Worldwide Impact of Nurse Migration

Change and challenge is in the wind as 2008 comes to an end. The same is true when examining this month's ReachMD XM 160 special series Focus on Global Medicine. We take a look at both the changes and the challenges impacting global medicine.

International nurse migration can be a great solution to nursing shortage. What happens to the countries losing their nursing work force to migration? Welcome to Focus on Global Medicine on reach ReachMD, the Channel for Medical Professionals.

I am your host, Dr. Bill Rutenberg, and joining us to discuss nurse migration is Dr. Barbara Sheer, Professor Emeritus at the University of Delaware School of Nursing. For more than 35 years, Dr. Sheer has been actively involved in the nurse practitioner movement and has held regional, state, and national positions in nurse practitioner organizations including president of the American Academy of Nurse Practitioners, chair of the National Alliance of Nurse Practitioners, and chair of the Fellows of the American Academy of Nurse Practitioners.

DR. BILL RUTENBERG:

Dr. Sheer, welcome to ReachMD. Thanks for joining us.

DR. BARBARA SHEER:

Well, thank you very much for the invitation.

DR. BILL RUTENBERG:

Nurse migration, is this is a new phenomenon?

DR. BARBARA SHEER:

Actually, it is not a new phenomenon, but it has received greater attention with global awareness and certainly with the nursing shortage. Nurse migration and the nursing shortage are kind of interrelated and are symptom of global issues. As most of us know all nations are facing health care crisis. We have rising health care cost and it's taking up a larger part of the gross national product. We have increased, you know our extensive technologies or looking at the ageing population, the baby boomers in United States are now reaching 60s and in other nations, actually in Japan it is getting to be ground zero because they have zero population growth and looking at an ageing population, some of the Japanese are living to be over 100. So, with zero population rates that certainly is a major issue. Also, in other countries, the populations are dealing with chronic diseases such as HIV/AIDs, and in Sub-Saharan Africa, they are dealing with that as a health care crisis. Yesterday, it was announced in Zimbabwe that they had a cholera epidemic and on the news it said that most people are living in that country to be 35 years of age, but is certainly a significant issue.

DR. BILL RUTENBERG:

How is this global heath care crisis driving nurse migration? Are you saying that these countries because of their health care crises cannot produce enough nurses in their own countries and so they are bringing them in from elsewhere? Tell me how the 2 are linked together.

DR. BARBARA SHEER:

Actually, it's a difference between the developed nation and a developing nation. Certainly, we have had shortages in US and it tends to be relatively cyclic. When there is a nursing shortage, we are able to produce more nurses and then we say well the market is flooded, the salaries drop, and then again we have the nursing shortage because young women, its predominantly a women’s profession still, young women’s find other professions to enter. This particular cycle actually began around 1998 and it is expected to grow to well beyond 2020. The projected shortage in 2010 is 275,000 nurses, and this is because in the US, we have an ageing workforce. Most of our nurses are above 45, most of them are actually between 45 and 55, and it is a particular concern for nursing faculty because most of our faculty, by the time they have doctoral degrees, are over 50. We also have women coming into the profession later in their life, so they are spending less time practicing as a nurse. So, all of this, along with the issues that we are experiencing, needing additional nurses around the world, it is somewhat of a problem, and because the developing nations have shortages, we have a global shortage; because they have more resources, they are able to pull from developing nations.

DR. BILL RUTENBERG:

And which countries are the nurses coming from and which countries are consuming most of the migrating nurses?

DR. BARBARA SHEER:

Most of the nurses are coming to the US, the UK. Ireland used to produce more nurses and they were exporting and now they need to also import nurses. Canada, Australia, and New Zealand. Actually, New Zealand is importing more nurses than anyone else and the source countries are usually the developing nations, South Africa, Zimbabwe, and Nigeria. The Philippines is not a developing nation, but has had a long history of exporting nurses. They actually have exported more than any other country.

DR. BILL RUTENBERG:

I would think that the education of nurses in such various countries is significantly different. Is there is any kind of code or agreement amongst the countries which regulate nurse migration, are there any standards that we require before someone say comes in to the United State as a nurse?

DR. BARBARA SHEER:

That is a of question. Let me start out by saying there is no international agreement per se and there is any international mutual agreements, but several countries have worked on this. There is Trans-Tasman Mutual Recognition for the AU, for Australia and New Zealand, so those nations can go back and forth. The European Union has developed a system or is developing a system whereby nurses in the European Union as part of the Bologna process can migrate from EU to EU Country and this is causing somewhat of an issue. They are going to have standards developed by 2010, but while they are developing the standards, they are looking primarily at baccalaureate prepared nurses, and one of the issues that the UK has right now is that if nurses are graduating from other countries and they have met their requirements educationally, they are registered in the UK and there is no cultural orientation for those nurses. Otherwise, if you are coming in from another country that is not an EU country to the UK, you can be registered with a credential check, but you also have to be culturally competent, so that's an issue for them. The United States is not very easy to immigrate to. We think that the concept of nurses coming into the United States and we are just importing them, is greater than what actually happens in practice. The statistics that we have from the COGFNS Group, which is the Commission on Graduate of Foreign Nursing Schools, reported in 2002, 19,000 nurses applied to take the screening test, 17,000 took the exam, only 5000 of them passed. Looking at the number of these screening, we are estimating that of that 20,000 only 5000 actually came in.

DR. BILL RUTENBERG:

And that was for how long period of time?

DR. BARBARA SHEER:

That was for the year 2002.

DR. BILL RUTENBERG:

Okay, and that's the last time we had data for?

DR. BARBARA SHEER:

Yes.

DR. BILL RUTENBERG:

Do you think the number is about the same that we are still averaging about 5000 a year?

DR. BARBARA SHEER:

I think the number is probably the same or may be a little bit less, because now the visa screens are somewhat problematic.

DR. BILL RUTENBERG:

So, numbers are, you would say, probably 4000 to 5000 now per year?

DR. BARBARA SHEER:

Probably. There really isn't a great estimate because in United States, we act as if we are 50 different nations because each state has its own regulation, I am sure it's the same in medicine. If you are coming in from another country, what you first need to do is look at the state in which you want to be employed because each state has different regulations, but one thing that is consistent is that everyone needs to pass an examination, which we call the NCLEX examination, its the National Council Licensure Examination. We call it the NCLEX and now it is offered in other countries too. We have always offered it in the Philippines, but now we are also offering it in London, Singapore with one of the countries that will have this NCLEX exam offered, because now it's online.

DR. BILL RUTENBERG:

You hadn't mentioned India, is India a source of nurses to the United States?

DR. BARBARA SHEER:

India is a source of nurses, but they are not producing that many, and they also have a significant shortage.

DR. BILL RUTENBERG:

I would imagine they did, I was just bringing up that ethical issue.

DR. BARBARA SHEER:

Actually, I have a statistic for India. They have 45 nurses per 100,000 population.

DR. BILL RUTENBERG:

And the recommended number is?

DR. BARBARA SHEER:

Much more than that, the US has about 782.

DR. BILL RUTENBERG:

Wow.

DR. BARBARA SHEER:

Right. The lowest statistic I found and you will just be fascinated by this was Malawi. Malawi has 12 million people. They have 94 physicians and 300 nurses.

DR. BILL RUTENBERG:

So, I guess if it gets really bad for me in this country I know where to go.

DR. BARBARA SHEER:

I am sure there will always be a position there.

DR. BILL RUTENBERG:

But how about the ethical issue, isn't it robbing Peter to pay Paul to allow nurses from these countries to enter into our country and really rob their own populations of the nursing care they need?

DR. BARBARA SHEER:

There are significant ethical issues and actually the World Health Organization has put up a common wealth code for practice for international recruitment of health workers. Some of the problems that we have are that there is the international, we do not always have a place to work, even though their nation is deprived of health care workers they are not employable. They are not on the table. In Kenya, they have a category called ghost workers and these are people who appear on the table, but don't really exist and is estimated that there are 5000 ghost workers in Kenya.

DR. BILL RUTENBERG:

Oh, that happens in Chicago a lot.

DR. BARBARA SHEER:

Oh really?

DR. BILL RUTENBERG:

Yeah.

DR. BARBARA SHEER:

(Laughs)

DR. BILL RUTENBERG:

I mean there are always people , his entire family on the pay role, I don't know if they actually work.

DR. BARBARA SHEER:

Okay, well that's one of the problems and some of the recent graduates from Uganda and Zambia were unemployed because the health systems cannot pay their salaries. So, some nurses are working in those systems for free, so that they can just keep up their skills and also there is a lot of corruption in many places. If we import them, if they are eligible to come to a developed nation, which really actually only comprises 5% to 10% of our workforce, they have the advantage of better working conditions. They state, when I was in Africa, I visited the public hospital in Johannesburg and unfortunately they are running about a 70% vacancy rate for nurses, and when I went in, there were no universal precautions, many nurses did not have the availability of gloves. When I asked about the patients and what their HIV population was, they said they assume it is 100%. There are personal safety issues. Nurses are frequently abused, so there are some significant issues in some of the developing nations. So, nurses are able to come to a developed nation to practice, to increase their level of practice. Some of them actually do go back to their nation, but they are able to send money back to their families, and actually in the Philippines, the nurses were a major export.

DR. BILL RUTENBERG:

If you are gonna your hospital safety and nursing shortage and you needed to increase your staff, which country would you turn to and what's the process by which you identify nurses willing to immigrate to the United States?

DR. BARBARA SHEER:

I am not quite sure how to answer that. I know that in the UK, there estimate was that 5000 nurses apply to them to come into the country and in that year they hired 50,000, so recruiters were getting 10,000 from other places. I think one of the most important things when we recruit nurses is ethical recruitment, that they don't have a commitment and outstanding obligation to the country. In many of these nations, when the nurse has education in that country, she owes that country a year or two. It would also be very nice if we could have like a rotational system. I know South Africa was trying to work out a system with the UK, in that when their nurses were recruited by the UK, the UK would also send nurses for a cultural experience to Africa.

DR. BILL RUTENBERG:

Wow that's a great program!

DR. BARBARA SHEER:

And if we could do that kind of circular thing, we could improve the educational level of the nurses in the developing nations. When we look at people coming into the US, we have to make sure that they have language competency and that's not easy, particularly if you have English as a second language. Many countries are doing unethical advertising, nurses come in, and they find out that they are not qualified for an actual nursing physician.

DR. BILL RUTENBERG:

I would like to thank my guest, Dr. Barbara Sheer, Professor Emeritus at the University of Delaware School of Nursing for joining us to discuss nurse migration. I am your host, Dr. Bill Rutenberg, and you've been listening to Focus on Global Medicine on reach ReachMD, the Channel for Medical Professionals, and thanks for listening. I wish you good day and good health.

Thank you for listening to our special series Focus on Global Medicine, as we celebrate this annual holiday season. Everyone at ReachMD wishes you and your family a happy holiday and a successful New Year.

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