Nurses on the Move

8/6/2019 Nurses on the Move

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Nurses on the Move: Historical Perspective

and Current Issues

MireilleKingma, PhD, RN

Abstract

The number of international migrants on the move each year continues to increase. Womenmigrants are becoming agents of economic change as they enter the international labor marketand participate in a new distribution of global wealth. Professionally active nurses are importantplayers in an increasingly competitive, global labor market. Thousands of nurses migrate eachyear in search of better pay and working conditions, career mobility, professional development, a

better quality of life, personal safety, or sometimes just novelty and adventure. In this article, theauthor looks at the characteristics and the effects of nurse migration, addresses the factorsdriving international nurse mobility, and discusses current issues regarding nurse migration. Theauthor advises that rather than focusing on national and international recruitment, seriousattention be given to retention strategies to successfully address the critical shortage of healthprofessionals willing to remain in active practice.

Citation:Kingma, M., (May 31, 2008) "Nurses on the Move: Historical Perspective and CurrentIssues" OJIN: The Online Journal of Issues in Nursing. Volumn 13, No 2, Manuscript 1.

DOI: 10.3912/OJIN.Vol13No02Man01

Key words: ethical recruitment, health human resources, health professionals, internationalrecruitment, nurse, nurse migration, nurse shortage

The number of international migrants on the move each year continues to increase. While theyrepresent a steady three percent of the worlds population, their numbers have doubled in the lastfour decades, now reaching a total of 191 million international migrants (InternationalOrganization for Migration [IOM], 2005; United Nations [UN], 2006). There has been aparticularly marked growth in labor migration flows to industrialized countries (Zlotnik, 2003).In the Organization for Economic Co-operation and Development (OECD) countries, whose 20member States tend to be the industrialized countries, including the United States (US), United

Kingdom (UK), Australia, Japan, and Switzerland, among others, people with tertiary educationsaccounted for nearly half the increase in migrants older than 25 years during the 1990s (UN,2006). There is an increasing feminization of migration flows, with women representing almosthalf of todays international migrants. Patterns of migration are evolving with many morewomen migrating independently of partners or families (Timur, 2000), thus changing familydynamics and community networks in both source and destination countries. Women migrantsare becoming agents of economic change as they enter the international labor market andparticipate in a new distribution of global wealth (IOM, 2003).


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The eight Millennium Development Goals, which range from halving extreme poverty to haltingthe spread of HIV/AIDS and providing universal primary education, all by the target date of2015, form a blueprint agreed to by all the worlds countries and all the worlds leadingdevelopment institutions. They have galvanized unprecedented efforts to meet the needs of theworlds poorest. Countries having the greatest difficulty in meeting these UN Millennium

Development Goals (MDGs) tend to be faced with absolute shortfalls in their health workforce,seriously limiting their potential to respond equitably to even basic health needs (World HealthOrganization, 2006). The international recruitment efforts and subsequent migration of healthprofessionals from these areas affects the national workforce supply in these countries.Increasingly, these recruitment efforts appear on the political agenda as a possible major factorcontributing to the shortage of healthcare professionals in these countries (Stilwell et al., 2003;International Council of Nurses [ICN]/Florence Nightingale International Foundation [FNIF],2006; World Health Organization [WHO], 2006).

Migration is increasingly recognized as a symptom of our failing health systems and not theprimary disease.Migration in the context of a supply surplus would not be an issue. In such

situations, it may even be considered a positive strategy to reduce unemployment, improve thenational economy through the transfer of funds between migrant workers and their families leftbehind (estimated to be US$ 232 billion in 2005) (UN 2006), and advance healthcare through theglobal exchange of knowledge and skills. However, within a context of critical staff shortagesaffecting access to healthcare, international migration becomes a challenge that needs to beurgently addressed. Migration is increasingly recognized as a symptom of our failing healthsystems and not the primary disease.

This article will look at the characteristics and the effects of nurse migration, address the factorsdriving international nurse mobility, and discuss current issues in nurse migration. The authorwill argue that rather than focusing on national and international recruitment, serious attentionbe given to retention strategies to successfully address the critical shortage of healthprofessionals willing to remain in active practice.

Characteristics of Nurse Migration

Nurse migration is a social phenomenon which occurs in a context of increasing global mobilityand a growing competition for scarce skills... Nurse migration is a social phenomenon whichoccurs in a context of increasing global mobility and a growing competition for scarce skills,including skills needed in the healthcare sector. Looking at the numbers of migrating healthcareprofessionals and migration flow patterns provides a framework for the discussion and strategicplanning that takes into account current realities.

The Numbers

The percentage of foreign-educated physicians working in Australia, Canada, the UnitedKingdom (UK) and the United States (US) is currently reported to be between 21% and 33%.Foreign-educated nurses represent only 5% - 10% of these countries nurse workforce. While thepercentages of migrating nurses are much smaller than those of physicians, the absolute numbersare always increasing and represent an important depletion of the source countries supply ofnurses. Thousands of nurses, the vast majority of them women, migrate each year in search of


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better pay and working conditions, career mobility, professional development, a better quality oflife, personal safety, or sometimes just novelty and adventure (Kingma, 2006).

New Zealand reports that 21% of its nurses are trained abroad, a significant increase in the lastdecade (WHO, 2006). In Switzerland, 30% of employed registered nurses are foreign-educated;

and in at least one university hospital 70% of new recruits are from abroad (Artigot, 2003). In2005, 84% of the new entrants to the Irish nursing register were foreign-educated (AnBordAltranais, 2005). There is no doubt that foreign-educated nurses make a significantcontribution to the delivery of healthcare in most industrialized countries and in manydeveloping countries, with regional or sub-regional hubs, for example South Africa, attractingnurses from neighboring countries by offering better pay, working conditions, and/orprofessional development opportunities.

Migration Flow Patterns

The carousel mobility of physicians around the world is widely acknowledged. Physicians in

the carousel mobility pattern leave their source countries and migrate to several countries overthe course of their professional lives, each time developing their skills and credentials until theyreach the US, repeatedly identified as the epicenter of international migration (Martineau et al.,2002). Nurses are duplicating this multiple step pattern. For example, forty percent of thesurveyed Filipino nurses employed in the UK had previously worked in Southeast Asia and theMiddle East (Opiniano, 2002). Forty-three percent of working international nurses surveyed inLondon were considering relocating to another country, in many cases to the US (Buchan et al.,2005).

Historically, there has been a tendency for international nurse migration to be a North-Northphenomenon (in which the place of origin and destination are both in industrialized countries) or

a South-South phenomenon (in which the place of origin and destination are both in developingcountries). An example of the North-North phenomenon would be Irish nurses working in theUK or Canadian nurses practicing in the US; an example of a South-South phenomenon wouldbe Fijian nurses migrating to Palau, an island nation south of Tokyo and east of the Philippines.

However, it is estimated that 30,000 nurses and midwives educated in sub-Saharan Africa arenow employed in seven OECD countries, specifically, Canada, Denmark, Finland, Ireland,Portugal, UK, and US (WHO, 2006). This rapid growth in international recruitment fromdeveloping countries to industrialized countries has gained considerable media and policyattention in recent years (Dugger, 2006; WHO, 2006).

In 2000, more than twice the number of new graduates from nursing programs in Ghana left thatcountry for employment in the industrialized countries (Zachary, 2001). In Malawi, between1999 and 2001 over 60% of the registered nurses in a single tertiary hospital (114 nurses) left foremployment in other countries (Martineau et al., 2002). In 2003, a hospital in Swaziland reportedthat 30% of their 125 nurses left to work abroad (Kober& Van Damme, 2006) and, between 1999and 2001, Zimbabwe lost 32% of their registered nurses to employment in the UK (Chikanda,2005).


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Migration patterns may be seen to change over time. More and more developing countries arecontributing to the pool of international nurse migrants. The number of countries sendinginternational nurse recruits to the UK increased from 71 in 1990 to 95 in 2001 (Buchan&Sochalski, 2004). The Philippines, once the leading source of nurse migrants to Ireland and theUK, was outranked by India in 2005 (Health Service Executive - Employers Agency [HSE-EA],

2003; HSE [Health Service Executive], 2004;Nursing and Midwifery Council [NMC], 2005).While Ireland was a nurse exporting country for decades, it is now an importing countryrecruiting mainly from the Philippines, Australia, India, South Africa and the US (ICN, 2004;Department of Health and Children, 2001).

Effects of Nurse MigrationYet, within a context of shortage there are nurses, even in industrialized countries, such asCanada, who are professionally qualified but without employment. Social phenomena do notexist in isolation. There are certain dynamic forces operating that influence individual,institutional, and societal phenomenon. The nursing shortage is presently on the political agenda.It is important to look at nurse mobility within the context of the nursing shortage and toconsider the paradox of unemployed nurses seen in the very countries with the greatest shortage,so as to understand how various societal forces contribute to the effects of nurse migration.

NursingShortage

Nurses migrating from developing to industrialized countries often leave behind an alreadydisadvantaged system. The nurses who remain assume heavier workloads and experiencereduced work satisfaction and low morale contributing to high levels of absenteeism and adeteriorated quality of care delivery (Dovlo, 2005; Chikanda, 2005). This in turn continues tofeed the desire of health professionals to seek better working conditions, often outside theirnational boundaries. The loss of healthcare professionals weakens a countrys health system andthe consequences in extreme cases have been measured in lives lost (WHO, 2006).

Despite a growing supply of registered nurses in absolute numbers, the relative inadequatesupply of nurses has had a dramatic global impact in recent years. High nurse vacancy rates arepresent in industrialized as well as developing countries (Simoens et al., 2005). In the US, 1.2million new and replacement nurses will be needed by 2014 (Hecker, 2005). The number ofnurses currently in the older-nurse cohort is expected to significantly decline after 2010, and therequired 40% increase of younger people enrolling in nursing programs so as to meet the future,domestic need is unlikely to occur (Buerheus et al., 2003). Many of the factors contributing tothe high vacancy and attrition rates in health systems appear to influence the level of migration.With few exceptions, nurse shortages are present in all regions of the world and constitute a

priority concern (ICN, 2004).

The ParadoxofUnemployed Nurses

Recent nurse graduates from Uganda, Grenada, and Zambia are faced with unemployment astheir health systems do not have the funds to cover their salaries.Yet, within a context of shortagethere are nurses, even in industrialized countries, such as Canada, who are professionallyqualified but without employment. This is a modern paradox, i.e., nurses who are willing to work


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but who are refused posts by national health systems unable to absorb them, not for lack of need,but for lack of funds and/or health sector reform restrictions. WHO (2006) confirms thatparadoxically, insufficiencies often coexist in a country with large numbers of unemployedhealth professionals (p. xviii). For example, although half of all nursing positions in Kenya areunfilled, a third of all Kenyan nurses are unemployed (Volqvartz, 2005). Recent nurse graduates

from Uganda, Grenada, and Zambia are faced with unemployment as their health systems do nothave the funds to cover their salaries.

Ghost workers, persons who appear on payrolls but do not exist at workplaces, may blockaccess to health worker positions. An estimated 5,000 ghost workers exist in Kenya alone(Dovlo, 2005). This further worsens nurse:patient staffing ratios by giving an on-paper illusionthat hospitals are adequately staffed. Nurses in Tanzania, the Philippines, and parts of EasternEurope are working for free in order to maintain their competencies and be next in line when abudgeted position becomes available.

Driving Factors of Nurse Mobility

Behind every social phenomenon there are driving factors. If nurse migration is to be understood,these causative factors must be well known and considered when introducing health and laborpolicy.

...most nurses are reluctant to leave their home countries and would be willing to stay if offered aliving wage. Migration theory has evolved over many decades. No one theory, however, capturesall the forces that influence an individuals decision to move. Traditionally, migration wasthought to occur when the perceived cost of moving was less than the perceived cost of staying(Lowell & Findlay, 2002). Yet, one might ask how this explains nurse migration in the absenceof wage incentives, or, in contrast, the disregard for comparatively higher wage incentivesoffered in certain countries? One study compared migration flows in relation to the pull of wageincentives. The nurse wage in Australia and Canada is estimated to be approximately fourteentimes the nurse wage in Ghana and about twice the nurse wage in South Africa once purchasingpower parity is applied. If wages were the decisive factor, more Ghanaian nurses than SouthAfrican nurses should migrate because the rewards are much greater. In fact, the proportion ofhealth workers who intend to emigrate from South Africa is approximately equal to that inGhana, suggesting that factors beyond pay also influence workers decisions (Vujicic et al.,2004).

While financial incentive is not the only factor contributing to nurse migration, there is no doubtthat it plays a key role in deciding whether or not to migrate. According to the InternationalOrganization for Migration (IOM), remaining in ones country of birth is the norm and many

field studies confirm that most migrants would prefer to stay home in familiar surroundings andwithin their extended family (IOM, 2003). Research continues to find the major reasons behindhealth worker migration are...better remuneration, safer environment, improved livingconditions, and...a lack of support from supervisors, non-involvement in decision making, lack offacilities, lack of promotions, lack of a future, and heavy workloads in their home countriesSimilarly, most nurses are reluctant to leave their home countries and would be willing to stay ifoffered a living wage. Recent research suggests that the relative income of nurses within theirhome countries is a critical influence on attrition and migration rates (Brown & Connell, 2004).


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The substantial wage disparities found between nurses and other professional workers within thecountry are felt to be denigrating, a major source of frustration, and now a recognized motivatingfactor in attrition and international migration (Simoens et al., 2005).

There has been a great deal of discussion of the push and pull factors behind decisions to

migrate (Kingma, 2006). Research continues to find the major reasons behind health workermigration are the pull factors of better remuneration, safer environment, improved livingconditions in the destination countries, and the push factors of a lack of support fromsupervisors, non-involvement in decision making, lack of facilities, lack of promotions, lack of afuture, and heavy workloads in their home countries (PAHO, 2001, WHO, 2006). Non-financialfactors, such as political forces, poverty, age of the migrant, past colonial and cultural tiesbetween source and destination countries, facilitated emigration process,employment/educational opportunities for family members, and existing diaspora (transnationalcommunities), also play a very important role (Padarath et al., 2003). In one way or another, abetter life and livelihood are at the root of decisions to migrate (WHO, 2006).

Issues in Nurse Migration

Nurse migration has attracted a great deal of political as well as media attention in recent years.The right to healthcare as well as workers rights are paramount to understanding the interests ofhealth sector stakeholders, including the consumer or patient, the government or employer, andthe worker or health professional. In this section a discussion on the right to work and the right topractice is, by necessity, followed by a warning that cases of exploitation and discriminationoften occur when dealing with a vulnerable migrant population. Additionally, internationalmigration policy issues addressing the somewhat conflicting sets of stakeholders rights arepresented, and ethical questions related to nurse migration are noted.

The Right to Work and the Right to Practice

Professionally active nurses are important players in an increasingly competitive and global labormarket. Unable to meet domestic need and demand, many industrialized countries are lookingabroad for a solution to their workforce shortages; the magnitude of current internationalrecruitment is unprecedented (ICN, 2005).

For nurses to practice their profession internationally, they need to meet both professionalstandards and migration criteria. The right to practice, e.g., to hold a license or registration, aprofessional criteria, and the right to work, e.g. to hold a work permit, a migration criteria, aresometimes linked. Yet they often require a different set of procedures with a distinct set ofcompetent authorities.

...in many countries, a nurses right to practice is limited if the foreign-educated nurses languageskills do not support safe care practices. In the interest of public safety, nurses qualificationsmust be screened in a systematic way to ensure they meet the minimum professional standards ofthe country where they are to deliver care. This may be in the form of a paper screen, forexample automatic recognition of qualifications received from a given country or school; tests,such as the NCLEX licensing exam; supervised clinical practice, as seen in an adaptation period;and/or successful completion of an orientation course/program.


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Language is a crucial vehicle for the vital communication needed both between the patient andcare provider, and also between members of the health team. It is not surprising that in manycountries, a nurses right to practice is limited if the foreign-educated nurses language skills donot support safe care practices. Passing specific language tests are required in certain countries.In others, the employer is held responsible for ascertaining the language competence of the

employees/health professionals. Clearly, history has demonstrated a tendency for migrant flowsto be the strongest between source and destination countries that share a common language(Kingma, 2006). For example, nurses wishing to migrate from Morocco will tend to go to Francewhile nurses from Ghana will be attracted by the United Kingdom. As the pools of nurses willingto migrate change, and as language competency becomes a professional advancementrequirement, language barriers may prove to be less of a constraint, and we may see Chinesenurses working in Ireland and Korean nurses going to the US.

Foreign nurses also need to meet national security and immigration criteria in-order-to enter thecountry and to stay on a permanent or temporary basis, with or without access to employment.There is no doubt that nurse mobility will be affected by national security concerns and decisions

on how fluid the borders will be maintained. For example a tightening of border restrictions afterterrorism attacks or the opening of borders with new economic agreements, such as theexpansion of the European Union, will continue to influence nurse migration patterns.

Negotiations to facilitate the temporary employment of foreign healthcare workers through theintroduction of the General Agreement on Trade in Services (GATS) have not progressed. Thefuture impact of this agreement on global nurse mobility is therefore unclear (ICN, 2005: WHO,2006). On the other hand, mutual recognition agreements that allow for automatic re-accreditation and that are often linked to an economic cooperation have encouraged nursemigration at the regional level. Examples of such agreements include Protocol II of theCaribbean Community and Common Market (CARICOM), the North American Free TradeAgreement (NAFTA), the Trans-Tasman Agreement, and Nursing Directives of the EuropeanUnion.

Exploitation and Discrimination

If we recognize that international migration will continue and probably increase in coming years,the protection of workers is a priority issue and should be safeguarded in all policies andpractices that affect migrant health professionals.One of the most serious problems migrantnurses encounter in their new community and workplace is that of racism and its resultingdiscrimination (Chandra & Willis, 2005). Incidents are, however, often hidden by a blanket ofsilence and therefore difficult to quantify (Kingma, 1999). Migrant nurses are frequent victims ofpoorly enforced equal opportunity policies and pervasive double standards. Some migrant nursesare experiencing dramatic situations on the job where colleagues purposefully misunderstand,undermine their professional skills, refuse to help, and sometimes bully them, thus increasingtheir sense of isolation (Allan & Larsen, 2003; Hawthorne, 2001;Kingma, 2006). If we recognizethat international migration will continue and probably increase in coming years, the protectionof workers is a priority issue and should be safeguarded in all policies and practices that affectmigrant health professionals.


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InternationalMigration Policy

There have been various attempts to reduce migration through legislation, national guidelines, orinternational agreements. Increasingly, however, it has been acknowledged that migration is acharacteristic of todays globalized world and that such control mechanisms may have the

perverse effect of infringing individuals freedom of movement and exposing the recruitmentprocess to even greater corruption and double standards. A delicate balance must be maintainedbetween the human and labor rights of the individual and a collective concern for the health of anations population.

A delicate balance must be maintained between the human and labor rights of the individual anda collective concern for the health of a nations population.Various codes of practice addressingethical, international recruitment, or similar instruments, have been introduced at national andinternational levels. Their effectiveness, however, is yet to be demonstrated (WHO, 2006); andthe support systems, incentives/sanctions, and the means for monitoring their implementationcontinue to be weak or non-existent (Willets & Martineau, 2004). Buchan and Sochalski (2004)

argue that codes are flawed by the inadequacy of information systems needed for policyanalysis and decision-making (p. 5). For example, codes tend to assume migration is apermanent loss to the source country but the evidence is missing to support this assumption(Kingma, 2006). By some estimates, 60% of Africans who go to the United States eventuallyreturn to their source countries; such circular mobility may result in a net gain of knowledge andskills for a continent, such as Africa (Zimmerman, 2008).

Brain drain, which implies a loss to the source country of vital skills, professional knowledge,and management capacity, is only relevant as a concept if linked with permanent migration. Infact, there has been an increasing mix of temporary/permanent migration (Timur, 2000) with anoted growth in temporary migration (Findlay & Lowell, 2002). If migrants return to their home

country (or the country that has invested in their education), they will once again be a nationalresource, and even an enriched resource if their acquired skills and knowledge are put to gooduse. Until we have better data, it is impossible to know if brain circulation; rather than braindrain, is the current reality. Brain circulation, however, definitely has the potential for being abest case scenario for the future.

If migrants return to their home country...they will once again be a national resource, and evenan enriched resource if their acquired skills and knowledge are put to good use. Migration isincreasingly seen as a means for development and a better distribution of global wealth (IOM,2003). While some developing countries are hemorrhaging from nurse migration, others arebenefiting from exchange programs, by the channeling of remittances from nurses workingabroad to public sector development projects in their source country, or finding migration asolution to high unemployment levels (ICN 2005). Industrialized countries faced with dramaticnurse shortages continue to see the recruitment of foreign-educated nurses as part of the solutionto their failing health systems.

Ethical Questions Related to Nurse Migration


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The ICN Position Statement on Ethical Nurse Recruitment protects the individuals freedom ofmovement. It also emphasizes the need for good-faith bargaining between employer andemployee and the right of health workers to decent work and protection from exploitation. Itcalls for effective regulatory mechanisms for screening nurses qualifications as well as forregulating recruitment agencies (ICN, 2007). A full discussion on the ethics of nurse migration is

beyond the scope of this article, but some of the questions that need answers include: Is itacceptable to recruit nurses from countries suffering from dramatic nurse shortages? Is it ethicalto refuse employment to nurses looking to improve their living conditions and the future of theirfamilies? Is it appropriate to refuse employment to nurses without work in their home countries?

The pros and cons of nurse migration have been and will be debated. A table developed by theInternational Council of Nurses summarizes the key points commonly raised (See Table).

ConclusionInternational mobility is a reality in a globalized world, one that will not be regulated out ofexistence. International migration is a symptom of the larger, systemic problems that makenurses leave their jobs and, at times, of the problems in a countrys health sector. The dataclearly show that no matter how attractive the pull factors of the destination country, littlemigration takes place without substantial push factors driving people away from the sourcecountry (Kingma, 2006). It can be difficult to determine which comes first the recruitmentfactor or the wish to migrate.

Migration is frequently a decision individuals make because of the constraints experienced in theworkplace or the broader society. Nurse migration is pushed, pulled, and shaped by aconstellation of social forces and determined by a series of choices made by a multitude ofstakeholders. International mobility is a reality in a globalized world, one that will not beregulated out of existence. It becomes an issue only in the context of shortages or migrantexploitation and abuse. If South-North migration is to be reduced, it will be more appropriate toaddress the reasons why nurses migrate than to artificially curb the migration flow. Therecruitment process (including the practices of recruitment agencies) must be regulated andworkers rights in the destination country firmly upheld if migrant exploitation is to beeliminated, the negative consequences of international migration mitigated, and the potentialbeneficial outcomes realized (Kingma, 2007).

Rather than continuing to focus on national and international recruitment, more serious attentionmust be given to retention strategies, including effective incentive packages. The growing healthneeds of national and global populations require health systems with strong infrastructures andsustainable domestic workforces that effectively deliver equitable care.

Author

MireilleKingma, PhD, RNE-mail: [email protected]

MireilleKingma is a consultant for nursing and health policy with the International Council ofNurses, a federation of 130 national nurses associations. She has a BS in nursing from Cornell


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University and an MA in human resources development from Webster University, Switzerland.Her doctoral thesis, Economic Policy: Incentive or Disincentive for Community Nurses? waswritten for the London School of Hygiene and Tropical Medicine. During the past twenty yearsshe has been responsible for international consultations and training programs in more than sixtycountries. Her recent book,Nurses on the Move: Migration and the Global Health Care

Economy, was released by Cornell University Press in 2006.

Table. Pros and Cons of International Nurse Migration

INTERNATIONAL NURSE MIGRATION

PROS -

y Educational opportunitiesy Professional practice opportunitiesy Personal and occupational safetyy Better working conditionsy Improved quality of lifey Trans-cultural nursing workforce (e.g. racial and ethnic diversity)y Cultural sensitivity/competence in carey Stimulation of nurse-friendly recruitment and contract conditionsy Personal developmenty Global economic developmenty Improved knowledge base and brain gainy Sustained maintenance and development of family members in the country of origin

CONS -

y Brain and/or skills drainy Closure of health facilities due to nursing shortages in a given areay Overwork of nurses practising in depleted areasy Potentially abusive recruitment and employment practicesy Vulnerable status of migrantsy Loss of national economic investment in human resource development

Reprinted with permission from ICN (2002) Career Moves and Migration: Critical Questions.Geneva: International Council of Nurses. Accessed at www.icn.ch/CareerMovesMigangl.pdfApril 21, 2008

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