The number of international migrants on the move each year continues to increase. While they represent a steady three percent of the world’s population, their numbers have doubled in the last four decades, now reaching a total of 191 million international migrants (International Organization for Migration [IOM], 2005; United Nations [UN], 2006). There has been a particularly marked growth in labor migration flows to industrialized countries (Zlotnik, 2003). In the Organization for Economic Co-operation and Development (OECD) countries, whose 20 member States tend to be the industrialized countries, including the United States (US), United Kingdom (UK), Australia, Japan, and Switzerland, among others, people with tertiary educations accounted 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 almost half of today’s international migrants. Patterns of migration are evolving with many more women migrating independently of partners or families (Timur, 2000), thus changing family dynamics and community networks in both source and destination countries. Women migrants are becoming agents of economic change as they enter the international labor market and participate in a new distribution of global wealth (IOM, 2003).

The eight Millennium Development Goals, which range from halving extreme poverty to halting the spread of HIV/AIDS and providing universal primary education, all by the target date of 2015, form a blueprint agreed to by all the world’s countries and all the world’s leading development institutions. They have galvanized unprecedented efforts to meet the needs of the world’s 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 Health Organization, 2006). The international recruitment efforts and subsequent migration of health professionals from these areas affects the national workforce supply in these countries. Increasingly, these recruitment efforts appear on the political agenda as a possible major factor contributing 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 the primary 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 the national economy through the transfer of funds between migrant workers and their families left behind (estimated to be US$ 232 billion in 2005) (UN 2006), and advance healthcare through the global exchange of knowledge and skills. However, within a context of critical staff shortages affecting access to healthcare, international migration becomes a challenge that needs to be urgently addressed. Migration is increasingly recognized as a symptom of our failing health systems and not the primary disease.

This article will look at the characteristics and the effects of nurse migration, address the factors driving international nurse mobility, and discuss current issues in nurse migration. The author will argue  that rather than focusing on national and international recruitment, serious attention be given to retention strategies to successfully address the critical shortage of health professionals willing to remain in active practice.

Characteristics of Nurse Migration

Nurse migration is a social phenomenon which occurs in a context of increasing global mobility and a growing competition for scarce skills... Nurse migration is a social phenomenon which occurs 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 healthcare professionals and migration flow patterns provides a framework for the discussion and strategic planning that takes into account current realities.

The Numbers

The percentage of foreign-educated physicians working in Australia, Canada, the United Kingdom (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 the percentages of migrating nurses are much smaller than those of physicians, the absolute numbers are always increasing and represent an important depletion of the source countries’ supply of nurses. Thousands of nurses, the vast majority of them women, migrate each year 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 (Kingma, 2006).

New Zealand reports that 21% of its nurses are trained abroad, a significant increase in the last decade (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). In 2005, 84% of the new entrants to the Irish nursing register were foreign-educated (An Bord Altranais, 2005). There is no doubt that foreign-educated nurses make a significant contribution to the delivery of healthcare in most industrialized countries and in many developing countries, with regional or sub-regional hubs, for example South Africa, attracting nurses from neighboring countries by offering better pay, working conditions, and/or professional 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 over the course of their professional lives, each time developing their skills and credentials until they reach 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 the surveyed Filipino nurses employed in the UK had previously worked in Southeast Asia and the Middle East (Opiniano, 2002). Forty-three percent of working international nurses surveyed in London 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-North phenomenon (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 developing countries). An example of the North-North phenomenon would be Irish nurses working in the UK or Canadian nurses practicing in the US; an example of a South-South phenomenon would be 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 are now employed in seven OECD countries, specifically, Canada, Denmark, Finland, Ireland, Portugal, UK, and US (WHO, 2006). This rapid growth in international recruitment from developing countries to industrialized countries has gained considerable media and policy attention in recent years (Dugger, 2006; WHO, 2006).

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

Migration patterns may be seen to change over time. More and more developing countries are contributing to the pool of international nurse migrants. The number of countries sending international 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 the UK, 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 country recruiting mainly from the Philippines, Australia, India, South Africa and the US (ICN, 2004; Department of Health and Children, 2001).

Effects of Nurse Migration

Yet, within a context of shortage there are nurses, even in industrialized countries, such as Canada, who are professionally qualified but without employment. Social phenomena do not exist 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 to consider 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.

Nursing Shortage

Nurses migrating from developing to industrialized countries often leave behind an already disadvantaged system. The nurses who remain assume heavier workloads and experience reduced work satisfaction and low morale contributing to high levels of absenteeism and a deteriorated quality of care delivery (Dovlo, 2005; Chikanda, 2005). This in turn continues to feed the desire of health professionals to seek better working conditions, often outside their national boundaries. The loss of healthcare professionals weakens a country’s health system and the consequences in extreme cases have been measured in lives lost (WHO, 2006).

Despite a growing supply of registered nurses in absolute numbers, the relative inadequate supply of nurses has had a dramatic global impact in recent years. High nurse vacancy rates are present in industrialized as well as developing countries (Simoens et al., 2005). In the US, 1.2 million new and replacement nurses will be needed by 2014 (Hecker, 2005). The number of nurses currently in the older-nurse cohort is expected to significantly decline after 2010, and the required 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 to the 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 Paradox of Unemployed Nurses

Recent nurse graduates from Uganda, Grenada, and Zambia are faced with unemployment as their health systems do not have the funds to cover their salaries.Yet, within a context of shortage there are nurses, even in industrialized countries, such as Canada, who are professionally qualified but without employment. This is a modern paradox, i.e., nurses who are willing to work 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 that “paradoxically, …insufficiencies often coexist in a country with large numbers of unemployed health professionals” (p. xviii). For example, although half of all nursing positions in Kenya are unfilled, 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 not have the funds to cover their salaries.

“Ghost workers,” persons who appear on payrolls but do not exist at workplaces, may block access 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 illusion that hospitals are adequately staffed. Nurses in Tanzania, the Philippines, and parts of Eastern Europe are working for free in order to maintain their competencies and be next in line when a budgeted 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 labor policy.

...most nurses are reluctant to leave their home countries and would be willing to stay if offered a living wage. Migration theory has evolved over many decades. No one theory, however, captures all the forces that influence an individual’s decision to move. Traditionally, migration was thought 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 absence of wage incentives, or, in contrast, the disregard for comparatively higher wage incentives offered in certain countries? One study compared migration flows in relation to the pull of wage incentives. The nurse wage in Australia and Canada is estimated to be approximately fourteen times the nurse wage in Ghana and about twice the nurse wage in South Africa once purchasing power parity is applied. If wages were the decisive factor, more Ghanaian nurses than South African nurses should migrate because the rewards are much greater. In fact, the proportion of health workers who intend to emigrate from South Africa is approximately equal to that in Ghana, 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 doubt that it plays a key role in deciding whether or not to migrate. According to the International Organization for Migration (IOM), remaining in one’s country of birth is the norm and many field studies confirm that most migrants would prefer to stay home in familiar surroundings and within their extended family (IOM, 2003). Research continues to find the major reasons behind health worker migration are...better remuneration, safer environment, improved living conditions, and...a lack of support from supervisors, non-involvement in decision making, lack of facilities, lack of promotions, lack of a future, and heavy workloads in their home countries Similarly, most nurses are reluctant to leave their home countries and would be willing to stay if offered a living wage. Recent research suggests that the relative income of nurses within their home countries is a critical influence on attrition and migration rates (Brown & Connell, 2004). The substantial wage disparities found between nurses and other professional workers within the country are felt to be denigrating, a major source of frustration, and now a recognized motivating factor 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 worker migration are the pull factors of better remuneration, safer environment, improved living conditions in the destination countries, and the push factors of a lack of support from supervisors, non-involvement in decision making, lack of facilities, lack of promotions, lack of a future, and heavy workloads in their home countries (PAHO, 2001, WHO, 2006). Non-financial factors, such as political forces, poverty, age of the migrant, past colonial and cultural ties between source and destination countries, facilitated emigration process, employment/educational opportunities for family members, and existing diaspora (transnational communities), also  play a very important role (Padarath et al., 2003). In one way or another, a better 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 of health sector stakeholders, including the consumer or patient, the government or employer, and the worker or health professional. In this section a discussion on the right to work and the right to practice is, by necessity, followed by a warning that cases of exploitation and discrimination often occur when dealing with a vulnerable migrant population. Additionally, international migration policy issues addressing the somewhat conflicting sets of stakeholders’ rights are presented, 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 labor market. Unable to meet domestic need and demand, many industrialized countries are looking abroad for a solution to their workforce shortages; the magnitude of current international recruitment is unprecedented (ICN, 2005).

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

...in many countries, a nurse’s right to practice is limited if the foreign-educated nurse’s language skills do not support safe care practices. In the interest of public safety, nurses’ qualifications must be screened in a systematic way to ensure they meet the minimum professional standards of the country where they are to deliver care. This may be in the form of a paper screen, for example 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.

Language is a crucial vehicle for the vital communication needed both between the patient and care provider, and also between members of the health team. It is not surprising that in many countries, a nurse’s right to practice is limited if the foreign-educated nurse’s language skills do not 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 flows to 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 France while nurses from Ghana will be attracted by the United Kingdom. As the pools of nurses willing to migrate change, and as language competency becomes a professional advancement requirement, language barriers may prove to be less of a constraint, and we may see Chinese nurses 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 the country 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 after terrorism attacks or the opening of borders with new economic agreements, such as the expansion of the European Union, will continue to influence nurse migration patterns.

Negotiations to facilitate the temporary employment of foreign healthcare workers through the introduction of the General Agreement on Trade in Services (GATS) have not progressed. The future 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 nurse migration at the regional level. Examples of such agreements include Protocol II of the Caribbean Community and Common Market (CARICOM), the North American Free Trade Agreement (NAFTA), the Trans-Tasman Agreement, and Nursing Directives of the European Union.

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 and practices that affect migrant health professionals.One of the most serious problems migrant nurses encounter in their new community and workplace is that of racism and its resulting discrimination (Chandra & Willis, 2005). Incidents are, however, often hidden by a blanket of silence and therefore difficult to quantify (Kingma, 1999). Migrant nurses are frequent victims of poorly enforced equal opportunity policies and pervasive double standards. Some migrant nurses are experiencing dramatic situations on the job where colleagues purposefully misunderstand, undermine their professional skills, refuse to help, and sometimes bully them, thus increasing their sense of isolation (Allan & Larsen, 2003; Hawthorne, 2001; Kingma, 2006). 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 and practices that affect migrant health professionals.

International Migration Policy

There have been various attempts to reduce migration through legislation, national guidelines, or international agreements. Increasingly, however, it has been acknowledged that migration is a characteristic of today’s globalized world and that such control mechanisms may have the perverse effect of infringing individuals’ freedom of movement and exposing the recruitment process to even greater corruption and double standards. A delicate balance must be maintained between the human and labor rights of the individual and a collective concern for the health of a nation’s population.

A delicate balance must be maintained between the human and labor rights of the individual and a collective concern for the health of a nation’s population.Various codes of practice addressing ethical, international recruitment, or similar instruments, have been introduced at national and international levels. Their effectiveness, however, is yet to be demonstrated (WHO, 2006); and the support systems, incentives/sanctions, and the means for monitoring their implementation continue 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 policy analysis and decision-making“ (p. 5). For example, codes tend to assume migration is a permanent 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 eventually return to their source countries; such circular mobility may result in a net gain of knowledge and skills 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. In fact, there has been an increasing mix of temporary/permanent migration (Timur, 2000) with a noted 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 national resource, and even an enriched resource if their acquired skills and knowledge are put to good use. Until we have better data, it is impossible to know if brain circulation; rather than brain drain, is the current reality. Brain circulation, however, definitely has the potential for being a “best case” scenario for the future.

If migrants return to their home country...they will once again be a national resource, and even an enriched resource if their acquired skills and knowledge are put to good use. Migration is increasingly 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 are benefiting from exchange programs, by the channeling of remittances from nurses working abroad to public sector development projects in their source country, or finding migration a solution to high unemployment levels (ICN 2005). Industrialized countries faced with dramatic nurse shortages continue to see the recruitment of foreign-educated nurses as part of the solution to their failing health systems.

Ethical Questions Related to Nurse Migration

The ICN Position Statement on Ethical Nurse Recruitment protects the individual’s freedom of movement. It also emphasizes the need for good-faith bargaining between employer and employee and the right of health workers to decent work and protection from exploitation. It calls for effective regulatory mechanisms for screening nurses’ qualifications as well as for regulating 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 it acceptable to recruit nurses from countries suffering from dramatic nurse shortages? Is it ethical to refuse employment to nurses looking to improve their living conditions and the future of their families? 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 the International Council of Nurses summarizes the key points commonly raised (See Table).

Conclusion

International mobility is a reality in a globalized world, one that will not be regulated out of existence. International migration is a symptom of the larger, systemic problems that make nurses leave their jobs and, at times, of the problems in a country’s health sector. The data clearly show that no matter how attractive the pull factors of the destination country, little migration takes place without substantial push factors driving people away from the source country (Kingma, 2006). It can be difficult to determine which comes first – the recruitment factor or the wish to migrate.

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

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

Author

Mireille Kingma, PhD, RN
E-mail: kingma@icn.ch

Mireille Kingma is a consultant for nursing and health policy with the International Council of Nurses, a federation of 130 national nurses’ associations. She has a BS in nursing from Cornell University and an MA in human resources development from Webster University, Switzerland. Her doctoral thesis, “Economic Policy: Incentive or Disincentive for Community Nurses?” was written for the London School of Hygiene and Tropical Medicine. During the past twenty years she has been responsible for international consultations and training programs in more than sixty countries. Her recent book, Nurses on the Move: Migration and the Global Health Care Economy, was released by Cornell University Press in 2006.

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