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

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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
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