Friday, May 11, 2007

International Nurses Migration

International Nurse Migration

Issue being addressed: International nurse migration as a solution to nursing shortages

Background of Issue:

International recruitment and nurse migration--- moving from one country to another in search of employment are increasingly being seen as solutions to nursing shortages. Historically, nurse migration has been mostly opportunistic or based on individual motivation and contacts (Buchan, 2001). During the past decade, however, active large scale planned international recruitment has occurred with developed countries recruiting nurses from both other developed countries and developing countries (Huston, 2006). In addition, developing countries are recruiting from each other, even within the same geographic region (International Council of Nurses [ICN], 2002). As a result, foreign- educated health professionals represent more than a quarter of the medical and nursing workforces of Australia, Canada, the United Kingdom, and the United States (Oulton, 2004).

This nurse migration has occurred primarily as a result of push/pull factors. Push factors are those things that push or drive a nurse to want to leave their country to go to another. Push factors identified by Awases, Gbary, & Chatora (2003) include economic factors (unsatisfactory remuneration), institutional factors (lack of proper work facilities and equipment), professional factors (lack of career development options) and political factors (socio-political instability).

Pull factors are those things that draw the nurse toward a different country. Pull factors encouraging nurse migration include opportunities for professional development, aspirations for a better quality of life, personal safety, improved pay and learning opportunities (Kingma, 2001; Buchan, 2001).

The literature suggests that different countries have experienced different impacts as a result of the push-pull of international nurse migration. Positive impacts include the economic benefits associated with the generation of remittance income (Huston, 2006). It is estimated that globally, remittances contribute more than 70 billion dollars to world economies (Oulton, 2004). More commonly, however, donor countries report “brain drain- the loss of skilled personnel and the loss of investment in education (Kline, 2003) that is experienced when scarce human resources migrate elsewhere. International migration threatens global health because the “loss of human resources through migration of professional health staff to developed countries usually results in a loss of capacity of health systems in developing countries to deliver health care equitably” (ICN, 2004). Migration of health workers also undermines the ability of countries to meet global, regional and national commitments and even their own development (ICN, 2004). For these reasons, the Commonwealth Code of Practice for the International Recruitment of Health Workers (2003) discourages the targeted recruitment of health workers from countries which are experiencing shortages. Aiken, Buchan, Sochalski, Nichols, & Powell (2004) concur, arguing that developing countries need to do all they can to create a sustainable professional nurse workforce that meets their own needs.

Kingma (2001) suggests that the negative effects of international migration on “supplier” countries are beginning to be recognized, but that they have not been effectively addressed. Certainly, there must be some sort of a balance between the right of individual nurses to choose to migrate (autonomy), particularly when push factors are overwhelming, and the more utilitarian concern for a donor nations’ health as a result of losing scarce nursing resources (Huston, 2006). The Commonwealth Code of Practice for the International Recruitment of Health Workers (2003) argues that such a balance is possible only when there is “mutuality of benefit-” the extent to which the donor country is compromised is minimized as a result of the importer country providing assistance in the form of money, technology, training upon return to the home country; or facilitation of the return of recruits to their home country.

International migration also poses potential negative consequences for the individual migrating nurse. Due to the lack of regulatory oversight of agencies and practices of global nurse migration contracting, nurses who have migrated are at increased risk for employment under false pretences and may be misled as to the conditions of work, possible remuneration and benefits (Huston, 2006). Thus, they are placed at risk for unethical, if not illegal employment practices in their host country.

Haddad (2002) also voices her concern that nurses from donor countries may not be given the respect they deserve in the workplace due to negative bias and prejudice by their peers, who regard them as outsiders. Workplaces must actively seek to create a culture through education and training which accepts and even welcomes nurses from other countries.

Finally, Huston (2006) suggests that “one must at least consider whether recruiting nurses from other countries to solve acute staffing shortages is simply a poorly thought out, quick fix to a much greater problem and in doing so, not only are donor nations harmed, the issues that led to the shortage in the first place are never addressed. Clearly, large scale recruitment of nurses from other countries would be less necessary if both importer and exporter nations made a more concerted effort to improve the working conditions, salaries, empowerment, and recognition of the native nurses they already employ.”

Policy or position developed, recommended, adopted:

Sigma Theta Tau International (STTI) recognizes international nurse migration as a serious issue impacting nurses worldwide. Since nurses and the nursing profession are a vital and integral partner in every health care system (Dickenson-Hazard, 2004), global health is dependent upon all nations having the human resources necessary to provide nursing care. STTI, with its vast leadership and knowledge resources, is committed to the exploration of this issue and to the identification of solutions that do not promote one nation’s health at the expense of another.

STTI’s commitment to this issue is demonstrated in many ways, including, but not limited to:

    1. Encouraging leadership development that focuses on effectively informing and influencing decision-makers (if they are not in decision-making roles); and contributing to the development of public and workplace policy development in their home country and world region.
    2. Providing opportunities and forums for nurses and others around the world to be informed, share knowledge, and to openly discuss health care, nursing and social concerns such as international nurse migration.
    3. Disseminating strategies, findings, and best practices on international nurse migration to a variety of publics through its publications, meetings, electronic communication forums, etc.
    4. Developing policies, position statements, briefs, guidelines, by-laws or white papers on international migration and ethical recruitment for distribution to members and external stakeholders.
    5. Supporting research initiatives and other scholarly activities that assess the magnitude and effects of international nurse migration, the cost of the loss of human resources, distribution and migration patterns, and innovative approaches for addressing the distribution and migration of nurses.
    6. Supporting leadership and research initiatives directed at working with donor countries to address the push and pull factors driving the loss of irreplaceable human nursing resources (i.e- institutional factors such as lack of proper work facilities and equipment and professional factors such as lack of career development options, a desire for more autonomous practice).
    7. Collaborating with health professionals, stakeholders, and policy makers to call for the development of national and regional (world regions) strategies to deal with international nurse migration issues.
    8. Encouraging society leaders to further participate in policy development, implementation, monitoring and evaluation related to international nurse migration and ethical recruitment, including practice differences and supportive transitioning programs.
    9. Supporting the work of colleagues (nurses, other health providers, and policymakers) in responding to the myriad of issues related to global nursing shortages.
    10. Encouraging international fellowships or exchange programs.
    11. Endorsing the Guiding Principles established by the Commonwealth Code of Practice for the International Recruitment of Health Workers (2003)
    12. Endorsing the following two position statements by the International Council of Nurses (ICN):
      1. Nurse retention, transfer, and migration. (1999). Retrieved 2/10/04 from
      2. Ethical nurse recruitment.(2001). Retrieved 5/16/04 from

Both the Guiding Principles established by the Commonwealth Code of Practice for the International Recruitment of Health Workers and the ICN position statements support the right of nurses to migrate, and confirm the potential beneficial outcomes of multicultural practice and learning opportunities supported by migration, but acknowledge potential adverse impacts on the quality of health care in donor countries. All three statements also suggest that importer countries have an obligation to ensure that appropriate resources have been dedicated to the recruitment and retention of their own nurses before recruiting nurses from other countries, since nurse migration is often a symptom of more deep-seated problems in a country’s nursing labor markets relating to long-term relative under-investment in the profession and its career structure and failed policies (Buchan, 2001; Aiken et al, 2004; Huston, 2006; Clarke, 2001).

In addition, the documents denounce unethical recruitment practices that exploit or mislead nurses into accepting employment and working conditions that are incompatible with their qualifications, skills and experience. As a result, the ICN and its member national nurses’ associations call for a regulated recruitment process, based on ethical principles, that guide informed decision-making and reinforce sound employment policies on the part of governments, employers and nurses. In addition, the position statements encourage the monitoring and oversight of international flows of nurses to highlight the pressure points as well as importer countries that are being aggressive and unethical in their recruitment activities (Huston, 2006).

The Commonwealth Code of Practice for the International Recruitment of Health Workers (2003) also acknowledges the right of health workers to migrate to countries that wish to admit and employ them. Yet it seeks to encourage the establishment of a framework of responsibilities between governments – and the agencies accountable to them – and migrant nurses. This framework would balance the responsibilities of health workers to the countries in which they were trained – whether of a legal kind, such as fulfilling contractual obligations, or of a moral kind, such as providing service to the country which had provided their training opportunities – and the right of health professionals to seek employment in other countries.

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