Managers’ perspectives on promotion and professional development for black African nurses in the UK

An exploratory qualitative study design was adopted for this study and underpinned by Rex’s migrant workers framework (Rex, 1999). Semi-structured interviews were conducted with ten ward managers from four NHS trusts in the north-east of England to gain an insight into their experiences of working with black African nurses with regard to equal opportunities in accessing professional development and promotion. Managers reported that black African nurses experienced racism from patients, racism from colleagues, discrimination and lack of equal opportunities. A unique finding of the study was that managers stereotyped black African nurses as lacking motivation for professional development and promotion. The authors recommend that NHS ward managers receive training in implementing antidiscrimination policies and valuing equality and diversity.


Introduction
The 1990s and early 2000s saw unprecedented recruitment of nurses from overseas to the UK, to work both in the NHS and in the private sector. Data from the Nursing andMidwifery Council (2004, 2005) showed that during 2002-2003 more than half of all newly registered nurses were from outside the UK. A substantial number of these nurses came from sub-Saharan Africa. Buchan et al (2004) found an increase in the number of African nurses being recruited to London hospitals. The highest proportion were from South Africa (17%), followed by Nigeria (6%) and Ghana (3%). Allan and Larsen (2003) reported that nurses from South Africa, Zimbabwe and Nigeria contributed a large number of nurses to their focus group interviews on the experience of internationally recruited nurses. Data from the World Health Organization (2006) indicate that nurses and midwives trained in sub-Saharan Africa and working in Organisation for Economic Co-operation and Development (OECD) countries represented 5% of the workforce. Nurse migration is a global phenomenon as more and more countries become reliant on international recruitment to address nurse shortages (Kingma, 2001(Kingma, , 2006. Nurse academics have focused their research on motivational factors for overseas nurses relocating to the UK, and experiences of overseas nurses working in the UK (Shields and Wheatley Price, 2002;Buchan, 2002;Allan and Larsen, 2003;Withers and Snowball, 2003;Gerrish and Griffith, 2004;Taylor, 2005;Smith et al, 2006;McGregor, 2006;Alexis et al, 2006;Larsen, 2007;Henry, 2007;Alexis, 2009;Okougha and Tilki, 2010;. These authors reported that overseas nurses were motivated to relocate to the UK for personal reasons such as material gain and professional development.  also pointed out that recruitment of overseas nurses and policies have contributed to nurse migration. The nurses in most of these studies reported negative experiences, including racism, discrimination, and lack of equal opportunities in the workplace. In particular, Shields and Wheatley Price (2002) reported that black African nurses experienced discrimination and faced racism more often than other groups of ethnic minority nurses. This paper focuses on the perspectives of nurse managers of wards in which black African nurses were employed.
Previous studies have investigated the experiences of overseas nurses from their managers' perspectives (Gerrish and Griffith, 2004;Smith et al, 2006;O'Brien, 2007;Allan, 2010). Most of their findings were also negative. Gerrish and Griffith's measurement of success was biased towards the advantages of employing overseas nurses in the NHS, with little focus on the experiences of the nurses themselves during the adaptation period, or their social experiences in the UK (Gerrish and Griffith, 2004). Smith et al (2006) reported that promotion to management posts in the NHS appeared to involve a system of patronage and sponsorship. Furthermore, they observed that stakeholders recognised that differences in culture contributed to some overseas nurses experiencing feelings of isolation, and that this in turn affected their career progress. Overseas nurses perceived the system of promotion that was dependent on patronage and sponsorships as institutional racism and discrimination, as the process was not transparent. Allan (2010) reported that managers were concerned that skills learned overseas might not be up to UK standards, and as a result overseas nurses were placed at the bottom of ward hierarchies and discriminated against. Ashraf (2013) has stated that BME staff are still experiencing discrimination, especially in leadership and management posts in the NHS, despite various positive action initiatives, such as Getting on Against the Odds (Department of Health, 2002) and the 'breakthrough' programme (NHS Executive, 2003). Kline (2013) echoes the same sentiment by stating that BME staff are discriminated against in the recruitment and promotion processes. Kline (2013, p. 6) adds that 'BME staff are grossly under-represented among senior management but disproportionately involved in disciplinary grievances, bullying and harassment cases and capability reviews.' In addition, black African nurses are over-represented in referrals more than any other ethnic group, and most of them are dismissed with no case to answer (Royal College of Nursing, 2013).
The reasons for discrimination are complex. One explanation is provided by the implicit association test (IAT), which was developed by Greenwald et al (1998) to establish why people discriminate. Implicit attitudes are associated with unconscious bias and can help to predict certain behaviours and judgements directed at members of certain groups or inform decisions about who should be employed or promoted (Dasgupta, 2004). Implicit attitudes may explain why black African nurses face the most discrimination in the NHS.
Promotion of equality of opportunity has a business as well as a moral case. A systematic review of the literature conducted on behalf of the UK Government's Equalities Office in 2013 (Department of Business, Innovation and Skills, 2013) stated that the implementation of equality policies is good for recruitment and retention of staff, productivity of staff in the organisation, a good reputation and mitigation of the risk of litigation. The UK Equality Act (2010) aims to eliminate all forms of discrimination in order to foster these factors.
It is acknowledged that different groups of overseas nurses may have different experiences in the NHS depending on cultural, nurse education and development factors of their home countries (Royal College of Nursing, 2008). It is therefore important to gain managers' perspectives on their experience of working with overseas nurses. This study aimed to explore, from their managers' perspectives, black African nurses' experiences of discrimination and equal opportunities in the NHS, in relation to access to professional development and promotion opportunities.
Rex's migrant workers' framework was used to underpin the study. Rex (1999) links race relations to other sets of social relationships, such as class. In Rex's model, race relations are encouraged by the existence of structural conditions such as conflict over scarce resources. He identifies the existence of a number of unwanted and low-status industrial jobs that are associated with immigrants, and shunned by locals, as a source of greater relative deprivation for immigrants. The situation with regard to nursing is of course different, as nursing is classed as a skilled profession (Iredale, 2001), and qualified nurses have an entry level to the profession regardless of immigration status. However, it is progression in the profession that may relate to Rex's framework, since immigrant nurses are most likely to be found in the lower grades, as these are the grades that are least appealing to UK nurses. In the present study all of the nurses were employed at entry grade regardless of their qualifications and experience. Managers reported that this was NHS policy because the nurses required an adaptation period in which to familiarise themselves with UK nursing practices. However it was not uncommon for nurses to be on this grade for two years or longer. Rex (1999) argues that stratification and other structural factors characterise race relations situations. Some race relations are based on a class system in which there is an exploitative relationship between the upper and lower classes. However, Rex concedes that a system of this kind is less perfect in modern times, and that it breaks down into a status system: 'Everyone is therefore allocated a certain standing in society along a quantitative scale. This position accorded to a man may be high or low according to the lightness or darkness of his skin' (Rex, 1999, p. 339).
A race relation situation arises when: 1 one group of people behaves towards another group of people in a way that denies them equal access to social services 2 the groups involved are recognised by signs that are regarded as unalterable 3 the unequal relationship between the groups is justified by various deterministic beliefs (Rex, 1970).
The first of these conditions emphasises the significance of inequality, the second emphasises the importance of physical differences, and the third emphasises the subordinate group's possession of the negative characteristics that justify racial inequality (Pilkington, 2003;Department of Health, 2005). These ideas, which originated in the nineteenth century, have their foundation in the belief that black people are biologically inferior to white people. The above-mentioned three conditions which give rise to race relations are distinguished by Pilkington (2003) as racialism and racism. Racialism consists of practices that disadvantage people on the basis of their supposed membership of a particular race, whereas racism consists of beliefs that the disadvantaged group invariably has those characteristics attributed to it. Racism is directly related to discrimination, as it creates and justifies unequal relationships between groups (Pilkington, 2003).The best example of a race situation is imperialism, which involved the domination of white western European countries over countries in which most people were of different skin colour (Rex, 1999;Pilkington, 2003). In the case of Britain, this was manifested by colonisation of most of sub-Saharan Africa. It can therefore be argued that nurse recruitment from sub-Saharan Africa is a colonial legacy brought about by a common language and education. This colonial legacy manifested itself as the perception of 'the other' directed towards black African nurses expressed as overt or covert racism and discrimination. This is supported by the findings of Larsen (2007), Smith et al (2006) and Allan (2010), among others, who reported that overseas nurses felt they were isolated by managers when it came to professional development and promotion.

Aim of the study
This study is part of a larger qualitative study, aimed at exploring the experiences of black African nurses in the UK, which took place between 2006 and 2009. This part of the study focused on exploring the experiences of the nurses from their managers' perspectives in the various settings in which they were employed.

Study sample
Four large NHS trusts where the proportion of ethnic minority nurses was known were chosen for this study. Managers were selected on the basis that they supervised and worked with black African nurses and therefore had had the experience that the researchers wanted to study. There was no need for nurses to share their experience with their managers, as it was the managers' perspective of their experience with black African nurses that was required. Eight managers were interviewed individually and two managers were interviewed together (see Table 1).

Ethical considerations
Before the study commenced, a protocol describing its aims and objectives as well as the methods of investigation and dissemination of the results was sent to the Central Office of Research Ethics Committee (COREC) and the Multi-Centre Research Ethics Committee (MREC), and was granted approval. The protocol was then sent to the research and development committees of the four selected hospitals (Department of Health, 2005), and was granted approval in all four cases. Managers were assured that they would not be identified in any report or publication emanating from the study. They were also informed that they could terminate the interview at any time if they had any concerns about it. Information relating to the research was provided and managers were informed that they could withdraw at any time without giving any reason. All of the managers agreed to participate in the study. Informed consent was obtained from each of the managers prior to the interviews.

Data collection
Data for this part of the study were collected in December 2009. Semi-structured interviews were used to collect data from managers who were supervising black African nurses, in order to obtain their perspectives on the experiences of nurses from this section of the population. This method allowed the participants to talk about their experiences in order to obtain 'thick' descriptions (Brinkman, 2012). Flexi-bility allowed for responses to be fully probed and explored (Kvale and Brinkman, 2009). This involved interpreting both what was said and how it was said. For this reason the interviews were tape recorded so that they could be transcribed verbatim and also listened to again during data analysis.
The interviews lasted for 90-130 minutes. Each interview started with the question 'Please tell me your experiences of working with black African nurses.' Subsequent questions depended on the answer to this question. Other broad questions and probes included the following: . 'How do you value the skills of the Black African nurse?' . 'Tell me about any difference in practice that you notice.' . 'What support do you give to black African nurses?' . 'What is your understanding of equal opportunities?' . 'Tell me how you make sure that opportunities are accessed equally on your ward.'

Data analysis
The audio-recorded data were transcribed verbatim soon after the interviews. The analytic framework described by Spencer et al (2003) was used as a platform for initial ordering of the data. This involves four recursive phases: 1 construction of a coding table based on issues and questions derived from the literature review, the aims and objectives of the study, and recurring views and experiences of the participants 2 coding or indexing of the data, whereby the framework is applied to the data in a systematic way 3 charting, whereby a chart is created and the data are sorted by summarising the participant's views and experiences 4 mapping and interpretation, whereby the summarised data are used to find relationships between themes and to provide explanations for the findings.
In order to do this the first researcher familiarised herself with the data by listening to the tapes again and comparing them with the transcriptions. This process continued until the researcher felt that she had understood the characteristics of the data. While reviewing the data the researcher simultaneously identified recurring themes and ideas. These themes were then sorted and grouped under main themes and subthemes.

Findings
Managers' experiences with black African nurses centred on two main themes and their related subthemes: 1 racism and stereotyping: . racism from patients . racism from colleagues . stereotyping from managers 2 discrimination and equal opportunities: . availability of information on development opportunities . lack of support.

Racism and stereotyping
The majority of the managers indicated that black African nurses suffered racism from patients as well as from colleagues. Some managers also displayed stereotyping between different groups of overseas nurses. The language used by managers in the interviews was carefully worded, yet stereotyping could be discerned. Racism can be very subtle; one can practise it without even realising it (Potter and Wetherell, 1987).

Racism from patients
Racism from patients was manifested in various ways, but mainly through racist comments and attitudes: When we are working we hear them say things [about the African nurses] but we just carry on because we know that's what old people can be like.
(Charge nurse, medical elderly ward) From a cultural point of view I think the issues are when nurses come towards the patients who are prejudiced but I haven't really come across a lot of that, they tend to be more isolated incidents.
(Charge nurse, medical ward) Some managers attributed patients' racist attitudes to age. Others attributed them to personality or a patient's condition: There is one patient who has got psychological problems and he would say like I don't want a black nurse but you do make allowances for that but generally they are alright.
(Charge nurse, colorectal ward) Comments about racism towards African nurses came mostly from charge nurses on medical wards. It may be that older adults have had the least contact with black people and have had the longest exposure to stereotyped images of black Africans, and are therefore more likely to display racist attitudes. Marks (1994) described cases in South Africa where white patients refused to be nursed by black nurses, and attributed this attitude to racist socialisation. However, lack of appreciation of cultural differences on the part of black African nurses could account for interpreting older patients' behaviour (in some cases) as racism. Larkey (1996) also highlighted categorisation of different races and specifications of various cultures as two processes that inform the way people stereotype each other and anticipate certain types of behaviours.
It was not clear from managers what was done to manage the situation so that stress could be minimised.

Racism from colleagues
Managers described cases where black African nurses were bullied and some of them were subjected to name calling: I think she felt bullied as well because people's expectations were a lot higher, all the time she was aware that people were looking at her practice.
(Charge nurse, colorectal ward) I don't like saying these things either because I feel disloyal to them [white nurses] by saying that. But some of the staff are harsh, they have got this harsh side to them but I really feel sorry saying that.
(Charge nurse, surgical ward) Managers appeared to contribute to racism through inappropriate scrutiny of black African nurses and instructing others to practise such scrutiny as well: I still observe because they could fib to me. They might say yes I can do this but I still got to be aware that they could be telling me a few mistruths. It's not only my eyes but somebody else's eyes as well, and they are monitoring as well.
(Charge nurse, colorectal ward) This charge nurse mistrusted black African nurses to the point of arranging special observations.

Stereotyping from managers
Although the managers recognised that black African nurses were facing racism, they failed to recognise that they themselves were contributing to this. Racism from managers came in the form of stereotyping, as they indicated that other overseas nurses were better at their job than black African nurses. For example, a ward manager made the following statements about a Filipino nurse and black African nurses on her medical ward: She is Filipino and she is an excellent staff nurse and I think she would be excellent as a junior sister but she is not interested, she doesn't want the aggravation, doesn't want the responsibility. So what I have done is we have two kits for our Band 6, I have dug them out and I have started to work through them with her to develop her further, but at the end of the day if they don't want to develop you can't make them, can you? ... I would probably say that [name of black African nurse]'s knowledge of hospital policies it is probably very limited, because again they focus on patients.
(Charge nurse, renal ward) African nurses are not bothered about developing themselves; they just want to go back to Africa. They are just concerned with their work but they are not bothered.
(Charge nurse, renal ward) These statements seem to favour the Filipino nurse. This manager thought that the Filipino nurse was excellent and that the African nurse had no comprehension of hospital policies. The fact that the manager seemed to be providing information to the Filipino nurse and not to the black African nurse is noteworthy; this information would apparently be wasted on the African nurse as she would be unable to articulate and use the information. Here it seems that stereotyping led to discrimination as the African nurse was denied information on the premise that African nurses do not want to develop themselves. A charge nurse from a different area also said: There was one Filipino nurse who was here for three years and was extremely good and I had jobs on ward 19A and she was really good, an E grade post came up and I said why you don't go for it. But it took a good two years of bullying in a nice way. But like I said for [the black African nurse] there hasn't been an opportunity on this ward, but there have been on other wards. I know she likes it here, she likes the people, she likes the work, and it works out well within her home life.
(Charge nurse, colorectal ward) The charge nurse went out of his way to encourage the Filipino nurse to apply for promotion because she was 'extremely good', but preferred the black African nurse to stay on the ward as she supposedly liked it there. The charge nurse had apparently not informed the black African nurse of promotion opportunities elsewhere, but assumed that she was happy with her grade on the ward. Different managers made similar remarks about overseas nurses from different areas that seemed to indicate that black African nurses had low motivation and were less capable than other overseas nurses, so it was not worth encouraging them to develop professionally.

Availability of information on development opportunities
Some managers saw it as their responsibility to inform nurses of development opportunities on the ward through various means, and blamed nurses for not being motivated enough to take up opportunities when they were offered. These opportunities were mainly in the form of courses and study days: It's my duty to make sure that I disseminate all the information that I get to my staff. So I will put out all the information, but it's up to them to read it. I will pop out information for them to read. And it's not just for [name of black African nurses], but you will find junior staff, because they are junior, they can't see past the ward. I find that they do not push themselves to do courses. Again it's all about patients.
(Charge nurse, surgical ward) Some managers admitted that they did not discuss any professional development plans with black African nurses: I don't know what they think because I have not had any discussion with them about their career path.
(Charge nurse, renal ward) Others said that it was difficult to send African nurses for professional development because of funding problems: I know colleagues who have African nurses in their wards and when they are doing their personal development plans on lots of courses and they ask for help with funding but at the moment the trust is quite stringent with how many study days one can do because they have to pay for them. So a lot of people don't get an awful lot but as far as I am aware it is fair between all the nurses on the ward and the ward manager would ensure that everybody would have equal access to study leave.
(Charge nurse, surgical ward) However, some managers admitted that it was difficult if not impossible to apply equal opportunities, as applicants could be identified from their application forms: Someone on the panel that shortlist does not have access to the geographic background of the individuals. Having said that, we know that on the application form you have to write down where you had your education or professional qualifications, so you can identify individuals who were not educated in this country according to that. I am not suggesting that people don't work within equal opportunities, but I am saying if somebody knows that person whether they can be truly objective I don't know.
(Charge nurse, renal ward) The only ethnic minority (black) manager who was interviewed in the study recounted how it had been difficult for her to develop and advance in her career: To get the sister's post I have applied about three times before I got the sister's position, and I was convinced am going to leave the unit because I had to go off and do a Master's degree, I had to do a lot of courses, did everything and then when I applied for the job I realised that I am just banging myself against a brick wall, then I thought I am going to leave and see if I can work with the consultants to do some sort of research.
(Charge nurse, critical care) This charge nurse explained that black nurses had to prove themselves if they wanted to move up the career ladder. They had to get extra qualifications, and even then they did not gain the recognition they deserved: I think that is where the problem lies. They do the courses and then afterwards they don't always get the responsibility.
(Charge nurse, renal ward) Henry (2007) described the same phenomena in a study of perceptions of career progression in the NHS of a group of nurses and midwives who had been trained in Ghana. Henry (2007) noted that lack of opportunities in career progression can lead to a demoralised, resentful and divided workforce. One then wonders how such a workforce is supposed to provide good-quality care for patients.

Lack of support
A related theme on equal opportunities was the lack of support for black African nurses. Managers explained that often there was no support on wards for nurses, due to staff shortages. Newly qualified nurses were able to cope better because they were educated in UK institutions but were also required to have a preceptor and a period of supervised practice. Black African nurses were allocated mentors, but working with a designated mentor was not always possible: She didn't get as much support as what she should have done really, and she kind of came in and just got on with things and we tried to do it as best as we can, so it just took that bit longer, and slowly as months went by she just got more and more confident.
(Charge nurse, colorectal ward) The charge nurses agreed that although the black African nurses were well qualified and practitioners in their own right, they still needed support to adapt to the UK system of nursing. Documentation and policies were special areas that were singled out as needing supervision.

Discussion
This paper has presented managers' perspectives of the experiences of black African nurses in the UK. According to these managers, black African nurses experienced racism both from patients and from white colleagues. They also had less access to professional development and promotion opportunities. This is consistent with the findings of previous studies of overseas nurses (Shields and Wheatley Price, 2002;Buchan, 2002;Allan and Larsen, 2003;Withers and Snowball, 2003). More recently, in a survey of 30 NHS trusts in England, Kline (2013) found that the probability of BME staff being shortlisted for a job was less in 29 of the trusts; the probability of a white candidate being shortlisted was on average 3.48 times higher than for a BME applicant, and a white candidate was 1.78 times more likely to be appointed than a BME applicant. In addition, a report by the NHS Institute for Innovation and Improvement (2009), cited by Kline (2013, p. 8), observed that the shortage of BME senior managers in the NHS is partly due to 'racially biased recruitment' practices, and added that overseas qualifications are undervalued.
The Royal College of Nursing (2013) has launched a 3-year project entitled 'Is That Discrimination?' The first phase focuses on raising awareness of what discrimination is, and reminding RCN members of their employment rights as well as their right to work in environments that are free from unlawful discrimination. The second phase will focus on providing enhanced learning and developmental support for RCN's accredited representatives and caseworkers in identifying and effectively challenging workplace discrimination. It will be interesting to see how the different ethnic groups are treated in this project, and how effective developmental support will prove to be. Kline (2013) explains that there is a clear correlation between how BME staff are treated in the NHS and the experience of patient care. This study has looked at the experiences of black African nurses from their managers' perspective, and confirms the experience reported by nurses in previous studies, suggesting that despite changes in equality legislation and equal opportunity policies, the situation has not changed much. The implication might be that patients are being denied the best care because selection and recruitment are biased by race, ethnicity and nationality.
The experience of racism from patients and colleagues observed by managers has been included in this discussion as this phenomenon has not been well explored in the literature. It may be that managers are influenced by the behaviour of patients and other nurses in their application of equal opportunities in the workplace, or it could be that implicit racial attitudes are in operation. If this is the case, there is an even stronger case for implementation of antiracist policies in the workplace, and for continual monitoring of this to ensure that these attitudes are eliminated among both staff and patients.
Managers often displayed prejudice and stereotyping attitudes toward black African nurses. They often described these nurses as abrupt and less motivated than other overseas nurses. Black African nurses were not trusted with regard to their skills, and were closely watched by both managers and white nurses. Managers often favoured other overseas nurses over African nurses. Although all BME staff are discriminated against with regard to professional development and promotion, this study has shown that black African nurses are at a particular disadvantage. This could be because their qualifications are perceived to be inadequate, or because managers are influenced by the state of healthcare in Africa, which is generally portrayed negatively both by the media and by the nurses themselves. It may be that managers need to be made aware that although black African nurses work in often under-resourced and poor conditions, it is these same conditions that provide opportunities for them to develop nursing skills which are often lacking among UK nurses (Likupe, 2011). The existence of racist attitudes as described by Rex (1999) earlier concerning skin colour should not be dismissed.
In addition to black Africans, nurse migration into the UK included a wide range of ethnic groups, including Afro Caribbean, European, Filipino and Indian nurses. Therefore the tendency to categorise all immigrant nurses as a homogeneous group perhaps needs to be revised. This may be a mistake, as different overseas nurses are viewed differently by both managers and white nurses in the UK, which may influence their chances of professional development and promotion. It may also influence their experiences of racism from both patients and colleagues, and thus how they are affected by these experiences.
The findings also suggest that managers are aware that black African nurses are discriminated against on the basis of race and nationality with regard to professional development and promotion. These findings are similar to those of Lemos and Crane (2001). Furthermore, Shields and Wheatley Price (2002), Allan and Larsen (2003), Alexis et al (2006) and Taylor (2005) reported that overseas nurses are denied training and career development. However, the majority of the managers did not seem to realise that they contributed to discrimination, nor did they take any action following allegations of discrimination from patients and colleagues. Likupe (2011) and Likupe and Archibong (2013) found that black African nurses are particularly disadvantaged. This is consistent with the findings of Sears and Henry (2003), who posited that symbolic racism and negative feelings about black people are based on early learned fears and stereotypes.
The results of this study are similar to those of O'Brien (2007), who reported that managers discriminated against overseas nurses not only with regard to use of technological skills but also in terms of selfdevelopment and promotion. However, the findings that managers did not trust black African nurses to tell the truth and that they thought black African nurses lacked motivation for self-development are unique to this study. This lack of trust in and stereotyping of black African nurses by managers could have implications for them in accessing professional development opportunities and promotion, and may contribute to what Kline (2013) calls 'discrimination by appointment.' Equality and diversity have moral, business and legal implications. An inclusive work environment encourages participation by all staff members who share common values. According to the Equalities Review (2007), staff are more likely to be motivated and perform well in an organisation where everyone is valued and respected. They are also less likely to leave their jobs if they are working in such an environment. The costs associated with bad practice related to equality far outweigh the costs of implementing good practice (Employment Tribunal and EAT Statistics (GB), [2006][2007].
The managers stereotyped black African nurses as unmotivated, and therefore may have discriminated against them when allocating professional development opportunities and promotion. According to Rex (1999), this practice keeps a certain population on the bottom rung of the ladder, which is what seems to have happened to some of the black African nurses. The management approach adopted in this study appears to be embedded in institutional racism and consistent with treatment of migrant labour in the way described by Rex (1999). In this study, prejudice as practised by managers may have served as a divisive factor both among overseas nurses and among the nursing staff as a whole, with the potential to create a stressful environment for all concerned. It may also have resulted in discrimination with regard to pro-fessional development and promotion, which would directly affect the quality of care given to patients.
The managers in this study did not mention competency and education as issues that were of concern in allocating resources for professional development or promotion. Racism appeared to be the primary motivation for denying the nurses opportunities. Kyriakides and Virdee (2003) reported that a climate exists in the NHS in which low standards are synonymous with overseas doctors from the new commonwealth, the term 'overseas doctor' being a euphemism for 'black doctor', whose medical standards are deemed inferior. Nursing studies of overseas nurses have not investigated this phenomenon to date. The results of this study indicate that perceptions of black African nurses in the UK may not be different from those of overseas doctors.
The study also highlights the importance of managers being aware of the experiences of overseas nurses. It is through this awareness that anti-discriminatory policies and practices which are locally relevant and locally owned can be implemented. There is a need to provide training in awareness of unconscious bias, as this study has shown that this influences decision making with regard to professional development and promotion. This training needs to be implemented at the time of recruitment of student nurses, and continue throughout their nursing training.

Conclusion
This study has demonstrated that black African nurses working in the NHS in the UK experience stereotyping, racism, discrimination and lack of opportunities. The practice among some managers of discriminating against black African nurses because of stereotypical attitudes could be detrimental to patient care and have a negative impact on the ability of NHS trusts to meet their responsibilities under the Equalities Act 2010. The NHS cares for a diverse population with different cultural needs. It is committed to providing care that is effective and sensitive to the needs of everyone. It is important that every nurse is valued, so that patients' healthcare needs are met in an inclusive and culturally sensitive manner.
Unfortunately, most of the managers in this study had stereotyped attitudes towards black African nurses. Some managers were positive and were operating equal opportunities policies in their practice. This is encouraging, and it should be promoted as good practice. However, managers need training in issues of inclusion and diversity in order to foster a positive team spirit in the workplace and ensure that nurses' skills from various backgrounds are utilised effectively in the care of patients. Robertson (2012, p. 5) supports this view, stating that 'diversity and inclusion training for managers should include bias testing and strategies for mitigating the impact of bias so that they have the opportunity to be consciously proactive. ' The Francis Report (Francis, 2013, p. 67) makes clear the importance of frontline staff in the provision of good-quality care, and states that 'patients must be the first priority in all that the NHS does ensuring that, within available resources, they receive effective care from caring, compassionate and committed staff, working within a common culture.' This culture can be created through a strong and fair leadership that values diversity and creates a common set of values among staff.