Propiedades estructurales

In this section I would like to briefly examine the most common negative and positive consequences of nursing migration for sending and receiving countries, and mainly for the migrating nurse and her family. One migratory trend can have some benefits and also some negative aspects, depending from which perspective it is viewed (Freeman et al., 2012a ). As the demand for nurses has been increasing worldwide, it has resulted in an intense migration of this group, with at least ambivalent consequences for all involved players (Buchan, 2006b), (Brush, 2008). Considering that nurses most often migrate from poorer countries to more wealthy countries (Kingma, 2006), a large proportion of migrating nurses come to developed countries from countries such as the Philippines, India, and Africa using post-colonial ties as a pull factor (Buchan, 2006b), (Brush, 2008).

16If the nurse has an extensive experience working in a pediatric neurosurgical ward in her home country, it is much easier for her/him to start working in the same type of unit abroad.

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Consequences for sending countries

Uncontrolled permanent migration poses a serious threat to the developing countries in terms of depleting their stock of nurses, i.e. the so-called brain drain (Aiken et al., 2004), (Kingma, 2006). Even migration of only a few experienced health care professionals can restrict the provision of health care services in a small country (Kingma, 2006), (Schultz and Rijks, 2014) and cause the so called “loss of institutional memory”, with inadequate supervision and the disrupted transfer of professional knowledge, skills and attitudes to new employees (Kingma, 2006). For example, in a study using registration data from the Nursing and Midwifery Council, the older nurses migrating from Africa meant a loss of experienced staff in Sub-Saharan Africa (Buchan et al., 2006c). The source countries then have to rely on fewer workers who have to manage heavier workloads, without the resources to train more health care workers and retain the future leaders and educators, because they cannot compete with the 5x – 10x higher salaries in destination countries (Glinos, 2015).

On the other hand, the return of nurses who gained new skills while working abroad, sometimes called “brain circulation”, could positively influence the provision of health care services in the source country, if the migrating nurses actually intended to return into nursing in their country of origin. It has been argued that temporary, short-term migration is optimal, managed by government contracts for 1-3 years, followed by a compulsory return (Kingma, 2006). Moreover, remittances significantly contribute to the GDP in some countries, especially in the poorest ones (Kingma, 2006), (Bieski, 2007).

Supposedly, 50% of skilled workers return back to their home country after 5 years of migration, but the longer they stay abroad, the less likely it is that they will return (Kingma, 2001). Return migration is more likely to happen if a spouse and/or children are left in the home country. Nurses tend to return more often than doctors (Kingma, 2006), but even nurses intend to stay permanently in some countries (e.g. in the USA) (Sherwood and Shaffer, 2014).

Even if the nurse originally intended to return to her/his home country, a lack of interesting, professional opportunities there may alter this intention. Vavreckova determined this in the general Czech population of skilled professionals who gained special skills and competencies

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abroad but could not utilize them within the Czech system. Many of these professionals soon opted for re-emigration or migrated out of their profession (Vavreckova et al., 2006). It is likely that a nurse who gained special skills and knowledge abroad and cannot use them after returning to the home country will do the same. The participants in the MoHProf project also reported disappointment after return because they were not able to use their newly acquired skills in their home country (Schultz and Rijks, 2014).

Consequences for receiving countries

Destination countries experience a mostly positive impact of migration on their health care systems, such as the brain gain, and a decreased shortage of nurses. However, extensive reliance on internationally educated nurses, combined with insufficient orientation, was found to have negative effects on a patient´s outcomes. In hospitals with a favorable nurse- patient ratio (less than 1:4), the place of the nurse´s education did not have any influence on the patients’ outcomes. However, in hospitals with the nurse-patient ratio higher than 1:5 and with more than 25% of internationally educated nurses, the mortality was higher and the trend was increasing (Neff et al., 2013).

The Commission on Graduates of Foreign Nursing Schools (CGFNS) conducted a study that assessed self-perception of nursing knowledge and skills of internationally educated nurses practicing in the USA. While acknowledging a proficiency in English, these migrating nurses considered the following skills as less proficient: cardiac assessment and the use of technology and medication administration (Edwards and Davis, 2006). These factors could potentially impact the quality and safety of care. Moreover, the foreign workforce is less stable than the domestic one - it could easily migrate again.

Lately, the USA has acknowledged a continuing reliance on internationally educated nurses. Unlike some other destination countries, the USA is typically a permanent destination for the migrating nurse. The USA has a thorough credentialing procedure in order to protect the consumers. The main current issue is the increasing role of American nurses in safety and risk reduction, which might be approached differently in other countries; further, the language barrier still exists, as well as differences in the organizational aspects of care. Strategies for a safe transition have been suggested previously (Sherwood and Shaffer, 2014).

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On the other hand, eighty-one percent of nurses migrating to the USA had a degree education (Davis and Nichols, 2002). Another study conducted in the USA also determined that internationally educated nurses were younger, better educated, more experienced and worked more often in direct care, especially in inner city hospitals and services for seniors in comparison to United States (US) educated nurses (Xu and Kwak, 2007). Also, the similarity of internationally educated nurses with some international groups of patients becomes an extra skill and advantage in the US multicultural society (Sherwood and Shaffer, 2014).

Viewed purely pragmatically, one could agree with Glinos´s example of efficiency, that a destination country vastly saves their resources by hiring qualified health care professionals instead of educating their own (Glinos, 2015). However, such an approach is considered unethical (ICN, 2007b), (WHO, 2010b).

Consequences for the migrating nurse and her family

Since approximately 2010, there has been an increased interest in the experiences of internationally educated nurses living and working in destination countries. Consequently, we now have a much clearer picture about the enormous demands which migration puts on migrating nurses.

Many studies have described the unfair treatment, discrimination, bullying and deskilling of internationally educated nurses by different subjects in the migration process (e.g. employers, clients, colleagues) (Kingma, 2008), (Jose, 2008), (Tregunno et al., 2009), (Blythe et al., 2009), (Cuban, 2010), (Moyce et al., 2015). In a survey of internationally educated nurses working in London, more than half of the respondents felt that their clinical position was appropriate to their role and responsibilities, however only 30% of African nurses felt this way (Buchan et al., 2006c). The positive discrimination of migrating nurses is less common and occurs in the Middle East where the western nurses receive higher salaries (Kingma, 2006). The participants in Bludau´s study also mentioned this issue, as well as the personal discomfort it generated (Bludau, 2012).

In a feminist qualitative study of eight Latvian nurses working as caregivers in Norway, the author describes a deeper lying consequence of migration which is usually not openly

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discussed: a complex disruption of the family life of the migrant nurse. In developed countries, the poorly paid care work, which was traditionally carried out by a stay at home mother as unpaid work, is now outsourced to workers from poorer countries. Even though the positive consequences of migration (e.g. economic gain for the family) seem to have a priority, it results in serious negative consequences for the family of the migrant nurse which was left behind (Isaksen, 2012). While this “global care chain” (Bach, 2008) is better documented in Filipino nurses, in past 25 years it became pertinent to female migrants from Eastern European countries.

Moreover, migrating nurses working undocumented in private care settings remain unprotected and legally vulnerable. These nurses are also risking a deterioration of their professional skills (Kingma, 2006), (Haour-Knipe and Davies, 2008), (Kingma, 2008), (Glinos, 2015).

There are other serious social consequences of international migration of nurses. While the decision to leave the whole family behind can be the most difficult, abandoning one’s original community and learning to live in a new culture is not much easier. Traditional social patterns are disrupted when the woman has a better paid job than her husband, something which, on the other hand, can contribute to gender equality (Kingma, 2006). Adhikari supports Kingma´s argument that migration can change the traditional view of social roles. Because of the high demand for nurses in western countries, the social position of a Nepali women is changing. Now it is acceptable that a female works as a nurse and even migrates, even though this change still produces some tension in the affected families (Adhikari, 2013).

To conclude this section, it is important to note that a middle range theory on nursing migration has been developed, explaining nursing migration in a more complex way. Nurses seem to be somewhat transformed by the migration experience and they impact others on their return migration. A national collection of valid data on nursing migratory flows is still a challenge, but collecting these data uniformly around the globe is important for an efficient workforce.

Based on recently conducted studies, we are now more familiar with the experiences of migrating nurses. These studies show that migrating as a registered nurse can be extremely

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hard, especially during the early stages of migration. The first barrier is the lengthy, demanding and expensive credentialing procedure in the destination country. The next obstacle is the ability to communicate effectively in a foreign language with colleagues, patients and families (in person, over the phone, through nursing documentation, while being assertive, in understanding colloquial language and in using medical abbreviations). Another fundamental obstacle is a potentially different nursing practice, with more clinical and organizational responsibilities, and more autonomy for the nurse (requiring decision making and critical thinking). Similarly, the different health care system in the destination country creates a barrier for the migrating nurses which needs to be quickly overcome (the use of technologies, cultural diversity, autonomy of the patient and holistic care, confidentiality, the need for constant prioritizing and time management.) Therefore, a longer and specific orientation period is suggested for migrating nurses, ideally using a previous migrant as a preceptor. Nurses in many studies reported experiencing discrimination and racism from their colleagues and patients. They felt discriminated personally, financially and regarding the available benefits.

The consequences of migration and their local implications for the safe provision of health care services were, to a certain extent, mapped out in this section as well. These consequences are very complex, depending on from which perspective they are viewed and as such, they pose multiple ethical challenges.