Barriers and Enablers for UK Home Grown South Asian Prospective Students Choosing Nursing and Midwifery Courses and Careers

Background: UK ‘home grown’ (people of South Asian ethnicity, born or socialised in Britain) South Asian (Pakistanis, Bangladeshis and Indians) are underrepresented in the NHS nursing and the allied health workforce. One of the key goals of Health Education England’s (HEE) national frameworkWidening Participation-It matters! is to increase understanding and evidence on the specific needs of underrepresented groups as they apply, commence and progress on healthcare courses and careers. There is a dearth of evidence on the views of UK ‘home grown’ South Asian prospective students. This study aimed to explore UK ‘home grown’ South Asian students views on the barriers and enablers to choosing nursing and midwifery courses and progressing into healthcare employment. Methods: A total of nine focus groups were conducted. Four focus groups in two schools/colleges in the town of High Wycombe (n=28) and five focus group discussions in two schools/colleges in Luton (n=27). Results: The main themes emerging for barriers to choosing nursing and midwifery courses and careers were: limited personal, parental and community knowledge influencing perceptions of nursing and midwifery, the role of religion and culture, gender roles-‘not man’s work’, the end of NHS bursaries and racial and religious discrimination. The main themes for enablers were presented as: good information available on applying for nursing or midwifery courses and suggestions on how to widen participation for South Asian groups. Conclusion: To increase numbers of UK ‘home grown’ South Asians on nursing and midwifery courses and in healthcare employment, targeted interventions that raise the profile and status of nursing in the South Asian community should be designed and delivered.


Introduction Background
In October 2014, Health Education England (HEE) launched a national framework-Widening Participation-It matters! Our Strategy and Initial Action Plan -the aim of which is to develop a healthcare workforce that can relate to the communities it serves 1 . The increasing importance of the widening participation agenda is a response to the growing evidence base arguing that it is essential that the National Health Service (NHS) workforce should reflect the growing ethnic diversity of the UK population because culturally responsive nursing is linked to improvements in cost management, quality of care for patients, patent safety and better outcomes [1][2][3][4][5]. Despite the increasing diversity of the UK population, Black Asian and Minority Ethnic (BAME) groups are proportionately under-represented in the NHS workforce. Within the BAME group the Black African groups are under-represented in medical and dental while South Asians (Pakistani, Bangladeshi and Indian) groups are overrepresented in medical and dental but underrepresented in the 1 HEE use the Office for Fair Access [OFFA] 2013 definition of widening participation, which is: 'seeking to remove the barriers to accessing and succeeding in higher education, including financial barriers' (HEE, 2014).
NHS nursing and the allied health workforce [5,6]. In terms of healthcare courses there is a significant available evidence base on University admissions but this largely presents descriptive data and shows that BAME groups are over represented in higher education but they are underrepresented on healthcare courses [7,8]. Research studies on widening participation have focussed on the viewpoint of the education providers, the experiences of underrepresented groups, specifically mature students disabled students and the social class of students [9][10][11][12][13][14]. Many of these studies are discipline specific and or have explored the views of students and not the perspectives of the prospective student community. Darr's (2001) work is an exception but is also discipline specific [15][16][17]. In her study, she interviewed South Asian nurses, a comparative sample of sixth form students and parents [18]. Daly, Swindlehurst and Johal (2003) study participants included students, parents and nurse practitioners [19].
Possible explanations in the literature for the under-representation of BAME groups in nursing (and the allied health professions) have been presented as a lack of awareness of careers in health and social care, a lack of cultural competence in the education process in nursing institutions (specifically marketing of nursing careers, recruitment of students), poor student experience and pedagogical/classroom practice, poor attainment retention and high levels of attrition, workplace harassment and racism, recruitment, employment and training disadvantage and barriers to BAME groups applying for senior roles [20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]. Studies looking specifically at the views and experiences of South Asians have found that nursing is perceived as being women's work, is poorly paid, and involves working night shifts and providing physical care to the opposite sex which is religiously and culturally unacceptable. These studies also report tensions and difficulties in academic life, lack of exposure to positive role models and poor knowledge of nursing career structure [17,36,37].
As part of the widening participation agenda, there have been changes relating to access requirements, access pathways and training into nursing and midwifery (and the allied health professions) [38,39]. Interventions to widen participation from under-represented groups have also been introduced but these have been criticised for a lack of differentiation in studies between the different under-represented groups and a lack of evaluation illustrating what practices have the best impact on outcomes [40].
One of the key goals of HEE's national framework is to increase understanding and evidence on what are the specific needs of under-represented groups as they apply, commence and progress on healthcare education courses and careers [5]. It is within this context that HEE commissioned the Institute for Health Research (IHR) at the University of Bedfordshire (UoB), UK, to carry out a qualitative study. The study was based in the East of England regions in the UK as towns within the for example Luton and High Wycombe have a high South Asian population. Ethnic groups make up 35% of the total Luton population. The 2011 Census identifies Luton's population as 203, 201 with the Pakistani community accounting for approximately 14.4% of the total making them the largest ethnic group [41]. Indians make up 5.2% and Bangladeshi 6.7% of the total population.
High Wycombe also has greater than average proportions of people from all of the non-white ethnic groups with 16% of the total population (68,900) being from Asian ethnic groups. The majority of Pakistanis and Bangladeshis are Muslims. We selected two schools/colleges each in Luton and High Wycombe as recruitment sites due to their high numbers of South Asian student population.
To the best of our knowledge, no study has explored the views of UK 'home grown' South Asian (Pakistani, Bangladeshi and Indian) 2 prospective students on the barriers and enablers to accessing and progressing on NHS funded nursing and midwifery courses and progressing into healthcare employment. The findings from this study will inform HEE's Widening Participation Strategy, NHS Trust recruitment departments, schools/colleges and Universities on decision-making to widen participation for people from South Asian backgrounds. The study may lead to further enquiry/interest in nursing courses and careers among South Asian prospective students.

Methods
The study used a qualitative interpretative research design using focus group discussions as we were interested in understanding participant's views. The discussions generated in-depth contextualised information from a range of opinions and experiences relatively quickly. We used a short questionnaire to collect the bio-characteristics, which included verification that participants were 'home grown' to contextualise the qualitative data during the analysis stage of the study.

Sampling
Prospective South Asian student participants (n=55) (age range [16][17][18][19][20] who had not accessed nursing and midwifery courses were recruited purposively [42]. Head teachers at the selected schools and colleges were contacted for access to potential participants. Heads of years/teachers, careers advisors and the student council (recruiters) recruited students through email, and through one to one communication during school hours. At one school, NA and AJ met with the Student Council for support with recruiting students. Prospective participants were provided with information sheets outlining details of the study and their participation. The focus group facilitators (NA, AM, SM, AJ) liaised with the recruiters and arranged a mutually convenient time for a focus group discussion to take place.

Data collection
A semi structured discussion guide was developed by NA, with input from all authors, HEE and after an in-depth literature review of the existing evidence base on widening participation for BAME groups into healthcare education and employment. The literature review was carried out by AM and IQ supported by NA. The discussion guide included open questions about perceptions of nursing/midwifery profession, views on choosing a nursing/midwifery course/career, encouraging and supporting students from South Asian backgrounds to apply 2 The term UK 'home grown' refers to those people of South Asian ethnicity, born or socialised in Britain [43]. Socialisation is referred to as a key construct of identity formation [44]. For context, it is most closely aligned with those born or socialised in Britain belonging to the ethnic group definition used in the United Kingdom 2011 census [45] where Asian/Asian British refers to Pakistani, Indian and Bangladeshi (not including Chinese or any other Asian background). and accept places on nursing/midwifery courses and moving into NHS employment. NA piloted the discussion guide with a small selection (n=3) of students at the UoB for suitability of the questions.
Nine focus groups were held between February-April 2016; four in two schools/colleges in High Wycombe (n=28) and five focus group discussions in two schools/colleges in Luton (n=27). A total of n=55 participants took part on the study. This was the number of focus group discussions to achieve data saturation, in other words no new themes/sub-themes were emerging from discussions [46]. SM and AJ carried out the focus group discussions in English using the discussion guide as an aidememoir. At the start of each focus group SM and AJ stated the purpose and what participation involved including intragroup confidentiality, audio recording and confidentiality. After giving written consent participants were asked to complete a short bio-characteristics questionnaire (age, sex, ethnicity, nationality, length of residence in the UK, course details and employment status part-time/full-time and type of employment). All participants were offered a £20 voucher as thanks for taking part in the focus group discussions. The focus group discussions were approximately 1 hour long.

Analysis
Focus group discussions lasted approximately one hour. The discussions were digitally recorded with permission and transcribed verbatim by SM and AJ. NA checked the audio recordings against transcripts to ensure the accuracy of transcription [47]. Participants were given codes so that they could remain anonymous. The transcripts were kept on password protected USB sticks and computers. The data was analysed using a framework approach which involved a detailed familiarisation with the data, identification of key themes to form a coding frame, indexing the material according to the coding frame, and finally interpreting the findings in the context of other research in the area and policy and practice considerations [48][49][50]. Overall, the framework analysis approach relies on a thematic, comparative organisation of narratives, which allowed the research team to compare and contrast between and within each sample.
Our approach incorporated issues of reflexivity, reliability and validity [49,50]. To minimise researcher bias during analysis NA developed the coding frame which was discussed and refined in an iterative process in meetings with the project team (authors). Themes were identified deductively guided by the semi structured discussion guides and inductively as they emerged from the data. Themes and sub-themes were also discussed with the project team (authors) redefined until a consensus was achieved. The number of focus group discussions was sufficient to generate adequate thematic depth on the barriers and enablers to accessing, progressing on nursing and midwifery programmes and moving into healthcare employment [50][51][52]. The paper follows the consolidated criteria for reporting qualitative studies (COREQ) [53].

Participants
The characteristics of the participants are reported in Table 1. The main themes for barriers and enablers to prospective SA students choosing nursing and midwifery courses and careers are discussed in more detail below using narrative extracts from the focus group discussions.

Barriers
Barriers are the social and personal factors that hinder prospective SA students choosing nursing and midwifery courses and careers. These barriers can be categorised as personal, as well as  (1) Muslim 17-20 Male (1) Female (5) BTEC Health and Social Care (6) High Wycombe School 2 * The majority of these students had selected a health and social care study option. Although the aim of the sampling structure was to have UK 'home grown' Pakistani, Bangladeshi and Indian prospective students who were from different religious backgrounds the majority (n=54 out of n=55) of our participants were Pakistani and Bangladeshi Muslims, which is reflected in the findings.
heads of the household and therefore responsible as the primary earner/provider within the family.
My auntie she was like to her son 'oh you should be a Doctor.' And then to her daughter she was like 'oh you can go into nursing' so I found that a bit sexist (Focus group 7, female 7).
All participants explained that nursing was culturally more suited to women because it was part of the 'natural' female caring role but that the SA cultural expectation of early marriage (marriage as soon as possible after school/college/University) for women and the associated homemaking role was incompatible with choosing a nursing and midwifery courses and careers.
The end of NHS bursaries: At the time of this research very few prospective students were aware that nursing and midwifery degrees were funded by the NHS. The minority of participants that were aware that NHS funding for courses was coming to an end argued that this would be a further disincentive for all prospective students regardless of ethnicity. Some participants pointed out Muslim parents are reluctant to take student loans as paying interest on loans is not permitted within Islam.
Racial and religious discrimination: Participants argued that the racial and religious discrimination in the application, recruitment, and selection process for University courses may explain low numbers of SA students on nursing and midwifery courses. Participants argued that if SA students managed to gain a place on a nursing or midwifery course they would not only have the 'normal' challenges related to being a student on a nursing and midwifery course at University but also the additional challenges of discrimination related to their religion and culture ....some people don't apply for it because maybe they're scared they might not get the job because of what background they come from and that so maybe that's why don't apply to Universities...(Focus group 5, female 2).
The majority of participants also explained that discrimination in obtaining jobs post study, during work, in career progression and from non-SA/Muslim patients in hospitals was preventing Muslim SA students in particular from choosing nursing and midwifery courses and careers. Enablers: Enablers are societal and personal resources that influence or contribute towards prospective SA students choosing nursing and midwifery education and careers [54]. A number of enablers for prospective South Asian students choosing nursing and midwifery courses and careers were identified. The main themes were the role of ethnicity (religion and culture), views on how to widen participation for South Asian groups. The themes are discussed below using samples of narrative extracts from discussions. contextual variables that enhance or constrain personal agency [54]. A number of barriers for prospective SA students choosing nursing and midwifery courses and careers were identified. The main themes were limited personal, parental and community knowledge influencing perceptions of nursing and midwifery, the role of ethnicity (religion and culture), NHS funding and racial and religious discrimination. These are discussed in more detail below.
Limited personal, parental and community knowledge: Some of our participants were unclear about the nursing role and the different types of nursing specialism, for example, adult, child and mental health nursing as well as possibilities of career progression. Participants argued that parental and community perceptions of nursing focussed on it being a low status career because of the poor salary, long working hours, shift work, and poor career progression and thus it was a poor career choice when compared with for example medicine (doctors and dentists), accountancy and law. Some participants said that there was a community perception that nursing and midwifery were chosen by 'failed' doctors. These views in turn influenced participant's course and career choices.

The role of religion and culture:
The majority of our participants were Muslim and spoke about Islam reinforcing the importance of caring for others but they also argued that religion was a potential barrier because Islam prohibits mixing between men and women who were non-mahrams (unmarriageable kin) and therefore providing personal care to the opposite sex may present as a barrier to choosing a nursing or midwifery course and career for some Muslims .…well going into like nursing not only are you dealing with females but males so that could also be something our parents weren't want us to go into especially if you come from a strict practising Muslim family (Focus group 4, Female 4).
Our female participants said that midwifery was a preferred choice over nursing as it involved personal care for women. Male participants said that they would avoid midwifery for the same reason. Some participants argued that not all SA students (Muslims, Hindus and Sikhs) would see religious (and/or cultural restrictions) as conflicting with their nursing role. All our participants discussed that nursing and midwifery uniforms may be a potential barrier for choosing nursing courses and careers. Our participants had discrepant views on current uniform regulations/guidance, for example if the hijab (headscarf) was permitted or not and if nurses and midwife uniform required the compulsory wearing of dresses and tights ...maybe Asian parents don't like the uniform maybe cause' they don't want them to wear tights, short skirts... (Focus group 5, female 2).
Yes, you're not allowed to wear a hijab are you? Like when you're a nurse (Focus group 8, female 6).

Gender roles-'not man's work':
Participants explained that nursing and midwifery were not considered 'manly' enough for men by SA males, parents and the community. Participants also argued that men were encouraged into professions with higher salaries as the expectation within SA culture is that men are the Good information on how to apply for courses: The majority of participants said that they had a good understanding of the entry requirements, application, recruitment and selection processes for the courses (including nursing and midwifery courses) and that they had spent time reviewing relevant University degrees. Participants explained that they were able to access information easily from University websites, school/ college careers services and UCAS. The majority of participants were aware of entry requirement of Maths and English at grade C or above.

Suggestions on how to widen participation for SA groups:
Our participants gave their views on how to widen participation for South Asian groups and are presented ( Table 2).

Discussion
This study explored the views of UK 'home grown' South Asian prospective students on choosing NHS funded nursing and midwifery courses and careers. In common with other studies our research findings identified a number of barriers for South Asian people [18,37]. Personal, parental and South Asian community misconceptions about nursing specialisms and roles perceptions of low incomes, long working hours, shift work and poor career progression was influencing ideas about nursing and midwifery as a low status profession [19,9]. These perceptions are not specific to South Asian groups and research carried out with the general public also suggests that nursing is perceived as poorly paid and a low status profession [18]. A study of physiotherapy reported that minority ethnic participants placed greater importance on having a high salary [20].
All participants argued that religion reinforced the importance of caring for others but for the majority culture and religion also presented as a barrier [55]. The issue of providing personal care to the opposite sex is well documented in the literature as a barrier for SA groups choosing nursing and midwifery courses and careers and this also dominated discussions with our participants who argues that SA culture (regardless of religion) does not promote the social mixing between sexes and SA people from more practicing religious families may regard providing personal care to the opposite sex more of a barrier than people from moderate families [18,19].
The issue of uniforms regulations as a barrier for some Muslim South Asian's choosing nursing and midwifery courses and careers is also identified in the literature [37]. Our research findings suggest that participants had discrepant views about current uniform regulations/guidance. Although each NHS Trust employer sets out its own uniform policy, there is guidance from the Royal College of Nursing [56]. In addition, there have been significant NHS developments towards adapting uniforms to accommodate the cultural and religious diversity of the NHS workforce for example, the wearing of the hijab (headscarf) or turban, wearing religious bangles (or Karra) as long as they are secured for washing, covering arms below the arms under half sleeved uniforms, using disposable sleeves with half sleeved uniforms, wearing trousers or for those choosing not to wear trousers under a short top to do so under a longer nurses dress but our participants were unaware of these developments [56].
As is the case for other research studies our participants also held stereotypical views and argued that nursing and midwifery are not masculine professions [60]. There is evidence to show that men choose 'high-tech', low touch specialities' in nursing but as discussed above our sample had limited knowledge about the different nursing specialities and discussions focussed on the centrality of the personal care aspect of the role [61]. In addition, whilst midwifery remains a feminised profession evidence from Middle-Eastern countries shows that men are more likely to choose nursing careers, seeing no conflict between religion (Islam), their profession and their masculinity [62]. M u s l i m countries have responded to the segregation of men and women and positively recruited men into nursing [63]. Certain Middle Eastern region universities such as the University of Jordan reported significant success in male student nurse recruitment, between 2000 and 2008 the number of male nursing students was double that of female students [64].
A lack of exposure to positive South Asian role models has been reported extensively in the literature as an explanation for under-recruitment of South Asian people into nursing and our research findings reinforce this and also suggest that the lack of positive ethno-religious South Asian male and female nurse and midwife images may be a contributing to low numbers of South Asian on nursing and midwifery courses [19,36]. More generally gender bias and discrimination in nursing education is reported as a factor contributing to low numbers of men in nursing [65]. Gender and culture intersected for our prospective students and Suggestions on how to widen participation for South Asian groups 1. The need for more University places on nursing and midwifery courses 2. More information on nursing and midwifery courses, careers, career progression and salaries for prospective students, parents and the South Asian community generally. 3. Information should be provided through social media, for example twitter, snap chat but acknowledged that more traditional media needed to be used to reach different groups within the South Asian community. Information should also be provided at community outreach events and delivered in the appropriate languages by South Asian nurses and midwives (male and female) who would be able to discuss religious and cultural concerns and how these can be negotiated in the workplace. 4. More South Asian nurse and midwife role models visiting schools and colleges to increase the visibility of nursing and midwifery courses and careers. 5. More South Asian nurses and midwives should be represented on relevant careers advertising. ...I swear every time I see a poster it is always white people (Focus group 4, male 2) 6. School/colleges should provide nursing and midwifery workshops, course tasters, hospital open days and work experience/shadowing. they explained that a nursing or midwifery course or careers were also incompatible with SA cultural expectations of early marriage and homemaking for women. McGee (2008) reported that family support was reported as key to the experiences of South Asian women and suggested that open day events could make more effort towards educating parents about nursing [66].
Participants felt that racial and religious discrimination in the application, recruitment and selection of South Asians onto University courses could explain low numbers of nursing and midwifery courses. There is now an extensive evidence base highlighting that BME groups apply to University nursing courses in high numbers but numbers on courses diminish at shortlisting and in terms of numbers of students offered a place on the course as explanation of under-representation [28,67]. Research highlights that there are high numbers of British Pakistani men and women perusing higher education but that selective school systems and racialised labour markets the effectiveness of the 'ethnic capital' [68]. Our participants also discussed racial and religious discrimination when applying for jobs post study, during work and in terms of career progression. In other words they felt that racial and religious discrimination would disadvantage them in the workplace [69][70][71][72]. A lack of BAME role models in senior NHS roles may therefore be reinforcing SA prospective student's views of choosing nursing and midwifery courses and careers [73]. Evidence suggests that despite under representations of BAME in the NHS little has been done to address the issue in terms of systematic strategies for positive actions [74]. Research has found that there is a lack of career opportunities for BME nurses and they fail to progress in the NHS careers because of discrimination [33].
Those participants that were aware of student bursaries for nursing and midwifery courses believed that they have been an enabler for South Asian prospective students and argued that end of the bursaries would affect the numbers and diversity of students. Evidence highlights that Muslims are less likely to take student loans as this is prohibited within Islam [75,76]. Furthermore, there has been global recognition of the inequality of access and real costs of student loans for minority students from poorer backgrounds [77].

Limitations
The focus of this study was to recruit 'home grown' SA prospective students. We were successful in recruiting prospective students through the selected schools in Luton and High Wycombe but the majority of our participants were Pakistani and Bangladeshi Muslims which is reflected in the findings. Therefore it is difficult to identify to what extent student perspectives are similar or different to those held by other religious and ethnic groups. Future research should therefore include a larger ethnic and faith population group. The sample was sufficient to reach saturation but may not be 'representative' of SA prospective student views, which limits the 'transferability' of the findings.

Conclusion
The findings from this study provide in-depth views that highlight evidence for widening participation for UK 'home grown' South Asian students onto nursing and midwifery courses, and careers. Our findings are similar to existing research on widening participation for South Asian groups into nursing and the allied health professions. Discussion with our participants indicated the importance of improving the knowledge, perceptions and status of nursing and midwifery by implementing targeted interventions to improve the knowledge, perceptions and status of nursing and midwifery among the South Asian community in the UK.
The targeted interventions should be designed collaboratively with schools/colleges, Universities, NHS trusts, prospective students and parents and delivered through schools/colleges, South Asian social networks and community media in appropriate languages and include the 'lived experiences' of South Asian male and female nurses and midwives. Targeted interventions would contribute to existing government initiatives to recruit more BAME nurses and midwives into the NHS as well as feed into HEE's national strategy for widening participation.
Raising the profile and status of nursing and midwifery is unlikely to address current shortages of nurses and midwives from South Asian backgrounds without also addressing the contextual barriers impacting on the application, recruitment and selection of South Asian students onto nursing and midwifery courses. Universities should review the diversity of nursing and midwifery admissions, selection/interview and teaching staff and deliver unconscious bias training as part of good practice. The costs of these interventions outweigh the long term benefits of having a nursing and midwifery NHS workforce that reflected the cultural diversity of the UK.

Funding
Funding was provided by Health Education England (HEE)

Author's Contribution
NA conceived the idea, designed the study and study materials and wrote this manuscript. TS, GR, EC, BB, CR made significant contributions to the study protocol and development of the study tools. NA, AM and IQ carried out the literature review. AM, SM, AZ, RG and IQ facilitated the focus group discussions. All authors read, contributed and approved the final manuscript.

Ethics Approval and Consent to Participate
Ethical approval was obtained from the University of Bedfordshire (UoB) Ethics Committee and consent forms were signed by all participants following a verbal and written explanation of the study through participant information sheets. Focus group discussion facilitators ensured that participants understood the voluntary nature of their participation and that all information would be treated as confidential, consent for audio recording of the focus group discussion.