Push and Pull Factors in International Nurse Migration

Purpose: To describe the push and pull factors of migration in relation to international recruitment and migration of nurses.
Organizing Construct: Review of literature on nurse migration, examination of effects of donor and 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 the loss of skilled personnel and economic investment; receiving countries receive skilled nurses to fill critical shortages with less economic investment. Ethical concerns include the potential for exploitation of foreign nurses.
Conclusions: Nurses migrate to seek better wages and working conditions than they have in their native countries. Given the current conditions, developed countries continue to actively recruit foreign nurses to fill critical shortages. Migration is predicted to continue until developed countries address the underlying causes of nurse shortages and until developing countries address conditions that cause nurses to leave.     

Use of Immigration Policy to Manage Nursing Shortages

Purpose: To examine long-term implications of using temporary, nonimmigrant nurse programs to manage fluctuations in the demand for registered nurses.
Organizing Framework: This discussion is located in the full context of migration—reviewing theories and concepts of labor migration—referring to experience with guest-worker programs worldwide, outlining recent nursing shortages in the United States, describing the Immigration Nursing Relief Act (INRA), and raising questions for nurses in the United States and in the global marketplace.
Sources: Review of scholarly literature on international migration, existing studies on nurse migration to the United States, and original research, conducted between 1992 and 1994, for the Immigration Nursing Relief Advisory Committee (INRAC) Report.
Methods: Policy analysis of theories, concepts, and perspectives related to nurse migration.
Findings: In the United States, highly skilled foreign nurses tend to complement rather than displace local labor. Yet recruiting foreign-educated nurses for entry-level jobs perpetuates patterns of dependency in the sending country and delays creative solutions to staff development in the host country. Nonimmigrant status creates a vulnerable workforce. There may be a disparity between the ideal of nurse migration as collaborative exchange and the reality of institutionalized occupational migration networks.
Conclusions: While foreign nurse recruitment might solve short-term needs, repetitive temporary nurse migration programs create long-term consequences that are not in the best interests of the profession. The absence of consistent policy creates an opportunity for nursing to take an active role in developing the rules and direction of future nurse migration.     

The role of internationally educated nurses in a quality,safe workforce

Migration and globalization of the nursing workforce affect source countries and destination countries. Policies and regulations governing the movement of nurses from one country to another safeguard the public by ensuring educational comparability and competence. The global movement of nurses and other health care workers calls for quality and safety competencies that meet standards such as those defined by the Institute of Medicine. This article examines nurse migration and employment of internationally educated nurses (IENs) in the context of supporting and maintaining safe, quality patient care environments. Migration to the United States is featured as an exemplar to consider the following key factors: the impact of nurse migration on the nursing workforce; issues in determining educational comparability of nursing programs between countries; quality and safety concerns in transitioning IENs into the workforce; and strategies for helping IENs transition as safe, qualified members of the nursing workforce in the destination country.     

国际护士流动趋势

综述了目前出现的几种国际护士招募和流动模式,资料集中在那些以英语为母语并积极招募发展中国家护士的国家：美国、英国、爱尔兰和新西兰。这些国家的卫生服务系统有相似之处,并且所需求的护理人员超过了其所培养的能力和速度;它们对护士的需求预计足以耗竭发展中国家的合格护士供给。对护士向这些国家的近期流动模式的研究提示了其对全球卫生所产生的可能的后果。     

International nurse migration: lessons from the Philippines

Developed countries facing nursing shortages have increasingly turned to aggressive foreign nurse recruitment, primarily from developing nations, to offset their lagging domestic nurse supplies and meet growing health care demands. Few donor nations are prepared to manage the loss of their nurse workforce to migration. The sole country with an explicit nurse export policy and the world's leading donor of nurse labor - the Philippines - is itself facing serious provider maldistribution and countrywide health disparities. Examining the historical roots of Philippines nurse migration provides lessons from which other nurse exporting countries may learn. The authors discuss factors that have predicated nurse migration and policies that have eased the way. Furthermore, the authors analyze how various stakeholders influence migratory patterns, the implications of migration for nurses and the public in their care, and the challenges that future social policy and political systems face in addressing global health issues engendered by unfettered recruitment of nurses and other health workers.     

Determinants of nursing students' intention to migrate overseas to work and implications for sustainability: The case of Indonesian students

High graduation of nurses and limited job opportunities in Indonesia may lead to the emigration of nurses particularly through facilitated migration. This study aimed at identifying the prevalence of Indonesian nursing students with intention to work in Japan and predictors of their intention to migrate as well as having a definite plan to work in Japan. The study adopted cross‐sectional design with a sample of 1,407 Indonesian nursing students. Factors associated with having migration intention, as well as a definite plan to work in Japan, were age, residence, and overseas experience. Other factors related to a definite plan to work abroad were family income, mastering a foreign language, knowledge about the nurse migration related to Indonesia‐Japan cooperation, and their motivations to migrate to Japan. Sustainability of this international recruitment of nurses is possible by understanding the context of both source and destination countries. Maximizing benefits of migration of nurses for Indonesia and Japan requires structured policies targeting the educational sector and addressing the sustainability issues.     

Exploring nurse education in Canada, Finland and the United States

A global registered nursing (RN) shortage has caused an increase in migration and international recruitment of nurses. There is growing interest among some countries of having common standards and competencies for entry-level registered nurses to guide future registered nurse agreements between countries or multi-country licensure programs. Nursing education in one country may not be accepted as equivalent for a nurse to become licensed in another country. An exploratory study was conducted to gain a better understanding of how nurses are educated in various countries. Nurse researchers sent a nursing education questionnaire to nurse educators in eleven countries inviting them to participate in the study. Nurse educators from six countries agreed to participate in the study. They provided information about their country's nursing history, types of nursing programs, use of national nursing licensing examination, and political influences on nursing education. The People's Republic of China, Japan and Turkey nurse educators' responses were the first to be analyzed and the results were published in the July/August 2005 issue of Contemporary Nurse (volume 19/1-2). This second article (in Contemporary Nurse volume 20/2) provides information about and a comparison of nursing programs in Canada, Finland and the United States.     

Perceptions of registered nurses working with assistive personnel in the United Kingdom and the United States

This study examines registered nurse perceptions of their role in acute care hospitals that use nursing care assistants (NCA) and unlicensed assistive personnel (UAP). Also studied was registered nurse (RN) satisfaction with nursing care assistants and unlicensed assistive personnel in the United Kingdom (UK) and the United States of America (USA). The purpose of this study is to assist RNs and managers in the re-design of health-care delivery systems by investigating: 1. The differences and similarities of registered nurses in the UK and the USA in the perceptions of changes in the RN role when working with nursing care assistants or unlicensed assistive personnel. 2. The differences between and similarities of registered nurses in the UK and the USA in perceptions of NCA and UAP abilities to perform delegated duties, to communicate pertinent clinical information and to provide more time for professional nursing activities. Registered nurse perceptions in the UK were compared with the findings of a previous study of RN role changes and satisfaction in the USA. Registered nurses in the UK did not perceive a profound change in their role when working with UAP and were more satisfied with their use than were RNs in the USA.     

Immigration policy and internationally educated nurses in the United States: A brief history

Since the 1980s, U.S. policy makers have used immigration policy to influence the supply of nurses by allowing or restricting the entry of internationally educated nurses (IENs) into the U.S. workforce. The methods pursued have shifted over time from temporary visa categories in the 1980s and 1990s to permanent immigrant visas in the 2000s. The impact of policy measures adopted during nursing shortages has often been blunted by political and economic events, but the number and representation of IENs in the U.S. nursing workforce has increased substantially since the 1980s. Even as the United States seeks to increase domestic production of nurses, it remains a desirable destination for IENs and a target market for nurse-producing source countries. Hiring organizations and nurse leaders play a critical role in ensuring that the hiring and integration of IENs into U.S. health care organizations is constructive for nurses, source countries, and the U.S. health care system.     

21st century nursing practice in Ghana: challenges and opportunities

DONKOR N.T. & ANDREWS L.D. (2011) 21st century nursing practice in Ghana: challenges and opportunities. International Nursing Review 58 , 218–224 Aim: This article is intended to stimulate critical thinking and generate fruitful discussion on nursing practice in Ghana as experienced by the authors. Its rationale is to promote exchange of ideas and creative partnerships to ensure that right decisions are made in preparing competent, adaptable and resourceful nurses who can contribute to health for all in the 21st century. The problem: The challenges of nursing education, practice and migration in Ghana seem grim. There is inadequate capacity of training institutions, low staff morale, poor distribution and serious workforce shortages. Methods: Government reports and policy documents on nursing were sourced from official websites and reviewed and discussed in the context of the international scholarly published literature. Opportunities: The authors note that despite the severe crises, a number of opportunities such as improved home‐based training, international nursing education partnerships and welfare and human resource development could foster effective nurse retention and managed migration. Conclusions: To address the issues with nursing health service delivery and nursing shortages in Ghana requires all stakeholders to move beyond the traditional stereotypes and be flexible and forward‐looking. Needed policy options include expansion of local nursing education and training capacity, collaborative training opportunities, improving the welfare and retention rates of current staff and international exchange of nurse resources that is mutually beneficial to both source and sink countries.     

Caribbean nurses migrating to the UK: a gender-focused literature review

Background:  International nurse recruitment is an integral part of government health care strategy in many countries. However, the gendered implications of nurse migration have been little explored despite the fact that the nursing workforce is predominantly made up of women.
Aim:  Based on the migration of nurses from the English-speaking Caribbean region to the UK, this paper explores the significance of gender at both the macro and micro levels.
Methods:  Four strands of inquiry were explored: nurse migration, impact on development, work experiences and family life. Key terms were used to search the electronic databases SSCI, EBSCO and JSTOR. An interpretative framework based on the feminist theory of intersectionality was used to systematically review the 15 studies that met the inclusion criteria.
Findings:  Gender issues are significant across all aspects of the migratory process. Migrant nurses contribute to social progress through remittances and knowledge gained abroad although overall, nurse migration negatively impacts development and there are hidden implications for women. For some Caribbean nurses, migration reflects increased economic freedom; however, for others, gender inequality lies at the centre of the decision to relocate. Gender inequality also permeates the lives of many migrant nurses even in countries where economic and work conditions are improved.
Conclusions:  The ramifications of nurse migration cannot be fully understood without attention to gender inequalities and the specific socio-economic contexts in which they exist. There is need for a gender-centred approach to international nursing recruitment policy that takes account not only of the impact on developing countries, but also of the well-being of migrant nurses themselves.     

Exploring nursing education in the People's Republic of China, Japan and Turkey

The global nursing shortage has caused competition and cooperation between countries desperate for registered nurses (RNs), and has led to an increase in migration and international recruitment of nurses. Some nursing diplomas or degrees earned in one country may not be transferable to another. As a result, there is growing interest in common standards and competencies of entry-level nurses to guide future registered nurse agreements between countries or multi-country licensure programs. An exploratory study was conducted to investigate how entry-level nurses are educated throughout the world. The researchers sent a nursing education questionnaire to nurse educators in eleven countries inviting them to participate in the study. Nurse educators from The People's Republic of China, Japan and Turkey were the first to agree to participate in the study. They responded to questions about their country's nursing history, types of nursing programs, use of national nursing licensing examination, and social and political influences on nursing education. The nurse researchers did an analysis and comparison of the nursing education in each country.     

The skills and brain drain what nurses say

Aims and objectives. To explore sub‐Saharan African nurses’ reasons for moving to the UK, their views on the skills and brain drain, and what can be done to stem the situation. Background. The UK and other developed nations such as the USA, Canada and Australia have been recruiting internationally qualified nurses including those from sub‐Saharan African, which has raised concerns of skills and brain drain from these countries that are known to suffer from nurse shortages. Methods. A purposeful sample of 30 nurses from sub‐Saharan African was drawn from four National Health Service trusts in the north‐east of England. Using focus group discussions and personal interviews, the study explored and examined nurses’ views on their motivation to move to the developed countries and what can be done to reduce nurse migration from sub‐Saharan African and give those countries a chance to develop their health systems by retaining their health personnel. Results. Five main themes emerged from data analysis: poor remuneration, lack of professional development in the home countries, poor health care and systems, language and education similarities and easy availability of jobs and visas. Conclusion. Data indicate that migration motives for nurses are complex and inherent in historical links and in global values. Nurses stressed that they would like to stay in their own countries and help develop healthcare there, but reasons for moving were often strong and apparently not within their control. Relevance to clinical practice. Nurse migration from sub‐Saharan African has often been cited as a limitation in providing effective healthcare in those countries. Delineating motivational factors for nurses could help to stem this migration.     

Globalisation, localisation and implications of a transforming nursing workforce in New Zealand: opportunities and challenges

Severe staff and skill shortages within the health systems of developed countries have contributed to increased migration by health professionals. New Zealand stands out among countries in the Organisation for Economic Co-operation and Development in terms of the high level of movements in and out of the country of skilled professionals, including nurses. In New Zealand, much attention has been given to increasing the number of Māori and Pacific nurses as one mechanism for improving Māori and Pacific health. Against a backdrop of the changing characteristics of the New Zealand nursing workforce, this study demonstrates that the globalisation of the nursing workforce is increasing at a faster rate than its localisation (as measured by the growth of the Māori and New Zealand-born Pacific workforces in New Zealand). This challenges the implementation of culturally appropriate nursing programmes based on the matching of nurse and client ethnicities.     

Experiences of African nurses in the UK National Health Service: a literature review

Aim. This review aims to highlight the experiences of black African nurses in the United Kingdom. Background. There is an acute shortage of trained nurses in the United Kingdom, which has occurred because of several factors including ageing of the nurse population and increasing demand due to an ageing population as well as under investment in nurse education during the 1980s. Government initiatives have included recruiting nurses trained overseas to meet present and future demands. Among these internationally recruited nurses, a large number came from Africa, but little is known about the experience of nurses once they are in the United Kingdom. Although it is known that ethnic minority nurses suffer discrimination in the National Health Service, experiences of internationally recruited nurses and nurses from African countries, in particular, merit attention as their nursing practices and culture in general are different from those of developed countries. Methods. A literature search was conducted using CINAHL, Medline and Cochrane databases by using the following terms in various combinations: Experiences, African nurses, international nurses, ethnic minorities, discrimination, equal opportunities, United Kingdom and NHS. Conclusions. There is very little research into the experiences of African nurses in the United Kingdom. Research has concentrated on the experience of internationally recruited nurses and ethnic minority nurses in general. There is agreement that most foreign nurses have a negative experience of working in the United Kingdom. Nurses face discrimination in pay and conditions of service and most are exploited by managers. There are also ethical questions surrounding the recruitment of nurses form developing countries and their treatment once they come to the United Kingdom. Relevance to clinical practice. As the nursing workforce in the United Kingdom becomes increasingly diverse through international recruitment, it is important to have knowledge of experiences of different groups of nurses. This helps to devise adaptation programs for smooth transition tailored to particular groups and training that will help United Kingdom nurses to work in harmony with their foreign colleagues.     

Ethical concerns in nurse migration.

International nurse migration is natural and to be expected. Recently, however, those who have fostered nurse migration believe that it will solve nursing shortages in developed countries and offer nurse migrants better working conditions and an improved quality of life. Whether natural or manipulated, migration flow patterns largely occur from developing to developed countries. In this article, nurse migration is examined using primary health care (PHC) as an ethical framework. The unmanaged flow of nurse migrants from developing to developed countries is inconsistent with "health for all" principles. Removing key health personnel from countries experiencing resource shortages is contrary to PHC equity. Often, nurse migrants are placed in vulnerable, inequitable work roles, and employing nurse migrants fails to address basic causes of nurse shortages in developed countries, such as dissatisfaction with work conditions and decreased funding for academic settings. Nurse migration policies and procedures can be developed to satisfy PHC ethics criteria if they (1) leave developing countries enhanced rather than depleted, (2) contribute to country health outcomes consistent with essential care for all people, (3) are based on community participation, (4) address common nursing labor issues, and (5) involve equitable and clear financial arrangements.     

The Ethical Recruitment of Internationally Educated Nurses: A Leadership Perspective on Labor Migration

The trend in labor migration depends on variables such as the country’s economy, immigration policy, aging and population health, and the health care industry’s supply and demand prospects. The World Health Organization (WHO) and the Migration Policy Institute reported a steady rise in hiring international educated nurses with developed countries relying on foreign-born nurses to fill vacancies. According to a survey conducted by the International Council of Nurses in 2020, the National Nurses Association reported a 20% increase in nurses leaving the profession. The aging nursing workforce, heavy workload, insufficient staffing, burnout, stress, mass trauma, and the growing effects of COVID-19 on nurses’ psychosocial and emotional health exacerbated the nurses’ intention to leave. Although health care organizations are strained dealing with the outbreak, nurses are either retiring or quitting, leaving administrators to rely on temporary employees while struggling to fill permanent positions. This cyclical nursing shortage in the past, now exacerbated by the global pandemic crisis, has prompted policymakers to revisit the WHO’s Code on recruitment of health workers and its impact on sending and receiving countries.     

Why do nurses migrate? – a review of recent literature

Aim To identify the reasons why nurses continue migrating across international borders. Background International nurse recruitment and migration have been increasing in the last decade and recent trends show an increase in the movement of nurses between developing and developed countries, resulting in a worldwide shortage of nurses. Methods A manual and electronic database literature search was conducted from January 2004 to May 2010. Qualitative content analysis was completed for the final 17 articles that satisfied the inclusion criteria. Results Motivators to nurse migration were linked to financial, professional, political, social and personal factors. Although economic factors were the most commonly reported, they were not the only reason for migration. This was especially evident among nurses migrating between developed countries. Conclusion Nurses migrate for a wide variety of reasons as they respond to push and pull factors. Implications for nursing management It is important for nurse managers in the source countries to advocate incentives to retain nurses. In the recipient countries the number of international nurses continues to increase implying the need for more innovative ways to mentor and orientate these nurses.     

What is a nurse? Is there an international consensus?

CURRIE E.J. & CARR HILL R.A. (2013) What is a nurse? Is there an international consensus? International Nursing Review 60 , 67–74 Background: Historical experience and health service modernization partly account for the variation seen in definitions of what a ‘nurse’ is from country to country. It is unclear if international disparities in nursing provision, apparent in health data for developed countries, demonstrate real differences in staffing patterns or simply reflect the wide variations in understanding and use of terms for different categories of nurse. Aim: This paper is an opinion piece of international interest discussing the need for standardization in definitions of different categories of nurse internationally. Discussion: The International Council for Nurses (ICN), the World Health Organization and the Organisation for Economic Cooperation and Development (OECD) all have different ways of defining a nurse. The wide variation in terms is particularly apparent from OECD countries however, where nursing density data present wide disparities, not readily accounted for by gross national product. Skill mix and clinical role developments may account for these better. Conclusion: Until proper consensus is reached on what a nurse is and does, any skill mix or clinical role developments will only have limited international relevance, especially in OECD countries. If nursing qualifications are to be valid even across the European Union, then recommended standards such as those of the ICN, must be specified in terms of what different categories of nurses actually can do, and their responsibilities and roles within that scope of practice. Standardization of definitions of categories of nurse internationally should reduce confusion and promote better understanding of patterns of nurse staffing and the effect these may have on patient outcomes.     

Can you help?

During her time as president of the International Council of Nurses, Christine Hancock (pictured opposite) had the opportunity to meet nurses from developing countries. While nurse shortages exist in developing countries, many nurses are unemployed. HIV/AIDS deaths among nurses can be a bigger problem than nurse emigration. Testing and treatment for HIV/AIDS can make nurses role models in their communities. Basic sanitation and equipment are often absent.