Nurses on the move: a global overview

Health Services Research, June, 2007 by Mireille Kingma

The number of international migrants on the move every year continues to increase. There has been a particularly marked growth in labor migration flows to industrialized countries in recent years (Zlotnik 2003). People with tertiary education accounted for nearly half the increase in migrants older than 25 years in the Organisation for Economic Co-operation and Development (OECD) countries during the 1990s (UN 2006). Women account for an increasing proportion of all migrants, reaching almost half of today's 191 million international migrants (IOM 2005; UN 2006). Many more women are migrating independently of partners or families (Timur 2000), thus changing the social dynamic associated with the migration process in both source and destination countries. Women migrants are becoming agents of economic change as they enter the international labor market and participate in a new distribution of global wealth (IOM 2003).

HEALTH CARE PROFESSIONALS

Data presented in the 2006 World Health Report strongly support the direct link between positive health outcomes and the density of professional health care workers. The evidence highlights the difficulty in reaching targets where health systems are experiencing critical staff shortages. Countries having the greatest difficulty in meeting the UN Millennium Development Goals (MDGs) are faced with absolute shortfalls in their health workforce, seriously limiting their potential to respond equitably to even basic health needs (WHO 2006). The international recruitment and migration of health professionals affecting national workforce supply is now a significant item on the political agenda (Stilwell et al. 2003; ICN/FNIF 2006; WHO 2006).

Nursing increasingly can be characterized as a mobile profession. Thousands of nurses--the vast majority of them women--migrate each year in search of better pay and working conditions, career mobility, professional development, a better quality of life, personal safety, or sometimes just novelty and adventure (Kingma 2006). It is estimated that 30,000 nurses and midwives educated in sub-Saharan Africa are now employed in seven OECD countries (1) (WHO 2006). This article looks at nurse migration flows in the light of national nursing workforce imbalances, examines factors that encourage or inhibit nurse mobility, and explores the potential benefits of circular migration.

International Migration

The percentage of foreign-educated physicians working in Australia, Canada, the United Kingdom, and the United States is currently reported to be between 21 and 33 percent, while foreign-educated nurses represent 5-10 percent of these countries' nurse workforce. New Zealand reports that 21 percent of its nurses are trained abroad, a significant increase in the last decade (WHO 2006). In Switzerland, 30 percent of employed registered nurses are foreign educated and in at least one university hospital 70 percent of new recruits are from abroad (Artigot 2003). In 2005, 84 percent of the new entrants to the Irish nursing register were foreign-educated; a total of 60 percent if European Union source countries are excluded (An Bord Altranais 2005). In 2002, the number of foreign-educated nurse entrants to the U.K. Nursing and Midwifery Council Register exceeded the number of newly qualified nurses educated in the United Kingdom (Ball and Pike 2004). While the percentage of new foreign-educated nurse registrations in the United Kingdom has decreased in recent years (approximately 35 percent in 2004-2005) (NMC 2005), there is a reported bottleneck of 37,000 foreign nurses in the country waiting for clinical placements in order to fulfill accreditation requirements (Parrish and Pickersgill 2005).

Migration Flows

Traditionally, international nurse migration tended to be a North-North or South-South phenomenon, e.g., Irish nurses working in the United Kingdom, Canadian nurses practicing in the United States, Fijian nurses migrating to Palau. However, it is the rapid growth in international recruitment from developing countries to industrialized countries that has gained most media and policy attention in recent years (Dugger 2006; WHO 2006).

In 2000, over 500 nurses left Ghana for employment in the industrialized countries. That was more than twice the number of new graduates from nursing programs in the country that year (Zachary 2001). In Malawi, between 1999 and 2001 over 60 percent of the registered nurses in a single tertiary hospital (114 nurses) left for employment in other countries (Martineau et al. 2002). In 2003, a hospital in Swaziland reported that 30 percent of their 125 nurses were lost to work abroad (Kober and Van Damme 2006) and, between 1999 and 2001, Zimbabwe lost 32 percent of their registered nurses to employment in the United Kingdom (Chikanda 2005).

The directional flow of nurses may change over time. While Ireland was known for decades to be an exporting country with Irish nurses migrating to the United Kingdom, it is now an importing country recruiting mainly from the Philippines, Australia, India, South Africa, and the United States (Department of Health and Children 2001; ICN 2004). Established flows in South-North migration are also subject to change as more source countries enter the international labor market. For example, the number of countries sending international nurse recruits to the United Kingdom has increased from 71 in 1990 to 95 in 2001 (Buchan and Sochalski 2004). The Philippines, once the leading source of nurse migrants to Ireland and the United Kingdom, was outranked by India in 2005 (HSE 2003, 2004; NMC 2005).