Generic Nursing in Through the Back Door? Concerns Around Nursing and Midwifery Council Processes for International Nurse Recruitment and Potential Impact on Mental Health Nursing in the UK

Abstract

This editorial discusses concerns raised through discussions among mental health nurse academics around the Nursing and Midwifery Council's (NMC) recruitment processes of international nurses who join the register as ‘registered nurse (mental health)’. However, given we exist in an age of political populism, where nuance can be reshaped into clickbait and potential for division is weaponised, it is first important to state what is not being said.

This piece takes aim at regulatory standards and processes around the recruitment of international nurses, not the international nurses themselves. This is not intended to overlook their valuable contribution to the NHS and other services in the United Kingdom (UK), nor to discourage international nurses from choosing to work in the UK. This is not intended to scapegoat international nurses for poor mental health care in the UK, which occurs plenty regardless of international recruitment. This does not suggest that international nurses are not well educated or incapable of being great mental health nurses. This is not right-wing propaganda nor anti-immigration. In writing, there is concern of being misrepresented as holding these attitudes, which contradict the values of the author and supporters. However, despite fears of being misunderstood or misconstrued, to say nothing about these issues feels worse, and to allow systemic issues that potentially dilute mental health nursing to go unchallenged feels negligent. Hopefully, these introductory paragraphs have set the tone intended before outlining legitimate concerns.

The current process for international recruitment has been in place since 2019, whereby “internationally trained professionals do not need to hold a specific mental health nursing qualification” to take a test of competence that would allow them to enter the NMC register as a mental health nurse (NMC 2024). International nurses must take a multiple-choice computer-based test from their home countries and fulfil English language requirements through qualifications, recent practice or tests, before undertaking practical objective structured clinical examinations (OSCE) held at one of five test centres in the UK (NHS Employers 2024, NMC 2025a, 2025b).

The NMC (2024) state that “before being able to join the register, internationally trained professionals must hold a qualification that will or has allowed them to register in their country of training”. However, the UK is in a minority of countries offering a direct entry mental health nurse education programme, with many others having a generic nurse education. This means the UK accepts international nurses with a general, generic or comprehensive nursing education, and allows these nurses onto the mental health part of the nursing register. Concerns raised through the work of international colleagues in Australia have noted limited mental health content in comprehensive curricula, and inadequate preparation for working in mental health settings (Lakeman et al. 2023).

In the NMC's UK education standards, they state proficiencies “apply to all registered nurses, but the level of expertise and knowledge required will vary depending on the chosen field(s) of practice” (NMC 2018, 27, 31), stating nurses must “be able to demonstrate a greater depth of knowledge and the additional more advanced skills required to meet the specific care needs of people in their chosen fields of nursing practice” (NMC 2018, 6). However, if people undertake international generic nursing education programmes, they cannot necessarily meet this same standard. The NMC asks for nurse education to be contextualised to the chosen field unless you are an international nurse, whereby, they change the rules and create a shortcut to specialist registration. The Royal College of Nursing (2024) remind “the UK nursing qualification that is generally transferable in every other country is the ‘Registered Nurse: Adult’” and that “not all countries have equivalents to the UK qualifications in mental health, learning disability, children's nursing, health visiting and the enrolled nurse”. This indicates a difference in underpinning education which is recognised worldwide, yet the UK now accepts a general nursing degree as a foundation for (following a test of competence) entry onto the mental health part of the register.

It may be little reassurance that the ToC is mapped to NMC standards when there have already been critiques of these standards as not being mental health specific and not adequately addressing concerns such as ethics, human rights and interpersonal relationships, instead focusing on physical health procedures (Mental Health Deserves Better 2023).

The NMC (2024) state: “while internationally trained professionals do not need to hold a specific mental health nursing qualification to take the mental health nursing ToC, they would have to be able to demonstrate their skills and knowledge in this field of nursing practice in order to complete the ToC”. The marking criteria for mental health nursing OSCEs show a varied range of tests (NMC 2021) which cover dementia and music, autism spectrum disorder, reminiscence therapy, talking therapies, de-escalation, restraint, nutritional assessment, physiological assessment, use of honey dressing for venous leg ulcers, pressure ulcer prevention, cervical screening and ankle sprain. It is not clear that this bag of all sorts is a robust assessment of any nurses preparation to work in mental health settings, and a fair assumption that what an OSCE cannot achieve is depth. It has been argued that complex concepts such as the validity of psychiatric diagnosis, mental health recovery, and ethical issues associated with mental health legislation which can impact human rights, should never be rushed or tokenistic (Warrender et al. 2023).

If the NMC have conviction that quality mental health nursing care can be assessed through a series of OSCEs, then why not also do this for current adult, children and young peoples and learning disabilities nurses in the UK who may wish for an additional registration? As a confusing aside, the NMC have in fact since 2020 allowed UK return to practice nurses into a field of their choosing based on completing the ToC, stating “if you're readmitting as a nurse, you can take a test that's relevant to the field that you'll be practising in, regardless of your initial registration” (NMC 2025a, 2025b). However, they then muddy these waters, following with “your entry in the register will still show the field from your initial registration if you take a test in a different field of nursing” (NMC 2025a, 2025b). This seems to indicate an endorsement of working in a different field to your initial training, provided the ToC is completed.

This does nothing to alleviate concerns that mental health nursing roles are already being filled by nurses from other fields of practice (Royal College of Nursing 2023), adding to a multitude of existential concerns for the profession. While this practice of international recruitment has occurred since 2019, and return to practice since 2020, with concerns only raised now as many of us have just become aware of it, we are left asking ‘what else don't we know?’ Perhaps underpinning this editorial may be a bewilderment around the NMC's approach, with critique that they have overlooked the unique complexity of the mental health nursing role for some time, having vague and inconsistent processes for ensuring the quality of the mental health nursing workforce, and thus quality of care.

In critiquing international nurse recruitment and return to practice policy, a fair point which may be levelled is ‘is this any worse than the current state of pre-registration education in the UK?’ Probably not. Concerns previously raised noted the dilution of mental health nursing education (Mental Health Deserves Better 2023), where students experience a lottery of depth for field-specific nursing education dependent on university, alongside a lottery of clinical placements which offer varying learning opportunities, some not field-specific, others dependent on clinical activity and workplace culture. The UK is veering into a circumstance with no robust approach, and so much inconsistency around entering the mental health register that all one needs to be a mental health nurse is for the NMC to agree you are one. In writing, this is a plea for yet another issue to be highlighted and discussed, inviting all with a stake in mental health nursing (in particular the Nursing and Midwifery Council) to respond to these concerns.

This editorial was written by Dan Warrender, and supported by the following mental health nurses who offered contribution of ideas, points of discussion and critical review: Oladayo Bifarin, Christopher Bye, Mary Chambers, Martina Doherty, Benedict Heinitz, Robert Griffiths, Emma Jones, Scott Macpherson, Stephen Marks, Steve McCarthy-Grunwald, Sue McGowan, Stephen McKenna-Lawson, Seren Roberts, Alan Simpson, David Solomon, Steve Trenchard.

The author declares no conflicts of interest.