and temporary workers, those on low incomes and/or working age benefits, older adults, those with literacy, numeracy or learning difficulties and some minority ethnic groups (HEE, [32]). Importantly, this scoping review identifies that these underrepresented groups are commonly considered as a homogenous group (i.e. underrepresented group) and therefore specific interventions aimed at individual underrepresented groups (i.e. BAME men) are not considered separately. In addition the interventions identified had not reported the evaluation of the interventions.

The lack of a nuanced approach to address the underrepresentation may offer some explanation for current shortages of BAME men in the NHS nursing workforce in the UK. Interventions aimed at widening participation are therefore too generic to consider the specific needs of individual underrepresented groups such as BAME men. These interventions lack the specificity required to target and successfully recruit BAME men into the nursing profession.

The authors suggest that specific interventions aimed at widening participation for BAME men into the nursing profession should be considered and implemented. All interventions should be appropriately evaluated to provide tangible evidence of their effectiveness in contributing to widening participation for BAME men into nursing. Specific details and evaluations of interventions should be reported to support recruitment departments of NHS Trusts to harness this hitherto underutilised resource.

These future interventions should be appropriately recorded and evaluated, so that policy makers, nursing educators, nurse recruiters, commissioners and providers can build on evidence based practice. Specifically, policy makers and those commissioning interventions around workforce diversity should incorporate empirical evaluation as part of their thinking when executing their commissioning processes around widening participation.

Declarations

Ethics approval and consent to participate - Not applicable.

Consent for publication - Not applicable.

Availability of data and material - Data used in this paper can be found at https://digital.nhs.uk/.

Competing interests - The authors declare that they have no competing interests.

Funding - This research is part of a bursary sponsored PhD study, funded by the University of Bedfordshire, England, United Kingdom.

Authors' contributions - IQ and RG carried out initial screening of potential papers for the scoping review. IQ carried out subsequent data extraction. All authors read and approved the manuscript.

Acknowledgements - The authors would like to acknowledge the support of Janine Bhandol and David Abdy, Academic Liaison Librarians, University of Bedfordshire, England, United Kingdom.

References

1. Buchan J, Calman L (2005) The global shortage of registered nurses: an overview of issues and actions. Geneva, International Council of Nurses.
2. Buchan J, Aiken L (2008) Solving nursing shortages : a common priority. J Clin Nurs 17: 3262-3268.
3. Oulton JA (2005) The Global Nursing Shortage: An Overview of Issues and Actions. Policy Polit Nurs Pract 7: 34-39.
4. O’Connor T (2015) Men Choosing Nursing: Negotiating a Masculine Identity in a Feminine World. J Mens Stud 23: 194-211.
5. O’Lynn C, Tranbarger R (2007) Men in Nursing; History, Challenges and Opportunities. Springer International Publishing, New York.
6. Mehtap O (2017) Sex Discrimination at Nursing in Turkey : To be a Male. COJ Nurse Healthcare 1: 51-52.
7. Achora S (2016) Conflicting image: Experience of male nurses in a Uganda’s hospital. Int J Africa Nurs Sci 5: 24-28.
8. Landivar LC (2013) Men in Nursing Occupations: American Community Survey Highlight Report. US Census Bur 1: 1-7.
9. Nursing and Midwifery Council (2018) Annual equality, diversity and inclusion report.
10. Office for National Statistics (2012) Ethnicity and National Identity in England and Wales. 1: 1-15.
11. Sullivan, Louis W (2004) Missing Persons: Minorities in the health professions; A Report of the Sullivan Commission on Diversity in the Healthcare Workforce.
12. Dorsey MT (2005) Nursing Education Administrators’ Perceptions of the Recruitment and Retention of African American Male Nursing Students. Electronic Theses and Dissertations: 209.
13. Wingfield AH (2009) Racializing the glass escalator: Reconsidering men’s experiences with women’s work. Gend Soc 23: 5-26.
14. Naqvi H, Razaq J, Piper SA (2017) NHS Workforce Race Equality Standard.
15. Vydelingum V (2006) Nurses’ experiences of caring for South Asian minority ethnic patients in a general hospital in England. Nurs Inq 13: 23-32.
16. Kline R (2014) Snowy White Peaks. Middlesex Res Repos 1: 1-76.
17. O’Neill R (2016) The importance of a diverse and culturally competent workforce. Busi Date 24: 9-13.
18. Hunt V, Dennis L, Sara P (2015) Diversity Matters.
19. Stanley D, Beament T, Falconer D, Haigh M, Saunders R, et al. (2016) The male of the species: A profile of men in nursing. J Adv Nurs 72: 1155-1168.
20. Rajacich D, Kane D, Williston C, Cameron S (2013) If They Do Call You a Nurse, It Is Always a “Male Nurse”: Experiences of Men in the Nursing Profession. Nurs Forum 48: 71-80.
21. Shevlin M, Kenny M, Mcneela E (2004) Participation in higher education for students with disabilities: an Irish perspective. Disabil Soc 19: 15-30.
22. Iganski P, Mason D, Humphreys A, Watkins M (2001) Equal Opportunities and Positive Action in the British National Health Service: Some Lessons from the Recruitment of Minority Ethnic Groups to Nursing and Midwifery. Ethn Racial Stud 24: 294-317.
23. Chambers C, Alexis O (2004) Creating an inclusive environment for black and minority ethnic nurses. Br J Nurs 13: 1355-1358.
24. Mistry M, Latoo J (2009) Uncovering the face of racism in the workplace. Br J Med Pract 2: 20-24.
25. Young K (2016) Working towards widening participation in nurse education. Br J Nurs 25: 112-116.
26. Heaslip V, Board M, Duckworth V, Thomas L (2017) Widening participation in nurse education: An integrative literature review. Nurse Educ Today 59: 66-74.
27. Roger K, Habib N, Saba Abid R, Wilhelm R (2016) Workforce Race Equality Standard Report: 2016 Data Analysis Report for NHS Trusts.
28. Trueland J (2012) Unequal Opportunities. Nurs Stand 81: 247-262.
29. Arksey H, O’Malley L (2005) Scoping studies: towards a methodological framework. Int J Soc Res Methodol 8: 19-32.
30. Levac D, Colquhoun H, O’Brien KK (2010) Scoping studies: Advancing the methodology. Implement Sci 5: 69.
31. Pham MT, Rajić A, Greig JD, Sargeant JM, Papadopoulos A, et al. (2014) A scoping review of scoping reviews: Advancing the approach and enhancing the consistency. Res Synth Methods 5: 371-385.
32. Health Education England (2014) Widening Participation Directory of Best Practice.
33. Bateson J, Richard G, Mary S, David H, Susan P (2016) Different people, different views, different ideas: Widening participation in nursing and radiography degrees. Inst Vocat Learn Work Res Bucks New Univ.
34. Kaehne A, Maden M, Thomas L, Brown J, Roe B (2014) Literature Review on Approaches and Impact of Interventions to Facilitate Widening Participation in Healthcare Programmes. Higher Education England.
35. Henderson L, Craig J, Willis N (2010) How to write a Cochrane systematic review. J Nephrology 15: 617-624.
36. Abraham C, Michie S (2008) A Taxonomy of Behaviour Change Techniques Used in Interventions. Heal Psychol 27: 379-387.
37. Handbook C (2011) The Cochrane Public Health Group Data Extraction and Assessment Template.
38. Rhodes S, Bouic L (2007) Summer schools to improve recruitment and retention of pre-registration mental health student nurses. Ment Heal Pract 10: 34-38.
39. Watson R, Norman IJ, Draper J, Jowett S, Wilson-Barnett J, et al. (2005) NHS cadet schemes: do they widen access to professional healthcare education?. J Adv Nurs 49: 276-282.
40. Reay D, Ball S, David M (2002) It’s taking me a long time but I’ll get there in the end: Mature students on access courses and Higher Education choice. Br Educ Res J 28: 5-19.
41. Shevlin M, Kenny M, Mcneela E (2004) Participation in higher education for students with disabilities: an Irish perspective. Disabil Soc 19: 15-30.
42. Zamanzadeh V, Valizadeh L, Negarandeh R, Monadi M, Azadi A (2013) Factors influencing men entering the nursing profession, and understanding the challenges faced by them: Iranian and developed countries’ perspectives. Nurs midwifery Stud 2: 49-56.
43. Modood T, Meer N (2009) Migration, identity and citizenship; Approches for addressing cultural diversity in 21st century Britain.