Editorial: Ethnocentrism and racism in nursing: reflections on the Brexit vote

Now that the dust after the Brexit vote is beginning to settle, it seems timely to consider how the debates on the UK's exit from the European Union are linked to issues around overseas-educated nurse migration to the UK and how the consequences of Brexit might shape nursing in the UK and our relationships with our European nursing colleagues. Leaving the EU (whatever that might mean in the end) may have rather more serious effects for me personally than I had anticipated before the vote on June 23. My contact with the idea of Europe began when I was sent to stay with a French family in 1969 where I learnt to speak French reasonably well albeit largely because they spoke no English. I did not feel alienated – just fascinated by a different culture and way of being. I am now a UK and a Swiss citizen as I married into a large Swiss-French family. The cousins meet up at regular intervals from all over Europe. In that sense, I feel and have always felt a strong connection to Europe and generally cringe over displays of nationalism. However, following the Brexit vote, I may not be able to travel easily in Europe if visas are demanded by other EU countries. So as a family, we are in the process of applying for Swiss passports; many of my Irish friends are applying for Irish passports for the same reasons – we wish to travel unheeded across Europe and to retain a connection with Europe. It feels like a political statement somehow – an attempt to stay connected with Europe at some level. We may be lucky to have that loophole. I cannot imagine what a restricted freedom of movement across the EU will mean for those who currently work in the UK in terms of travelling home but also, and importantly, in terms of their right to work in the UK. The negotiations to leave might restrict the freedom of movement altogether of course, and there could be a total withdrawal of free movement. It goes without saying that the NHS and the care sector rely heavily on internationally recruited nurses including nurses from European countries to ‘prop’ up the workforce. There are up to 110,000 health workers from Europe, including over 20,000 EU-trained nurses and 80,000 healthcare assistants working in the UK (Buchan 2016). As Jeremy Hunt (2016), a Remain campaigner, said, ‘We simply could not do without their contribution’. In my work life, I am a member of the European Academy of Nursing Scientists (EANS). The purpose of the academy is to be a scientific community in Europe providing inspiration, collaboration and academic leadership in nursing. We do this by sustaining a forum of European nurse scientists who are developing and promoting knowledge in nursing through research and scholarly achievement in the pursuit of excellence (http://european-academy-of-nursing-science.com). The President of EANS felt it necessary to reassure our European colleagues shortly after the vote that the British members of the Academy would still continue to be active members of our community. However, at this Summer's EANS doctoral Summer school at Halle University in Germany, I once again observed that there have only ever been a few UK doctoral students at this event which is always well attended by other EU nurses particularly those from Scandinavia. I have always found the lack of UK students at these Summer schools at the very least puzzling and now, after Brexit, perhaps troubling. I think our lack of presence may be indicative of a wider ethnocentric view of nursing among British nurses, which extends to a devaluing of European as well as non-European nursing (Allan 2007). Allied to an ethnocentric view of nursing in the UK are wider and more entrenched racist views (Allan et al. 2004, Larsen et al. 2005, Smith et al. 2008). I am not suggesting that the British nursing PhD students are themselves ethnocentric. Their funding might not stretch to cover a Summer school, their managers might not give them the time off, and their ability to juggle families and study might just not allow them the luxury of two weeks scholarly time in contact with their European peers. But the result is that our PhD students miss out on networking and scholarly discourse with their peers. This sends a message that the UK does not participate in Europe. The demonising of migrants and an antiforeigner rhetoric during the campaigning for the referendum led to fears for existing migrants and a spike in hate crimes; the number of hate crimes rose by 42% immediately after the vote in June this year (Stone 2016). BBC News reported that the United Nation's Committee on the Elimination of Racial Discrimination said it was ‘seriously concerned’ that British politicians whipped up hatred and then ‘failed to condemn’ racist abuse during the campaign. The UN also expressed concern about the negative portrayal of ethnic minorities in the British media. Because for quite a while I went to work in a country hospital and the fact I was foreign trained, although I'd worked here and had a midwifery qualification from here it was still more important the fact that I was foreign and people just treated me in such an odd way. (Female, 56 years old, South African, white, D grade) No matter if they know you are an overseas qualified nurse the way you are being approached or addressed is quite different completely from the so called UK trained nurses because they look at you as if you don't have anything upstairs at all. They look at you as if you don't know anything relating to nursing. So such attitude actually demoralize (a) human being. (Male, 39 years old, Nigeria, black, D grade) there's no ethics of nursing here. The respect is not just there and the racism… If not for the parliament that passed that issue allowing nurses to come to UK and be working so, they wouldn't have accepted us. So the racism is there, we are just fooling ourselves. We know it is there and they are not accepting us. (Female, 54 years old, Nigeria, black, D grade) In a larger study, Professor Pam Smith and I with colleagues from the Open University undertook an interview-based study to which we recruited over 70 overseas-educated nurses, and 30 mentors and managers to explore how overseas-educated nurses’ careers were developing in the UK. This was a multisite study carried out in collaboration with the RCN (Smith et al. 2008). Our findings confirmed the findings from the earlier study, namely that direct and indirect racism formed part of overseas-educated nurses’ experiences when working in the NHS as well as in care home sector. In addition, these nurses experienced poor career progression. We argued that indirect racism worked against these nurses, who frequently had further training, education and extensive experience, from being promoted to senior positions in the NHS. Overseas-educated nurses described the details of everyday indirect racism as they struggled to understand promotion mechanisms where their education and experience were seen as irrelevant for the UK context. Worryingly, these nurses reported a high number of allegations of poor practice brought against them by their British colleagues. We argued that these allegations were socially constructed in the sense that they were brought by their colleagues who struggled to value difference and diversity in the workforce, whose views of nursing were ethnocentric. As the Nigerian nurse says above, ‘they are not accepting us’. Their nursing practices were seen as other and suspicious. If the overseas-educated nurse could not find a way to fit in, they alienated their British colleagues and paid the price of being different – no promotion and at its worst, an allegation of incompetence or unsafe practice. More recent work carried out in London (Allan & Westwood 2015) points out that these racist practices have not disappeared; they have mutated into different forms. We cite the employment of overseas-educated nurses as healthcare assistants for periods of up to eleven years where their skills and knowledge are taken advantage of by trusts and their colleagues as examples of unthinking racist practices. We have never argued that these racist practices and systems are consciously racist but emerge from unreflective practices in an increasingly unstable and busy working environment (Allan et al. 2016). Spaces to talk about difference and diversity and how racist practices may be unwitting are not available in NHS as time for learning becomes squeezed even further and the NHS becomes even less of a learning organisation (Melia 2006). I think the recruitment of overseas-educated nurses both from the EU and outside the EU has been what might be called an unintended consequence (for the individual) of a public act or policy, where individuals struggle as they cope within a system that is unprepared for their inclusion. The pity is that we have been here before as the history of migration in nursing shows. Sadly, nurse education is not immune from racism – currently, I have a PhD student who is exploring the experiences of BME nursing and midwifery academics and their career progression. The early literature seems to suggest that there are racist practices in nurse education which militate against BME nurse lecturers progressing in their careers equally as their White colleagues. I believe that the debates for and against Brexit built on existing ethnocentric and xenophobic attitudes to difference in our society; nurses and nursing of course are parts of our society and may merely reflect those racist attitudes. However, in reflecting them, they also reproduce them leading to racist practices of direct and indirect discrimination which affect our colleagues from British BME backgrounds as well as those BME and White migrants. Therefore, in my mind, the consequences of Brexit will shape nursing in the UK and our relationships with our European nursing colleagues for the worse unless we actively work to prevent that happening. After Brexit it is even more important that as academics and nurses, we continue to cooperate to build nursing knowledge and work towards exposing and mitigating exclusionary and racist practices across Europe. And on a practical level, negotiations with the EU must ensure that the NHS. retains high-quality trained nurses irrespective of where they trained.