InternationalMigration of Nurses
Migrationof nurses is a global phenomenon in which nurses tend to migrate fromdeveloping countries to developed countries. In most cases, nursesleave their countries to look for better working conditions, bettercompensation packages, and opportunities for professional as well aspersonal development. Some of the policy makers involved in the issueof international migration of nurses include legislators (make lawsand policies to regulate nurses’ migration), regulators (controlthe movement of trained nurses in and out of the country), andinterest groups. Although nurses and the major stakeholders in thehealth care sector, they are not involved or engaged properly in theprocesses of finding viable solutions to the issue of internationalmigration of nurses. Ethical concerns that result from theinternational migration of nurses include the discrimination offoreign nurses, inequality in the health care system, and healthdisparity between developed and developing nations. Participatorydialogue, better compensation, and working conditions are viableoptions for addressing the issue.
Keywords:International migration, compensation packages, health inequality,working conditions, participatory dialogue.
InternationalMigration of Nurses
Theinternational migration of nurses is currently a controversial issuethat has created an imbalance in the supply of nurses betweendeveloped and developing countries. This is because most of trainedand experienced nurses tend to move from developing countries todeveloped nations to look for new opportunities. The shortage ofnurses is global challenges, but the movement of nurses from thedeveloping economies to developed countries undercuts the globalhealth initiatives and puts the underdeveloped economies at adisadvantage (Aiken, Buchan, Sochalski & Powell, 2004). Developedcountries import nurses to address the issue of their shortage, whichexacerbates the problem of the shortage of nurses in countries thatexport trained and experienced nurses. This paper will address theissue of the international migration of nurses with a focus on theevolution of migration, policy makers involved, nursing involvement,ethical concerns, options available to contain migration, and themost preferred solution. Migration of nurses is an internationalphenomenon that disfavors the developed countries and can beaddressed by offering nurses with market competitive salaries andother employment benefits.
Evolutionof the issue of international migration of nurses
Historyindicates that the international migration of nurses was described asa north-north or south-south phenomenon before 1998, when migrationbecame a problem deserving to be considered for public debate. Thenorth-north phenomenon implies that nurses used to move fromdeveloped to other developed economies while the south-southphenomenon means that nurses used to migration from developing todeveloping countries before 1998 (Kingma, 2008). For example, U.K.professionals could practice nursing in the U.S. or Canada, whileFijian professionals could only practice in other developingeconomies, such as Palau or Philippines (Kingma, 2008). However,these trends have changed over the years with the current statisticsindicating that more than 30,000 nurses working in the developedcountries, such as Canada, the United States of America, Portugal,the United Kingdom, Ireland, and Finland. The change in the trendwhere international recruitment of nurses from developing toindustrialized countries has increased rapidly has attracted policyas well as media attention.
Current trends in the international migration of nurses
Thenurse migration flow indicates that nurses from developing countriesare targeting three developed economies. These countries include theUnited States, Ireland, and the United Kingdom. This is consistentwith the recent findings indicating that about 77 % of the developedcountries are facing a significant shortage of nurses due to a rapidincrease in demand for the health care services (Li, Nie & Li,2014). These developing countries are trying to address the issue ofthe shortage of nurses by recruiting foreign trained nurses to workin domestic health care facilities. Among these countries, the UnitedStates absorbs the highest number of foreign registered nurses, whoare estimated to be 90,000 and projected to increase by 100,000within the next one decade (Aiken et al., 2004). The health caresystem of the United Kingdom recruits about 16,155 nurses annually,while that of Ireland started importing nurses in 2002 following thenation’s economic boom (Aiken et al., 2004). These countries sourcenurses from countries (such as Caribbean, Philippines, andSub-Saharan countries) that are already suffering from the shortageof nurses. For example, Ghana is one of the African countries withthe shortage of nurses, but over 13 % of its trained nurses work indeveloped countries and 62 % have the intention to leave in case theyget the job opportunities abroad (Crommet, 2008).
Mostof the nurses who migrate into foreign countries do so in search forbetter paying jobs. Economic hardships and poor compensation schemesare the leading factor that motivates trained and experienced nursesto move out developing to developed countries. For example, studiesshow that Philippine nurses are paid $ 169 in rural areas and between$ 75 and $ 95 in cities, while nurses with the same level ofqualification are paid between $ 3,000 and 4,000 per month indeveloped countries (Van, 2010). Therefore, a large number of nursesin developing economies do not graduate as registered nurses to servetheir countries, but they have the objective of searching forbetter-paying jobs abroad.
Thelack of job opportunities in developing countries motivate trainednurses to look for employment opportunities in foreign countries.Although these countries suffer from the shortage of nurses, theyface different challenges (such as the lack of financial capacity)that reduce their ability to absorb all nurses that trained locally(Li, Nie & Li, 2014). In countries like Philippine, which are theleading exporter of nurses globally, the government as taken theinitiative to encourage nurses to look for jobs abroad since thelocal health care system cannot absorb all trained nurses (Van,2010).
Poorworking conditions in the source countries motivate nurses to lookfor employment opportunities in countries where conditions arebetter. According to Cortes & Pan (2014) the quality of workenvironment is among the key determinants of on-the-job satisfactionand labor supply decisions among the registered nurses. Some of thenegative workplace characteristics of the health care system in thesource countries include the limited opportunities for promotion,workloads, poor interpersonal relationships, and limitedopportunities for personal as well as professional development.Nurses in the developing countries have a general perception thatworking conditions are better in the industrialized countries.Therefore, intentions to migrate are influenced by push (factors inthe source country) and pull factors (factors in the countries ofdestination).
Policymakers involved in the international immigration of nurses
Thelegislative arm of the government plays a key role in eitherencouraging or discouraging the international migration of nurses.This is achieved through the formulation of laws that support ordiscourage nurses from moving. Legislative organs in both thecountries that export nurses and those that import nurses have a roleto play. For example, the Congress of the United States passed theNursing Relief for Disadvantaged Areas Act that intended to encouragenurses to immigrate into the United States (Glazer, 2003). Schedule Aof the Act states that immigrants with the nursing qualifications canaccess the H 1-B visa that allows them to stay and work in the UnitedStates with the option to renew their stay at the end of the threeyears (Van, 2010). This encourages foreigners to migrate into theU.S. to fill nursing vacancies in the disadvantaged areas.
Legislatorsin the source countries may also formulate laws that encouragequalified nurses to move out of the country. For examples, PhilippineLabor Code (Article 22) encourages trained nurses and otherprofessionals to look for jobs outside the country and make someremittances to support the domestic economy (Van, 2010). In mostcases, legislators in the source countries are hesitant to make lawsthat can curtail emigration of nurses because their respectivegovernments cannot satisfy their job requirements and offeremployment opportunities for all trained nurses. Laws that preventnurses from emigrating are likely to face resistance in the sourcecountries in spite of the fact that these countries suffer from theshortage of nurses.
Regulatorsin both the recipient and the source countries use different policymeasures to regulate the international migration of nurses. In mostcases, recipient countries formulate policies to encourageimmigration of foreign trained nurses while the source countries seekto discourage emigration of professional nurses. Ghana’s governmenthas been regulating emigration of nurses through the Ministry ofHealth, Department of Human Resources. The department has been taskedwith the role of reviewing nurses’ wages and formulating anappropriate salary structure with the objective of motivating nursesto remain in the country (Crommet, 2008). Monetary incentive schemesare also used to enhance the loyalty of nurses working in thehardship areas, who are likely to leave the country than those whoare working in areas with fewer hardships. The Philippines governmentregulates emigration of nurses through the Department of Labor andEmployment. The department achieves its regulatory objectives bymanaging the registration of verification, and documentation ofemployees who wish to leave the country (Van, 2010). This gives thegovernment an opportunity to allow more nurses to leave the countrywhen there is a surplus and reduce emigration during the shortage.
Differentinterest groups (including the labor unions) have a major role toplay in the process of finding viable solutions to the issue ofmigration of nurses. Interest groups have demonstrated mixedreactions towards the increase in the rate of international migrationof nurses. Some of the U.S. labor unions have opposed the governmentpolicies (such as Wexler’s bill) that seek to encourage immigrationof nurses into the country. The leaders of these unions state thatsuch policies will undermine the nation’s efforts to establish asteady supply of nurses to domestic workforce and encourage the U.S.to continue sapping the nurses from other nations (Herbst, 2009).Labor unions that specialize on the rights of nurses, on the hand,hold that immigration of nurses will enhance the capacity of the U.S.health care system to address the health needs of the diverse patientpopulation in a globalized environment (Palmer, 2014). Nationalassociations that represent the health care facilities in thedeveloped countries (such as U.S. and Canada) have been pushing thegovernment to relax immigration standards since they are the onesthat bear the greatest burden of shortage of nurses (Kingma, 2008).Interest groups in the source countries often remain silent while orblame the government for the challenges that force nurses to leave.In the case of India, unions seek to fight for the rights of nurseswho have left for the developed economies instead of discouragingemigration out of India (Sudhakar, 2014). It is evident that indifferent groups fight for their own interest and fail to identifythe viable solutions.
Nurses’involvement and effects of migration on nursing
Engagingnurses in finding the solution
Nursesand the nurse leaders are interested in fighting for their rights andprotection of the nursing as a profession that serves humanity. Therehas been a reasonable involvement of nurses and their organization infinding solutions to the issue of nursing shortcake in recipientcountries. Nurses are given the opportunity to air their views andmake their contributions regarding the issue of the internationalmigration of nurses as a solution to the shortage that theircountries are facing. Nurses have different views where one campbelieves that going for the international migration as a solution totheir shortage will sabotage the efforts to empower the domestichuman resource while empowering the foreign nurses (Palmer, 2014).The other camp believes that the international migration of nurses isan appropriate practice that is consistent with the current rate ofglobalization, which has increased the diversity of the patientpopulation (Herbst, 2009). Therefore, increasing the diversity of thenursing population will address the needs of a diverse population ofpatients. However, there is limited involvement of nurses in thesource countries in finding solutions to their emigration.
Effectof migration on nursing
Althoughthere are many countries that have the capacity to export and importnurses simultaneously, underdeveloped countries only export nurses.Persistent export of nurses reduces the supply chain, which resultsin a significant shortage of nurses. Although underdevelopedcountries may not have enough resources to retain or employ alltrained nurses, it is evident that the most experienced and those whoare already working are more marketable in the developed countriesthan fresh graduates (Yeates, 2010). This implies that underdevelopedcountries loss the professions that they need the most to address thediverse health challenges as well as the persistent shortage ofnurses. For example, India and Philippine are world leading exportersof nurses, but they still have a significant shortage that reducesefficiency in the process of delivering quality health services(Yeates, 2010). Massive emigration of nurses in the Sub-Saharancountries has caused fatal impacts of the treatment outcome. Forexample, Malawi has 64 % of the nursing vacancies unfilled followingthe recent immigration of nurses who were already employed, butlooking for better pay and better working conditions (Yeates, 2010).Therefore, emigration of experienced nurses weakens the nursingprofession and affected the quality as well as the outcome oftreatment in an adverse way.
Thepersistent loss of trained and skilled nurses represents a loss ofpublic investment in education as well as the intellectual propertyto developed countries. Looking at the issue from the economicperspective, source countries spend large sums of money to trainnurses, who end up serving foreign countries that spend zero amountin the process of training them. Studies have shown that emigrationof a single nurse-midwife from sub-Saharan countries represent afinancial loss of $ 71,081-$ 7.5 million, while emigration of acertified nurse-midwife leads to a loss of $ 241,508-25.6 million(Yeates, 2010). With about 1 in eight certified nurses fromSub-Saharan countries serving in the developed countries, emigrationrepresents a sizeable financial loss to these countries and a subsidyto developed countries that would otherwise be expected to assist thedeveloping nations. Persistent emigration weakens the governmentcapacity and morale to train more nurses, which in turn weakens thenursing profession as a whole.
Ethicalconcerns related to international migration of nurses
Recipientcountries make the argument that the nurses they enroll in theirhealth care system transfer funds to the source countries, whichboost the economies of their countries. However, it is overwhelminglyagreed that when nurses, especially those who are highly trained andwith several years of experience leave, the population health in thesource country erodes. Studies have shown that the funds remitted bynurses working in the foreign countries do not contribute towards theimprovement of the health care system (Eckenwiler, 2014). This isbecause these funds are used for other purposes (such as helping theindividual families of the nurses manages their basic needs) insteadof compensating the country for the economic loses it has sufferedfollowing the loss of trained nurses. Ethical concern arises whenmigration is seen from the view that the developed countries sap thefew nurses in the developing nations, which exacerbates thechallenges of shortage of nurses and poor quality of care.
Discriminationand exploitation of migrant nurses are common in recipient countries.In most cases, incidents of discrimination and exploitation ofmigrant nurses are covered by the blanket of silence, which makes itdifficult to quantify them at national as well as the internationallevels (Li, Nie & Li, 2014). The fact that migrant nurses are thecurrently the frequent victims of under-enforcement of equalopportunity policies in the developed world confirms that the rate ofdiscrimination against them is extremely high. In addition,feminization of the issue of migration of nurses raises issues ofequity and autonomy of these migrants. Currently, the tendency ofwomen seeking for employment opportunities in more affluent nationsis an integral part of the world economy. This has reached an extentwhere the international migration of nurses is being fueled bysuitable femininity and in terms of cultural and racial stereotypes.For example, the construction of Indian as well as Caribbean ladiesas warm-hearted and Philippine women as caring serves as the aim ofrecruiters, employers, government, and other stakeholders inrecipient countries (Eckenwiler, 2014). These unfounded perceptionsreduced the probability of equal treatment in the labor market.
Optionsfor resolving international migration of nurses
Aparticipatory dialogue among the stakeholders in the health caresector should be enhanced. Some of the stakeholders who should takepart in discussions about the escalating migration of nurses includethe organizations representing hospitals, nurse leaders, governmentsin the source countries, community members, and employers (Mcelmurryet al., 2006). Studies have shown that different stakeholders havemixed reactions towards the issue of migration of nurses and suggestdifferent solutions to address the menace (Herbst, 2009). Therefore,creating a platform for the stakeholders to share ideas is aneffective way to help nurses in the developing countries feels thattheir role in the society is being recognized. In addition,participatory dialogue will allow nurses to share problems with therelevant authorities, which will give them a hope that theirworkplace issues will be addressed, thus reducing their intentions toleave.
Employeecompensation is among the leading factors that motivate them to work,increase their loyalty to the employer, and reduce the probability ofan intention to leave. Currently, poor payment is ranked as one ofthe issues that are motivating trained nurses to leave underdevelopedcountries and look for better-paying jobs in the developed world. Forexample, Philippine nurses are paid less than $ 95 when working inthe local health care system and more than $ 3,000 per month whenworking in the developed countries (Van, 2010). This suggests thatmoney is the key factor that motivates nurses to leave theircountries. To this end, increases the salaries and other benefits fornurses and reduce the tendency or desire to leave their homecountries for the developed countries.
Improvingthe working conditions
Alarge number of nurses decide to leave their countries citing poorconditions as one of the factors that reduce their satisfaction withthe current jobs. For example, nurses from Sub-Saharan countriesclaim that the health care systems in these countries do not givethem opportunities for professional as well as personal development,given them a limited career opportunity, and overwork them (Li, Nie &Li, 2014). In addition, political environment in most of theunderdeveloped countries is not favorable for nurses. Therefore,improving the working conditions for nurses in the source countriescan reduce the intentions to leave, thus addressing the issue of theinternational migration.
Preferredsolution: Improved compensation package
Althoughall options aforementioned have the capacity to reduce internationalmigration of nurses, better salaries and other financial benefits aremore effective. This means that the source countries should increasesalaries and employment benefits for all registered nurses to a levelthat can be considered as market competitive. This can be achieved byincreasing salary for nurses close to or equal to the amount thatnurses in recipient countries earn. For example, the government ofPhilippine should increase the salary of midwife nurses from $ 169per month to about $ 50,000 per month, the amount the nurses with thesame qualifications earn when they migrate to Canada (Van, 2010).Money is an extrinsic motivator that will motivate nurses to continuedelivering surfaces in their underdeveloped countries as long astheir financial needs are addressed satisfactorily. In addition,high salaries and benefits will help nurses overcome challengesassociated with economic hardships in underdeveloped countries. Witha better pay, nurses will also be able to deal cope with the highcost of living with ease. This proves that market competitivesalaries and employment benefits is the most viable solution toreduce the international migration of nurses.
Theinternational migration of nurses is a global challenge that can onlybe addressed through market competitive salary and employmentbenefits. Initially, nurses used to migrate from rich to rich andfrom poor to poor countries, current trends indicate that nurses areemigrating from developing countries to developed ones. This impliesthat the issue of international migration of nurses is exacerbatingthe current challenges (such shortage of health care professionalsand poor quality of care) in the developing countries while helpingdeveloping countries address the same challenges. Poor compensationand working conditions are the leading factors that motivate trainedand experienced nurses to leave their countries. Most importantly,developed countries prefer the most experienced and highly trainednurse, which implies that developed countries are deprived of thecream of their health care system, which cripples their health caresystem. The investment that the source countries make to train theirnurses goes to waste when a large number of nurses leave the country.Therefore, source countries should invest more in the compensation,in addition to the investment they make in training nurses.
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