Push and Pull Factors in International Nurse Migration - University of ...

Push and Pull Factors in InternationalNurse MigrationDonna S. KlineWorld HealthPurpose: To describe the push and pull factors of migration in relation to internationalrecruitment and migration of nurses.Organizing Construct: Review of literature on nurse migration, examination of effects of donorand receiving countries, and discussion of ethical concerns related to foreign nurse recruitment.Findings: The primary donor countries are Australia, Canada, the Philippines, South Africa,and the United Kingdom (UK); the primary receiving countries are Australia, Canada, Ireland,the UK, and the United States (US). The effects of migration on donor countries include theloss of skilled personnel and economic investment; receiving countries receive skilled nursesto fill critical shortages with less economic investment. Ethical concerns include the potentialfor exploitation of foreign nurses.Conclusions: Nurses migrate to seek better wages and working conditions than they have intheir native countries. Given the current conditions, developed countries continue to activelyrecruit foreign nurses to fill critical shortages. Migration is predicted to continue until developedcountries address the underlying causes of nurse shortages and until developing countriesaddress conditions that cause nurses to leave.JOURNAL OF NURSING SCHOLARSHIP, 2003; 35:2, 107-111. ©2003 SIGMA THETA TAU INTERNATIONAL.[Key words: nurse migration, push and pull factors, nursing shortage, international]* * *Ashortage of registered nurses (RNs) exists in countriesthroughout the world. Australia, Canada, France,Germany, Ireland, the United Kingdom (UK), andthe United States (US)—all wealthy, industrialized countries—are but a few of the countries reporting nursing shortages.Cyclical nurse shortages in many countries have usually beenthe result of increased demands outpacing the slower-increasingsupply of nurses (Buchan, 2001). The current shortage,however, appears more serious, with demand continuing toincrease while the projected supply indicates a continuedreduction in the availability of nurses, especially in the USand UK, countries that are primary destinations of migratingnurses.A survey conducted by the American Hospital Association(AHA) showed that the 715 U.S. hospitals surveyed posted168,000 open positions; of those positions, 126,000 or 75%were for RNs (AHA, 2001). A recent study indicated theprojected gap between supply and demand for RNs in the USto be 808,000 by the year 2020 (Bureau of Health Professions,2002). The UK is grappling with similar nurse shortageproblems. The Royal College of Nursing listed the currentnumber of RN vacancies at about 22,000 and estimated thatthe National Health System (NHS) will need to recruit110,000 RNs by 2004 (Finalyson, Dixon, Meadows, & Blair,2002b).In addition to current shortage problems in the US, afundamental shift occurred in the RN workforce during thelast 2 decades that has been predicted to substantially affectthe overall numbers of RNs available. According to Buerhaus,Staiger, and Auerbach (2000), as the opportunities for womenoutside nursing expanded over the last 20 years in the US, thenumber of young women entering the RN workforce declined.As a result, a demographic shift has occurred in the nursingworkforce. The decreased number of young people choosingnursing careers has resulted in a gradually increasing averageage of nurses, and thus an aging RN workforce withoutcommensurate replacement of retiring nurses. The authorspredicted that this aging will continue over the next decadewhen the largest percentage of RNs will be in their 50s and60s, after which the RN workforce will become even smalleras the aging RNs retire.One means to alleviate the shortage crisis in developedcountries has been to recruit foreign nurses to fill vacantDonna S. Kline, RN, MN, Nurse Manager, Seattle Veterans Affairs PugetSound Health Care System, Seattle, WA. Correspondence to Ms. Kline,Seattle VAPSHCS—S-111, 1660 S. Columbian Way, Seattle, WA 98108. E-mail: doje@myuw.netAccepted for publication February 20, 2003.Journal of Nursing Scholarship Second Quarter 2003 107

International Nurse Migrationpositions. However, not only are representatives fromdeveloped countries recruiting nurses, some of the samerecruiting countries such as Australia, Canada, and the UKare losing nurses through migration. The “brain drain” ofnurses has come under intense scrutiny in recent years withcomplaints from people in donor countries such as India, thePhilippines, South Africa, and Zimbabwe about the loss ofvaluable human resources (“Record overseas numbers,” 2002).The purpose of this analysis was to explore these issuesregarding the international migration of nurses:• the push-pull theory of migration;• identification of the major receiving and donor countries;• effects of nurse migration on donor and receivingcountries; and• ethical considerations of nurse migration.The Push-Pull Theory of MigrationAccording to Mejia, Pizurki, and Royston (1979), migrationis the result of the interplay of various forces at both ends ofthe migratory axis. Some of these forces are political, social,economic, legal, historical, cultural, and educational. Theauthors classified the forces as “push” and “pull” factors.Push factors are generally present in donor countries, andpull factors pertain to receiving countries. Both forces mustbe operating for migration to occur. In addition, facilitatingforces must be present as well, such as the absence of legal orother constraints that impede migration.Kingma (2001) discussed several reasons for nurse migrationthat constituted both push and pull factors. First, nursesmigrated in search of professional development that was notattainable in their current job or country, demonstratingeducational pull factors. The desire to practice nursing skillsmay have required moving from rural to urban areas or toanother country where opportunities existed for them to usetheir knowledge and skills. Second, nurses sought betterwages, improved working conditions, and higher standardsof living not present in their native countries, exhibitingeconomic and social push and pull factors.Third, nurses sought areas to work where they wouldencounter less risk to their personal safety. Personal safety isan increasingly strong political and social factor in nursemigration and “may be motivated by circumstances withinthe health sector or the external environment” (Kingma, 2001,p. 207). Push factors such as concerns for personal safetyare evident in African countries with high rates of HIVand other infectious diseases. For example, the WorldBank reported that Zimbabwe, a donor country, has one ofthe highest rates of HIV prevalence in the world, with26% of the population estimated to be infected. In addition,the number of tuberculosis cases has increased fivefold since1995 (Zimbabwe: National Health Strategy Support, 1999).Not only does the AIDS epidemic place health workers suchas nurses at risk, the demands for care by nurses in theseareas are much greater than in countries with lowerprevalence rates.Global Movement of NursesDeveloped countries are the primary destinations of mostmigrant nurses. Australia, the UK, and the US are the countriesreceiving the largest number of migrant nurses. Australiareceived 11,757 foreign nurses between the years of 1995and 2000 (Hawthorne, 2001). Between 1995 and 2000, theU.S. Immigration and Naturalization Service (INS) reportedmore than 10,000 foreign nurses were admitted to the USunder H-1A visas (Immigration and Naturalization Service,2000). In the 4-year period between 1998 and 2002, the UKadmitted 26,286 foreign nurses into the U.K. nurse registry(“Record overseas numbers join UK nurse register,” 2002).Countries such as Denmark, Norway, and Sweden generallyrecruit from other Nordic countries (Nursing WorkforceProfile 2002, 2002). Saudi Arabians have long depended onforeign nurses, with as many as 40 countries represented inthe nurse workforce. Estimates of foreign nurses there rangefrom 83% to 95% and include nurses in significant numbersfrom Australia, Canada, Indonesia, and the US (Aboul-Enein,2002; Marrone, 1999).Although Japan has had a homogeneous nurse workforce,the Japanese ruling Liberal Democratic Party recently approveda proposal to ease visa and residency regulations to includenurses (Lamar, 2002). Under current regulations, working visasin Japan are restricted to people deemed to have expertise inacademic fields, technology, and journalism. The shift in policyis partially related to Japanese estimates that nearly 1 in 5 of its120 million people are over 65 years of age, and the percentageis rapidly increasing (Population Aging, 2002).The Table shows the major receiving and donor countries.Major donor countries include Australia, India, Philippines,South Africa, and UK. The primary receiving countries areAustralia, Canada, Ireland, UK, and US.Table. Major Donor and Receiving Countries of Migrating NursesReceiving Australia Canada Ireland UK USAcountriesDonor China Ireland Australia Australia Canadacountries Germany Philippines Philippines Canada Hong KongHong Kong UK UK Finland JapanIndia South Africa Germany IndiaIreland Ghana MexicoMalaysia Ireland NigeriaNew Zealand India PhilippinesPhilippines Kenya Puerto RicoSouth Africa New Zealand South KoreaSri Lanka Nigeria UKUK Pakistan VietnamPhilippinesSouth AfricaSwedenUSAWest IndiesZambiaZimbabwe108 Second Quarter 2003 Journal of Nursing Scholarship

International Nurse MigrationNot only are industrialized countries recruiting from oneanother, developing countries also recruit nurses, often withinthe same geographic area. For example, Caribbean andsouthern African countries recruit from each other (“Recordoverseas numbers join UK nurse register,” 2002). The numberof foreign nurses admitted to the US is expected to increasewith the proposed revision of immigration requirements(H-1C visas). The revisions would allow entry of foreign RNsinto the US to work in hospitals on a temporary basis inareas most acutely affected by the nurse shortage (“Senatepasses workforce legislation,” 2001).Effects of Migration on Donor and Receiving CountriesThe movement of nurses from donor to receiving countriescan create hardships in donor countries because of the loss ofskilled personnel and loss of economic investment ineducation. The migration of nurses from developing countries,such as from African countries, results in the loss of “scarceand relatively expensive-to-train resources” (Buchan, 2001,p. 204). Many African countries have had significant increasesin incidence and prevalence of infectious diseases such asAIDS, malaria, and tuberculosis, thus placing further demandson already overburdened health care systems. The WorldHealth Organization (WHO) reported that at the end of 2000,25.3 million people in Sub-Saharan Africa had HIV/AIDS(WHO, 2000). Difficulties created by migration particularlyfrom the Sub-Saharan region come less from the loss of peoplein absolute numbers than from the loss of the few qualifiedprofessionals (Ojo, 1990). The loss of nurses in this regionresults in even fewer skilled nurses, increased care demandson the nurses who remain, and further deterioration ofinadequate health care systems.In addition to African countries, some other donor countriesalso have scarce nurse resources and can ill afford to losenurses to migration. WHO (1998) estimates showed thedistribution of health personnel per 100,000 of the population.China, India, and Pakistan indicated 99, 45, and 34 nursesrespectively per 100,000 persons. In comparison, the USreported 972 nurses (for 1996), the UK reported 870 nurses(for 2000; Buchan & Seccombe, 2002), Australia reported830 nurses (for 1998), Canada reported 897 nurses (for 1996),and Ireland reported 1,593 nurses (for 1998) per 100,000persons.Reports from the Philippines are mixed regarding effectson the health care system and the economy when largenumbers of nurses leave for other countries. The migration ofFilipino nurses is an example of the push factors of theeconomic conditions of oversupply, minimal employmentopportunities, and the political factors of an aggressive exportpolicy (Hawthorne, 2001). Sison (2002) reported that Filipinogovernment officials viewed the exporting of nurses as a newgrowth area for overseas employment. The 175 nursingschools in the Philippines produce more than 9,000 graduatesyearly, of whom 5,000 to 7,000 become licensed.Governmental encouragement for nurse migration isunderstandable, given the amount of money returned to thecountry in remittances. Lindquist (1993) reported over $800million received in remuneration per year from Filipinos livingabroad, money on which the Filipino economy had becomehighly dependent. Filipino nurses are sought in many Englishspeakingcountries because of the Western-oriented nursingcurriculums with English as the primary instructive language,making Filipino nurses “marketable to foreign countries”(Ortin, 1990, p. 11).However, Prystay (2002) reported that nursing directors inthe Philippines were greatly concerned about the high turnoverrates, with novice nurses staffing hospital wards and operatingrooms. In addition to losing experienced staff nurses, theUniversity of Santo Tomas reportedly lost one-fourth of itsteaching staff in 2001 to overseas hospitals. The Filipino nurseswho remain face (a) steep competition for jobs and poor wages,(b) little incentive from governmental health officials toimprove wages and working conditions, and (c) shortage ofexperienced nursing instructors.The effect on receiving countries is positive in that countriesreceive skilled nurses who can enter the workforce withminimal preparation to fill critical shortages. On an averageday, the UK uses 20,000 temporary or agency nurses to fillshortage positions in hospitals, costing the NHS $1,235million USD a year (Finalyson, Dixon, Meadows, & Blair,2002a). In the US, agency nurses can earn $50 per hour or$104,000 per year. Nurses who work as traveling nurses canearn $75 per hour or $156,000 per year (Gamble, 2002). Thecost of employing foreign nurses is a much less expensivemethod of filling vacant positions. One hospital in Kentuckyrecently recruited 50 nurses from the Philippines at the costof $300,000, which was roughly what the hospital paid foragency nurses for 1 month (Dooley, 2002).Nursing leaders in the US are concerned about the use ofimmigration as a means to address the nursing shortage.Glaessel-Brown (1998) reported that using foreign nurses as“readily available, expendable workers postpones sustainedefforts to resolve professional problems leading to a morestable work force and self-sustaining cycles” (p. 327). In hertestimony before the House Education and WorkforceCommittee, Mary Foley (2001), then president of the AmericanNurses Association, echoed Glaessel-Brown’s opinion thatusing foreign nurses to fill shortage positions only delayedaction on the serious workplace issues that have drivenAmerican nurses away from the profession.Ethical ConcernsAs the level of migration increases, the ethics ofinternational recruitment warrant consideration. TheInternational Council of Nurses’ (ICN) position statement(ICN, 2002) indicated the right of nurses to migrate, but italso acknowledged the adverse effects that migration mighthave on the quality of health care in donor countries. TheICN condemned the practice of recruiting nurses to countrieswhere human resource planning and problems related toJournal of Nursing Scholarship Second Quarter 2003 109

International Nurse Migrationretention and recruitment of nurses have not been addressed.The potential for exploitation of foreign nurses is of greatconcern. In 1998, six people in the US were charged withfraudulently obtaining H-1A visas and using them to employFilipino nurses as nurse aides rather than as registered nurses(Puente, 1998). In 1996, the Catholic Archdiocese of Chicagopaid $50,000 in fines and $384,700 in back pay to 99 Filipinonurses working in a Catholic nursing home. The nurses wereemployed as nurse aides (Allen, 1996). Filipino nurses inMissouri were awarded $2.1 million for failure to receivecomparable wages as U.S.-born nurses in the same facility(Grimsley, 2000). Brubaker (2001) reported that someWashington, D.C. area hospitals offered overseas nursessalaries that were less than those offered to comparable U.S.nurses, by crediting overseas nurses with only half of theiryears of experience. Reports also have indicated that foreignnurses working in the US are restricted to less-desirable jobs,have to work in entry-level positions because they are notnaturalized citizens, and are excluded from jobs in leadingfacilities (Glaessel-Brown, 1998).In the UK, foreign nurses have tended to fill entry-levelpositions (Hardill & MacDonald, 2000) and they earn muchless than do domestic nurses. In Ireland, a period of supervisedpractice and assessment can be required of foreign nurses,although qualified nurses from the EU, Australia, Canada,New Zealand, and the US are exempt from the requirement.Foreign nurses not exempt are paid a wage equal to one-thirdof a 3rd-year student salary for the required period ofsupervised clinical nursing practice, after which they are paida salary commensurate with their verified nursing experience(Department of Health and Children, 2002). The period ofsupervised practice was not specified.Finally, Mugera (2002) reported that the UK is consideringintroducing compulsory HIV tests for all foreign health staffworking in the country. The action is being considered afterhealth authorities found 10 nurses recruited from South Africawere HIV positive and they fear that more South Africannurses might carry the virus. In a newsletter, the Nurse andMidwifery Council’s (“HIV test for new NHS staff,” 2002)published view was that employees should be honest with theemployer and having the virus should not affect a nurse’sability to practice. The potential for discrimination based ontest results could affect thousands of African nurses who havebeen recruited to work in the UK.StrategiesPush and pull factors exist between donor and receivingcountries, and nurses continue to migrate in search of higherstandards of living and improved professional opportunities.International strategies vary in response to some of theproblems created by nurse shortages and the resulting “braindrain” of nurses. The Australian Nursing Federation calledfor a national workforce plan that would include timely andconsistent nursing workforce data (which has been severelylacking) and the creation of a chief nurse role at the federallevel to advise on nursing issues (“Senate submission callsfor a national workforce plan,” 2002). The South AfricanGovernment proposed to the Commonwealth that recruitmentof health professionals from developing countries take placeonly within formal bilateral agreements between richer andpoorer nations. In the US, the ANA has resisted the passageof the Rural and Urban Health Care Act of 2001 that wouldexpand the existing H-1C visas to ease the immigration offoreign nurses (Trossman, 2002) out of concern thatimmigration “doesn’t address the underlying problem thatdrives shortages—nurses’ deteriorating working conditions”(Trossman, 2002, p. 86). Buchan (2001) discussed severalstrategies being undertaken in the UK to address the migrationissue. The Department of Health in the UK established practiceguidelines in international recruitment for NHS employers.This attempt has had minimal success, because it did notinclude the private sector recruiters or employers. A bilateralagreement was established between Great Britain and Spainfor Spanish nurses to work in the NHS for a defined period oftime. The English-language Caribbean countries havedesigned a common approach to managed migration,including compensation from receiving countries.Migration can be considered a freedom of choice and italso is an expected result of globalization. However, the extentto which the recruitment of foreign nurses is used to solve theshortage problem raises many questions about nursing andhealth care. The UK, Australia, and Canada are importingnurses to fill vacancies left by their own nurses migratingelsewhere, as well as to meet the increased demands for nursesin their changing health care systems. In the US, changes inthe health care system in the 1980s and 1990s have increasedthe demand for nurses; at the same time, decreased studentenrollments in nursing and the undersupply of nursing facultyfurther compound problems in producing an adequate supplyof nurses.Addressing the nurse recruitment and retention issuescontributing to nurse shortages in developed countries seemsthe best strategy, but it is a long-term one. Aiken and colleagues(Aiken et al., 2001) reported on nurse surveys completed by43,000 nurses in five countries, three of which are majorreceiving countries, with different types of health care systems.These nurses reported similar inadequacies in their workenvironments and the quality of care provided. The authorsdescribed deficiencies on an international scale in hospitalorganization, work design, and nursing care that have resultedfrom the restructuring of health care systems and hospitals that“emulate industrial models of productivity improvement” (p.51) but stopped short of developing policies and benefits fornurses such as “opportunities for career advancement, life-longlearning, flexible work schedules, and policies that promoteinstitutional loyalty and retention” (pg. 51). Buchan (2000)advocated use of “an evidence-based approach to identify whichflexible employment practices and pay and nonpay incentivesare effective in specific labor market conditions” (p.204) inpromoting improved job satisfaction and nurse retention.110 Second Quarter 2003 Journal of Nursing Scholarship

International Nurse MigrationConclusionsNursing shortages affect nurses, health care delivery, andpopulations worldwide. A wide range of factors contributesto nurse shortages and migration, including political,economic, social, legal, historical, cultural, and educationalfactors. Many of those factors are beyond the scope of thisdiscussion. International migration of nurses is expected toremain high. While debates about nurse migration continue,people from recruiting countries should (a) actively examinetheir own recruitment practices, (b) assure ethical treatmentof foreign nurses, and (c) address the local problems thatcontribute to repeated shortages of nurses.ReferencesAboul-Enein, F.H. (2002). Personal contemporary observations of nursingcare in Saudi Arabia. International Journal of Nursing Practice, 8,228-230.Aiken, L.H., Clarke, S.P., Sloane, K.M., Sochalski, J.A., Busse, R., Clarke,H., et al. (2001, May/June). Nurses’ reports on hospital care in fivecountries. 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