Migration of Nurses: A Latin American Perspective

Nursing shortages...have become an increasing challenge in both industrial and developing countries, negatively affecting the health and well being of the global population The world has entered a critical period in its need for human resources to provide healthcare. Nursing shortages, in particular, have become an increasing challenge in both industrial and developing countries, negatively affecting the health and well being of the global population (Buchan, 2004).  The nursing shortage has a critical effect on healthcare because of its negative impact on both preventive and curative care. For example, in developing countries, fewer nurses have been available for providing immunizations and prenatal care. Hospitals in many industrialized and developing countries have been forced to close units when nursing staff has not been available (Oulton, 2006). To meet the growing needs resulting from this shortage, nurses are migrating in growing numbers from developing countries to the United States, Europe, Canada, and within Latin America. This phenomenon is depleting the nurse supply in developing countries and undermining global health initiatives (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004).

Nursing intervention is not only an essential component of health promotion, disease prevention, and care of the sick, but also of rehabilitation (WHO, 2004). While some information concerning nurse migration and the nursing shortage is available for Europe, Canada, the Caribbean, the Philippines, the United States, Australia, and Africa (Kline, 2003), limited knowledge exists for Latin American countries. The available information is inconsistent at best, partly due to the complexity of the subject.  

To address this lacunae, the Human Resources Unit of the Pan American Health Organization (PAHO) planned a symposium during the IX Pan American Research Conference in Lima, Peru (Malvarez, Famer Rocha, Cometto, & Siantz, 2006). The meeting focused on what is known about nursing resources, especially the nursing shortage in the region. This gathering was the first in a series of meetings whose purpose focused on the growing migration of nurses in Latin America and its impact on the nursing shortage. The discussion was timely given the growing impact of globalization on the region and nursing healthcare reforms during the last decade.  The symposium not only explored the major causes of immigration, but also the need for a Latin American database; research to investigate the problem of the nursing shortage and migration; and public policies to address the issue (Malvarez & Siantz, 2005). The complete report of the meeting, including the country presentations can be found in OPS/OMS (2008) Escasez y migracion de Enfermeras en Americana Latina - Notas Pleliminares. Serie Desarrollo de Recursos Humanos para la Salud No. 55 OPS/OMS. Washington, DC.

Background

Unlike the United States, in Latin America registered nurses are no longer the largest part of the healthcare workforce. Latin American nursing is based on three levels of training: (a) professional/registered, (b) technical, and (c) auxiliary. Mexico is the country with the largest proportion of registered nurses (65.1%) while Uruguay has the lowest proportion (12.2%). In the Southern Cone (Brazil, Argentina, Chile, Uruguay, Paraguay) the proportion of nursing auxiliaries in the workforce varies from 62.3% in Argentina to 87.8% in Uruguay. In the Andean area, it ranges from 67.7% in Ecuador to 78.1% in Colombia. In Central America, the Latin Caribbean, and Mexico, nursing auxiliaries vary from 39.5% in Mexico to 82% in Guatemala. These statistics indicate the extent to which nursing care is in the hands of auxiliary staff having only basic training, with professional ladders being used to increase the number of technical and professional nurses (Malvarez, & Castrillon Agudelo, 2005).

The migration and resulting shortage is symptomatic of inadequate policies on recruitment and retention of health workers Nurses are critical to the success of most health systems. Therefore, the effect of the nursing shortage in combination with nurse migration on some developing countries is negative. The impact is especially severe in high-income, industrialized countries where the ratio of nurses to the population is almost eight times greater than in low-income countries. For example, the average ratio of nurses to the population in North America is 10 times that in South America (Buchan & Calman, 2004). Less developed countries are not only losing a scarce resource through migration, but also the investments that have been made in the education of each nurse, as well as the skills and commitment to the healthcare of a particular region. The migration and resulting shortage is symptomatic of inadequate policies on recruitment and retention of health workers (Zurn, Dolea, & Stilwell, 2005).

As the migration, mobility, and international recruitment of nurses has gained attention in recent years, so has the need for nursing research. Reports have frequently relied on anecdotal information and media news which consist of misleading or fragmented assessments of trends and implications. Nevertheless, research has continued to document that nursing care affects population health (Buchan, Parkin, & Sochalski, 2003).

However, Latin America has been overlooked in such research during a period of growing crisis in the provision of healthcare to its citizens. As nurses migrate from developing countries, hospitals are increasingly forced to reduce services, compromising both preventive and restorative healthcare. Consequently, the Human Resources Unit of the Pan American Health Organization recognized a need to examine the trends of cross-country mobility and the deeper workforce problems driving the nursing shortage in Latin America based on country-specific data. This article presents the outcomes of an exploratory meeting that identified: (a) the problems related to the nurse migration and nursing shortage of Latin America, and (b) the need for collaboration on a regional study focused on these critical issues.

Methods

To explore issues in need of further study, the Human Resources Unit of the Pan American Health Organization organized a meeting of nurse leaders to discuss preliminary areas of mutual concern. A series of questions was developed prior to the meetings which focused on critical areas of interest. The Milagros Center of Excellence in Migrant Health participated in this initiative by helping to develop the questions, presenting an overview at the regional meeting in Lima, Peru (Siantz, 2004), and analyzing the presentations of all participants. The following seven areas were identified for exploration (Siantz, Hertzberg, Malvarez, & Famer Rocha, 2006):

• Occurrence of migration of nurses in the Latin American countries
• Reasons for nurse migration
• Identification of organizations that keep track of the migration of nurses
• Recognition of public policies that affected nurse migration in Latin America
• Delineation of the most important information needed to understand migration
• Acknowledgment of the nursing shortage
• Consideration of the most important nursing problems

The distribution process, findings, and discussion of findings will be presented below.

A guide for presentation was mailed to each of the Deans of the Schools of Nursing and Regional Nursing Directors of the Pan American Health Regions. Each nurse leader was asked to report the findings of their countries at the IX Latin American Nursing Research Colloquium, in Lima, Peru (Siantz et al., 2006).  Fifteen of the 19 Latin American countries participated in the study. Participants and non-participants are listed in Table 1. Participating countries included: Argentina, Bolivia, Brazil, Chile, Colombia, Dominican Republic, El Salvador, Ecuador, Guatemala, Honduras, Mexico, Panama, Peru, Uruguay, and Venezuela.

Findings

Migration was recognized as an emerging area in need of nursing research. Migration was recognized as an emerging area in need of nursing research. The economic and social implications of migration were thought to be critical to any successful reorganization of healthcare in Latin America. The need to systematically collect and communicate national and regional knowledge to understand why nurses migrate was identified. Reasons that drive migration, or push factors, were consistent. Low salaries, economic instability, poor quality of life, family needs, and limited opportunities for professional growth “pushed” nurses to leave their home countries.  Higher salaries, opportunities for advancing education, and better living and working conditions were factors that “pulled” nurses to migrate to more developed countries. The growth of auxiliary and technical nurses, along with the shortage of registered nurses was an additional concern. The lack of public policies to support nursing and help to regulate migration was also identified as a problem and as an example of the lack of commitment to the nursing profession’s role in population health. Table 2 summarizes these findings.

Discussion

It was notable that nurses to date have not been included in the long-term planning for the healthcare of the region. The purpose of the investigation reported in this article was to explore preliminary issues of concern regarding the nursing shortage and nurse migration in Latin America. While responses were limited by the available databases which varied from country to country, this was a first attempt to gather regional data. A consensus was reached on the need for more data, and further research on these issues and their impact on the healthcare of Latin America. It was notable that nurses had not been included in the long-term planning for the healthcare of the region.

The significance of this meeting was in the partnerships that were established among participating countries; the collaborative plans for future research, the mutual areas of concern that were identified, and the need for scientific evidence that could be used to develop public policies to support nurses, improve the nursing shortage, and strengthen healthcare for the region. The need to develop a study of nurse migration was agreed upon. It was recommended that future study consider Latin America within a global perspective and the economic implications of nurse migration for the short- and long-term planning for regional health. An area of additional concern included the evidence needed for policy development to support registered nurses in the region.  

Addressing the Public Policy Challenge

[A] policy challenge that Latin American countries face is to identify ways to sustain their nursing workforce...and to identify where the needed supply of nurses will originate...The policy challenge that Latin American countries face is to identify ways to sustain their nursing workforce in the near and distant future and to identify where the needed supply of nurses will originate, as other researchers have articulated (Buchan & Sochalski, 2004). Factors that pull Latin American nurses into international migration can no longer be ignored, with public polices needed to address the growing nursing shortage and its impact on each nation’s health. Economics, living and work environments, and overall quality of life must be considered as developed countries increasingly position themselves to offer such incentives. A scarce resource is becoming scarcer with a growing need to identify both national and regional policies that focus on improving working conditions and quality of life. Both are critical to the retention of current nurses as well as the recruitment and retention of the next generation.

The impact of the migration of professional talent on the country of origin is generally greater than its effect on the country of destination. The effect of migration is greater on developing countries than...industrialized nations... The effect of migration is greater on developing countries than it is on the industrialized nations where out-migration of professionals is largely compensated by in-migration of professionals from developing countries. While migrating nurses may be replaced in terms of numbers, they may not be replaced in terms of quality, especially in countries where auxiliary nurses are replacing registered nurses as in Latin American (Malvarez, & Castrillon Agudelo, 2005).

Planning for the efficient and effective delivery of healthcare in the 21^st century has become a global challenge with key stakeholders struggling to maintain a workforce that meets the health needs of specific populations. In addition to addressing the balance of quality of care with cost efficiency (Buchan, 2006), policies will require timely, multilevel actions at the international, national, and local levels through public/private partnerships that include investments to strengthen relationships with education, health systems, and professional nursing organizations (WHO, 2004).

Developing the Database

A need exists for data to inform policy makers about the negative impact of the nursing shortage and nurse migration on the public health of Latin American countries. Dialogues and convergence strategies need to be established among policy makers; educators; health service researchers; leaders of nursing auxiliaries; technical and registered nurse organizations; and other key stakeholders to support needed research. Data are needed to identify the best way to plan for a workforce that will meet population health needs across the life span, as others have noted in the global arena (Malvarez & Castrillon Agudelo, 2005; O’Brien-Pallas, Duffield, Murphy, Birch, & Meyer, 2005). Without data that combines education, health systems, and public health data, countries will be challenged to understand the impact of nurse migration and to integrate this information into strategic, regional health planning. As Buchan and Sochalski (2004) have noted, strengthening available data, including its reliable collection, verification, and monitoring of trends, is important to the planning of all concerned at the national, state, and local levels.

Conclusion

Without data that combines education, health systems, and public health data, countries will be challenged to understand the impact of nurse migration and to integrate this information into strategic, regional health planning. The negative impact on the health and well being of less developed countries through the migration of their professional nurses is a growing phenomenon. The scope of practice of the registered nurse, including the education that is needed, is not well understood. This preliminary exploratory meeting established consensus on the growing nurse migration in Latin America. A need exists for research that will establish a database to inform public policies that are needed to track and understand factors contributing to migration and to promote the recruitment and retention of professional nurses. It is clear that dialogues and convergence strategies will be needed at all levels for success. Better human resource planning and management strategies will help to recruit and retain the next generation of professional nurses. Healthcare is not provided in isolation. It has become a global challenge, requiring both human and non-human resources. Fully automated healthcare services are still a distant future (O’Brien-Pallas et al., 2005).

Acknowledgment. The authors wish to acknowledge the contribution of Ms. Emily Marie Herzberg in the development of the tables used in this article.

Authors

Mary Lou de Leon Siantz, PhD, RN, FAAN
Email: siantz@nursing.upenn.edu

Mary Lou de Leon Siantz is Assistant Dean Office of Diversity and Cultural Affairs, University of Pennsylvania School of Nursing, the former Director of the Milagros Center of Excellence in Migrant Health, and a past President of the National Association of Hispanic Nurses. She is a founding member of the Mental Health Nurses of the Americas, working with the Regional Advisor on Nursing for over a decade on various projects, including this survey on the migration of nurses in the Americas. A researcher on the effects of migration, through her investigation of the migration of Hispanic children in the US she has interfaced with Hispanic nurses on both sides of the border and recognized the impact of migration on children’s development and family well being.

Silvina Malvárez, PhD, RN
Email: malvares@paho.org

Silvina Malvárez is the Regional Advisor on Nursing and Allied Health Personnel Development at the Pan American Health Organization. She was professor and Dean at the School of Nursing, National University of Cordoba as well as professor in various universities in Latin America and Europe. Professor Malvárez was President of the Argentinean Association of Nursing Schools, Science-Technology Secretary of the Argentinean Federation of Nursing. She is also a former member of the Directing Council of the Latin American Association of Nursing Schools. She has been an internationally invited speaker in most of the countries of the Americas, and is a member of the scientific council of health journals in Argentina, Brazil, Spain, México, Colombia, Uruguay and the United States. She was a Member of the Expert Panel of the World Health Organization (WHO).