As a fluent English speaker, Indian-trained nurse Deepa was surprised to learn she had to sit a language test to practise in Britain, her home for many years. She was even more shocked when she failed it – not just once, but 11 times.
Deepa's story is hardly unique – estimates suggest thousands of qualified nurses in Britain are barred from practising because they cannot pass an English exam which they say even some native speakers would fail.
One former National Health Service (NHS) hospital chairman described the situation as "barking mad", adding that it smacked of racism.
The nurses - mostly from Asian and African countries - say their skills are being wasted at a time when Britain's creaking NHS is battling massive staff shortages and high burn-out rates, exacerbated by the COVID-19 pandemic.
Next month, Britain's nurses will stage an unprecedented strike over pay and "unsafe staffing levels".
Agimol Pradeep, a senior nurse who has led calls to reform the language assessment system, said anecdotal evidence suggested 8,000 nurses were in Deepa's situation. Many are trapped in low-skill, low-pay jobs in hospitals and care homes.
"Some have failed more than 15 times, but they speak perfectly good English and communicate confidently and clearly with patients and colleagues," Pradeep told the Thomson Reuters Foundation.
"Many, especially those with intensive care experience, told me they were very frustrated they couldn't use their skills during the pandemic when the NHS was under immense strain."
Pradeep said some senior NHS staff – dismayed by the nurses' situation - had tried the test themselves, and failed it, despite being native English speakers.
The Nursing and Midwifery Council (NMC), the profession's regulatory body, requires overseas trained nurses to sit a language test before they can register in Britain, unless they have worked or trained in a "majority English-speaking country".
It said a high standard of English was crucial for "safe, kind and effective" patient care.
But some nurses said the exam setting was artificial and the pass mark set too high. Others from countries where English is widely spoken questioned why they needed to take a test when their training had been in English.
Deepa, 41, a nursing assistant at a hospital in southern England, said it made no sense for the NHS to spend large sums recruiting new nurses from abroad when it already had a big pool of experienced nurses it was not using.
"They're crying out for nurses, but we're already here. It's very frustrating," said Deepa, who asked not to use her full name. "My colleagues know I'm fully qualified. They all want me to use my skills."
But things may be about to look up. Following a public consultation this year, the NMC has announced some changes, which it estimates will allow up to 3,000 more nursing and midwifery professionals to register annually.
The move comes amid a rapid rise in recruitment of overseas nurses to plug gaps in Britain's health service. England alone has about 47,000 unfilled posts.
In the year up to March 2022, about half of the 48,436 nurses registering with the NMC were trained overseas, up from about one in seven four years ago. About two-thirds come from India and the Philippines, and thousands from countries across Africa.
The NMC accepts two international language tests - the IELTS and the OET - which both score applicants on reading, writing, speaking and listening. Although the exams are external, the NMC stipulates the pass grades.
From next year, it is introducing reforms to the resit process for those who just fail.
In certain circumstances, it will also accept an employer's testimony about an applicant's language abilities if they have worked for at least a year in a health or social care role in Britain, and either received their training in English or narrowly failed the test.
However, the NMC rejected calls during the consultation to lower the pass mark, but said this would be kept under review.
"Of all health and care professionals, nurses and midwives spend the most time with patients ... It's therefore essential that everyone joining our register has strong English language skills," said NMC strategy director Matthew McClelland.
While some nurses sit the test in Britain, many have to take it in their home countries before they can get a work visa.
Last year the Kenyan media reported that 97% of nurses who had applied for jobs with the NHS failed the language test.
The Zimbabwean Midwifery and Nurses Association in Britain said it was particularly concerned about the cost of the test, which exceeds many nurses' monthly salary in poorer countries and risks sinking them into debt.
One Zimbabwean nurse with two decades of experience, now working in an NHS surgical ward, said she spent nearly $2,000 on taking the test four times – about 10 months' salary.
The 42-year-old said she had to set up a sideline business and borrow money to cover the test fees, exam coaching and long journeys to the test centre.
She suggested nurses should only have to retake the sections they fail, not the entire exam, with the resit cost lowered accordingly.
"The system is very unfair," she said. "People really struggle to raise the money."
Some nurses questioned whether a classroom exam was the best way to assess practical communication skills in a clinical setting.
Lubos Tranta, 43, a British citizen who recently trained as a nurse in his native Czech Republic, said the system was too rigid.
Tranta, who has dyslexia, failed twice despite being a fluent English speaker who has spent years in Britain, has a British university degree and is married to an American.
"They need to be more flexible," he said. "The NHS is wasting the skills of talented nurses."