nhs recruitment: School pupils, especially those from ethnic minorities, have a dated, negative and false view of nursing and other NHS jobs, as do many teachers and careers advisers. It is time to end the confusion, argue Lesley Mackay and Jacinta Elliot

Published: 18/04/2002, Volume II2, No. 5801 Page 30 31

The failure of the NHS workforce to reflect our multi-cultural, multi-ethnic society is a longstanding problem, which government initiatives seem incapable of solving.

It is ironic that while quite a few recruits from ethnic minority groups overseas are entering the NHS - for example nurses from India - it cannot recruit enough people from its own local communities.How can recruitment initiatives ensure that the NHS workforce is more representative of the people it serves?

We investigated the views of 203 young people, aged 14-17 and from a range of ethnic minority groups, in 12 schools in two cities in the north of England.Nine schools were in socially disadvantaged areas. Eighteen young people described themselves as black British, 40 as white, 20 as English (all white), 17 as African-Caribbean, two as Chinese, five as Irish, 61 as Pakistani, 20 as Bangladeshi, and the rest didn't want to be tied down to a description.

We also interviewed 14 teachers responsible for careers advice in the school and 16 people working in the careers advice service in the two cities, as well as 13 personnel and ward managers at three acute trusts in the two cities, and three staff members responsible for diversity and ethnicity issues in the trusts. Just two of the personnel staff, both men, were from ethnic minority groups, and both led on equality and diversity issues within their trusts.

Only 5 per cent of the young people we spoke to were contemplating a career in nursing.Most had rejected a career in healthcare. Some came from deprived households and lived in areas of high unemployment. Just over a quarter had been in hospital as an outpatient or for a short inpatient stay. They had gained largely negative views of nursing from these experiences. They described overworked and harassed nurses doing many menial tasks with high levels of stress. Some boys from south Asian family backgrounds raised concerns about violent attacks on staff, especially in accident and emergency departments and outpatients, which they had witnessed or heard about from family and friends.

Pupils without experience of being in hospital, seemed to base their views on television programmes like Casualty. There were negative comments about low pay and long hours and some mentioned nurses being bossed around by doctors.

When asked to say how much they thought nurses were paid, many underestimated the salaries by up to 50 per cent.When given the facts, pupils generally considered pay rates quite good.

An old-fashioned image of nurses'work prevailed.Most pupils thought you had to be very strong physically and emotionally, extraordinarily kind and patient, and prepared to put up with a great deal of menial work. They recognised that you had to be quite clever to obtain the required entry qualifications, but thought nursing provided little opportunity to use your brain. They had little idea of how the role of the nurse had evolved or how much technical and scientific skill was needed.

Having a nurse in their immediate family also seemed to have put the young people off nursing.

Pupils mentioned the hard work, long hours and the way the shifts 'mess up your life'.

Twelve pupils - around 5 per cent - had done work experience in healthcare.Most had enjoyed it, especially those who had worked in nursing homes.

This group included three boys who had no intention of going into nursing but spoke warmly of their experience in nursing homes. These young people did not associate work in nursing homes with healthcare or nursing work.

Other factors counteract recruitment initiatives targeting schools. The careers rooms in half the 12 schools we visited had no computer access and many were shabby and poorly lit. Only three schools had attractive areas with quiet space for students and computer access on demand. Poor physical resources for careers information are likely to reflect the lack of interest and importance attached to it within that school.

Teachers' and career advisers' views of nursing were not positive. They were asked: 'On a scale of one to 10, with 10 being the most desirable, where would you put it [nursing as a desirable profession]?'Out of the 12, 10 placed nursing below five on the scale, and five placed it at three or below.

The advisers recognised that good grades were required for nurse training but still perceived nursing as a low-status career.

Career advisers and teachers also thought that the parents of pupils from ethnic minorities saw nursing as a demeaning occupation.

Two-thirds of the young people had not made up their minds when we spoke to them. Of the third who had done so, those in year 12 appeared to be less sure than the year 11s. Career decisions are often tentative and changeable, suggesting that marketing activities might be best directed at a range of age groups and not confined to a limited timeframe, as at present. The young people themselves said they would like to receive more careers information over a longer period of time.

They wanted factual careers information with clear signposts about access and required entry levels. They also expressed interest in mini-stories, with pictures of 'real people like us'. They were negative about the way local trusts were presenting themselves - they found the information too dense, with too much printed on the page. Colourful, attractive layouts, keeping language simple and avoiding jargon were some of the recommendations they made for careers information. Some said they wanted more opportunities at school to meet NHS staff. A third of the young people, mainly from the wealthier areas, said they were more likely to use the internet for careers information, suggesting a need for trusts to maintain and develop interesting websites.

The three trusts in this area introduced recruitment-and-retention advisers after the research and their presence may alter attitudes to existing members of the workforce.

Our interviews with managers suggested that there was an acceptance of relatively high labour turnover among nurses, and that not much could be done about it.The Department of Health recruitment initiatives had had very limited impact on these three trusts. Personnel staff also showed suspicion of recruitment initiatives that had an equality/diversity flavour. Few were aware of initiatives within their own trusts.Not surprisingly, the equality and diversity officers in these trusts expressed a sense of isolation, commenting on the fine line they had to tread between being heard and being seen as a nuisance.

NHS staff could have a powerful role in promoting recruitment. But our research suggests that having a family member working in the NHS is a disincentive to joining.Young people, especially those from black British and Asian communities, need role models.They said they wanted to hear about 'people like themselves'. If 'people like themselves' are not working in the local trusts, where will the role models be found?

Responsibility for recruitment should be taken at local level, even though any payback may not be seen for a few years.National recruitment campaigns have to overcome the bad-news stories about the NHS and counter campaigns by professional bodies like the Royal College of Nursing which - in pursuing increased pay for nurses - have promoted the image of downtrodden, underpaid saints.

Our research has clear implications for trusts hoping to make their workforce more representative of their local communities, and to promote the NHS as a worthwhile career.Trusts should reconsider their relationships with local schools and ensure their workforces reflect the community.They should establish relationships with universities.Recruitment procedures should be monitored to ensure equality of opportunity.

They should consider how best to target careers advisers and teachers and develop work experience programmes for school pupils, and opportunities for NHS staff to go into schools to talk about their jobs.They should also produce information on careers that is attractive and accessible to secondary school pupils.

Key points

School pupils from ethnic minorities do not see the NHS, and nursing in particular, as offering attractive job opportunities, even in an area of high unemployment.

Nursing is perceived as menial, very poorly paid and stressful.

Trusts need to improve their literature and send staff into schools to improve recruitment.

Lesley Mackay is a freelance researcher and Jacinta Elliott is an independent consultant.