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Pulling the plug on brain-drain: understanding international migration of nurses.

The reliance on foreign nurses is symptomatic of ineffective staffing practices affecting health care professionals, particularly nurses, in the United States and other industrialized nations. This demonstrates a failure to alleviate the nursing shortage. The influx of foreign nurses (brain-drain) has serious ramifications that should be explored fully.

Brain-drain is a complex phenomenon that influences health care organizations from small municipalities to worldwide, large-scale national systems. The reliance on foreign nurses is symptomatic of ineffective policies in industrialized countries such as the United States and represents the failure of national and international policies to alleviate the perpetual worldwide nursing shortage. International nurses represent an estimated 5.4% of the U.S. nursing workforce (U.S. Department of Health and Human Services, 2010).

An estimate of foreign-educated nurses (FENs) who enter the United States is derived from the number of visas granted in a given year, but statistics regarding the outflow of FENs from developing countries are lacking. The reliability of the available statistics unfortunately remains in question because data collection often has been inaccurate, incomplete, unclear, and outdated (McCoy et al., 2008). No single agency collects standardized data on international flows of FENs (Clemens & Pettersson, 2008). This accounts for the lack of current available data found in systematic database searches. The lack of available, accurate data on the migration of nurses from developing countries is cited consistently throughout the literature (Khaliq, Broyles, & Mwachofi, 2008).

The supply-demand component of staffing is only one constituent of brain-drain. Another constituent is migration of nurses to this country, which often is treated with indifference as it is perceived simply as an American tradition to hire foreign workers. No single solution can resolve the problem of brain-drain. The author suggests it is essential to acknowledge the global consequences of brain-drain to begin developing the path for resolution.

This article is designed to broaden awareness of brain-drain, identify its complexities, describe its global impact on the nursing profession, and offer viable options for resolution of a multi-faceted, complex problem. The author has drawn upon first-hand experience in Ghana, located in Western sub-Saharan Africa, gained from providing nursing care through multiple medical missions with the Foundation for Orthopaedics and Complex Spine (FOCOS) (www.orthofocos.org).

Ghana: An Overview

The Republic of Ghana in West Africa borders the Cote d'Ivoire to the west, Togo to the east, and Burkina Faso to the north. Prior to independence from the United Kingdom in 1957, Ghana was known as the Gold Coast and became the first African nation to achieve independence. It is a democratic state with Accra as its capital city. Although the official language is English, there are numerous indigenous languages and dialects. The current population is 22,535,000 (International Office of Migration, 2010). The World Bank (2009) identified the per capita annual income as approximately $1,190.

Ghana is representative of countries with increasing workforce losses resulting from brain-drain as evidenced by an increasing number of nurses leaving the country each year (Kingma, 2004), as well as a trend in increased migration of nurses in Africa (Skeldon, 2009). Older immigration estimates report the number of nurses who left Ghana in 1 year outweighed nursing school enrollment (Eastwood, Conroy, Naicker, West, & Tutt, 2005).

In 2007, Ghana had 7,304 nurses despite an unsuccessful government attempt to increase the number to 11,000 (Ghana Ministry of Health, 2008). In the past decade, the country has lost 50% of its nurses to Canada, the United Kingdom, and the United States (Nullis-Kapp, 2005). Ghana's greatest health care resource is its health care personnel, of which nurses are a primary component (Talley, 2006). It is hard to find a Ghanaian nurse who does not personally know a colleague who has immigrated.

Brain-Drain Defined

Brain-drain refers to the immigration of technically trained professionals from one country to another. In the context of this article, it refers to nurses who immigrate in search of a financially enriching life. It is the transfer of human capital much as traditional trade is a transfer of goods from one country to another (Kingma, 2006). The combination of individual choice to immigrate and the enticements of working in another country has left developing nations with serious staff shortages.

The immigration trend traditionally follows a pathway from a developing nation either to a more stable developing country or to an industrialized one. Some nurses migrate to nearby developing countries in search of safety to avoid political turmoil, even though the move might be only a lateral one financially. The actual number of nurses who leave their countries is unknown because of a lack of statistics and inadequate record keeping (Bach, 2003; Buchan, Parkin, & Sochalski, 2003; Kingma, 2006; Lowell & Findlay, 2001; Naude, 2010; Zurn, Dolea, & Stilwell, 2005). Even large worldwide organizations such as the World Health Organization (WHO) have been criticized for their poor data collection (Munjanja, Kibuka, & Dovlo, 2005). Despite questionable statistics, WHO estimated 25% of nurses left Ghana in the last decade (Lane, Antunes, & Kingma, 2009). Other global organizations, such as the United Nations, the International Labour Organisation, and the Organisation for Economic Cooperation and Development, also may have been handicapped similarly by lack of reliable information. Without accurate statistics, it is improbable effective legislation could be enacted to alleviate the problem.

Growing evidence indicates far more nurses are immigrating than are returning. One survey found one in five Ghanaian households had a member who immigrated abroad (Anarfi, Kwankye, Ofuso-Mensah, & Richmond, 2003). However, statistics from destination countries appear more reliable than those from source countries (Bach, 2003; Stilwell et al., 2004). Because nurses and midwives in Ghana represent 71% of the total health care service providers, the loss of nurses takes on a new perspective (Lane et al., 2009).

However, not all influences of brain-drain are negative. Return migration, or brain circulation, can provide a transfer of new skills and an influx of knowledge. Contrarily, it can be argued technical skills may not be transferable because developing countries may lack the necessary technological resources, equipment, and scientific advances. Another positive effect is remittances emigrating nurses send home to help their families financially. This income also may bolster the source country's economy indirectly, although evidence to support this contention is lacking (Lane et al., 2009).

Brain-drain influences a broad spectrum of both local and national health care systems. The initial mobility pattern in a developing country is termed internal brain-drain, as professionals move from a rural setting to an urban center, from the public to private sector, and ultimately conclude with an external exodus to another country (Martinez & Martineau, 2002). A history of pay inequity also exists between rural and urban settings (GhanaWeb, 2004). This has created a large gap for rural inhabitants and an overwhelmed rural health care system (Eastwood et al., 2005; Munjanja et al., 2005). In Ghana and most African nations, the outflow trend is predominantly to five countries: South Africa, United Kingdom, United States, Canada, and Australia (Dovlo, 2003; Dovlo & Martineau, 2004; Munjaja et al., 2005; Nullis-Kapp, 2005). Because Ghana is an English-speaking nation, language represents a positive force for immigration.

The effects of brain-drain have had both positive results (sometimes referred to as brain gain) and negative results, some so deleterious entire health care systems have been crippled or compromised. Researchers Chen and Boufford (2005) and Nullis-Kapp (2005) forecasted Africa will need over 1 million health care workers over the next decade. Contributing to the problem, in destination countries that use the hiring of foreign nurses as an immediate solution to staffing shortages, there is little acknowledgment, understanding, or concern of the long-term consequences to source countries.

From a global perspective, recruiting nurses from overseas often serves to redistribute the shortage to a country less equipped to deal with it (Buchan & Sochalski, 2004). The recruitment of foreign nurses perpetuates the shortage on a worldwide scale (Joint Commission, 2005). Medical staff shortages have been reported in most countries, but the shortage seems most severe in Africa (Zurn et al., 2005). One significant, unresolved philosophical question looms over brain-drain: Does the hiring of foreign nurses represent exploitation or opportunity?

Conditions need to be ripe for the brain-drain phenomenon to transpire. For example, the high global demand for nurses increases the probability a substantial percentage of the nursing workforce will flee their countries (Chaguturu & Vallabhaneni, 2005). Worldwide demand for nurses far exceeds the supply (Booth, 2002). Skills are in short supply in both developing and developed countries (Buchan, Kingma, & Lorenzo, 2005).

Attrition from an aging workforce has created an environment conducive to attracting foreign nurses. This is especially true with the United States and Canada (Booth, 2006). The climate created by retiring nurses insures an inflow of foreign health workers (Bach, 2003; Booth, 2002; Joint Commission, 2005; Likupe, 2006).

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Ghana also has an aging workforce: 45% of nurses are ages 45-54 (Ghana Ministry of Health, 2008). This statistic takes on a new perspective given the average Ghanaian lifespan of 57 years (U.S. Department of State, 2010). The recession in the United States has put a temporary damper on hiring additional nurses, but the long-term nursing shortage is projected to grow to 260,000 by 2025 (Buerhaus, Auerbach, & Staiger, 2009). It is an inescapable conclusion the nursing shortage is destined to worsen over time.

Push and Pull Factors Defined

Two concepts that aid in understanding the circumstances that produce brain-drain are push factors and pull factors (see Figure 1). Push factors are conditions or circumstances that provoke or incite change. They are influences that alienate people and encourage them to leave their countries (identified as source or donor countries) in search of a location where these factors are insignificant or nonexistent (known as the destination country). Pull factors are influences that entice nurses from source to destination countries. They create an impetus to leave home or an attraction to seek work in a recipient country (Dovlo & Martineau, 2004). An example of a pull factor is the freedom of geographic movement, which is considered by many as a basic human right (Chen & Boufford, 2005). Because nursing is a portable profession, push and pull factors are compelling, active issues for nurses in developing nations. Nursing education in developing countries often represents a ticket to freedom, and thus a pull factor. In many countries, up to 50% of nursing graduates report their intention to work abroad (Kingma, 2006). The complex relationship between push and pull factors ultimately determines whether nurses will decide to immigrate. Both push and pull factors must be present for immigration to occur.

Understanding the components of brain-drain will prevent observers from blaming individual immigrating nurses and will shift the responsibility to international policies, contributing to a higher sensitivity to what impels a nurse to migrate. When over half the nursing positions in Ghana remain unfilled (Chaguturu & Vallabhaneni, 2005), it may not be surprising nurses choose to leave their country in search of a better life. However, the source country cannot be condemned for conditions that initially led to migration. While the decision to immigrate is ultimately a personal choice, it also is influenced by the individual's social and economic context (Bach, 2003). An individual's motivation, willingness to take risks in going to a completely new environment, and the ability to accept the social isolation from friends, family, and culture are all serious considerations.

Push and pull factors can be understood best as part of a continuum, rather than as a list or grid (see Figure 1). These factors do not exert their influence in isolation; rather they act simultaneously. No single factor can influence nurses to leave their countries. It is the net interplay of multiple push and pull factors that contributes to this monumental personal decision (Kainth, 2009).

Action of Push and Pull Factors

Increased communication technologies have empowered nurses in Ghana to take an active stance in finding alternatives to their work conditions. While few people own computers, inexpensive Internet cafes are common. Access has broadened the ability to assess working conditions in other countries as well as communicate directly with prospective employers. The Internet and easy access to cellular telephones have allowed nurses to see first-hand the contrast between the living conditions abroad and their own conditions--a strong push factor (Ros, Gonzalez, Marin, & Sow, 2007; Ros, 2010).

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Two of the most significant push factors are low pay and employment conditions (Buchan et al., 2003; Dovlo & Martineau, 2004; Talley, 2006). Ghanaian nurses often earn above the Ghanaian per capita income, but cannot compete with the income derived by migration (Lane et al., 2009). Salaries for Ghanaian nurses are estimated to be $200-$400 per month (World Bank, 2009). Income for a top-grade nurse is estimated at $300 monthly (BBC Mobile News, 2008). While this amount is above the gross national income, it does not result in surplus income. A recent study found a majority of nurses were not able to save even a part of their income to maintain financial stability (Anafri, Quartey, & Agyei, 2010).

Cultural and political situations in Ghana have not alleviated most conditions that lead to the outflow of nurses. Under current economic circumstances, salaries are unlikely to increase significantly (Agyepong et al., 2004). The short-lived Additional Duty Hours Allowance Act of 1998, an incentive to increase remuneration, benefitted doctors more than nurses, and was fraught with corruption until it was abolished in 2006. The Ghana Universal Salary Structure of 2007 failed to implement fair compensation structures. In 2009, new directors of the Fair Wages Commission were appointed to oversee salaries, wages, classification, and job analyses of governmental positions. Regrettably, no viable governmental agency performs this role for the nursing profession. The lack of a successful and fair salary structure represents a financial push factor. The flow of nurses is symptomatic of deeper policy, social, and economic issues in both source and destination countries (Buchan & Sochalski, 2004).

Medical Conditions in Ghana

The following description of an inpatient hospital in Ghana illustrates some conditions that push nurses to immigrate. Korle-Bu Teaching Hospital is Ghana's largest, where supplies are antiquated and the infrastructure is in disrepair (see Figures 2-5). Ceilings are crumbling and only one undependable elevator services the entire six-story Surgical Block building. The hospital's steel beds are manually operated, and the suction and oxygen equipment are obsolete. Equipment that requires electricity is subject to common power outages. One portable oxygen tank is available on a 22-bed unit, which also has no resuscitation cart or electrocardiogram equipment. There is no paging system, no overhead intercom, and no call bell system. The telephone at the nursing station is unreliable. To compensate for this technological shortcoming, the staff relies on their personal cell phones. Plastic buckets of water sit under sinks in preparation for power outages. The sharps container is a cardboard box with needles protruding from its sides. Although there is no MRI, the effectiveness of any high-technology devices would be nullified by dependence on unreliable electric power. These conditions act as a catalyst for immigration.

Ghana has no effective regulatory bodies similar to the National Council of State Boards of Nursing or The Joint Commission to define and maintain standards of nursing practice. No successful lobby supports the nursing profession. The Ghana Registered Nurses Association is long-standing, but its goals, effectiveness, and impact on the profession are unclear. No response has been received to multiple inquiries seeking information. The Ghana Ministry of Health oversees the entire health care system of the nation. To help offset the strain, approximately 40% of health care services are provided by private and faith-based organizations (Ghana Ministry of Health, 2008). The opportunity to work under effective national labor laws in other countries with multiple, organized professional nursing associations is viewed as an innovative pull factor.

The unfulfilled need for professional training or staff development is a consistent complaint of nurses in developing countries (Campbell, 2006; Zurn et al., 2005). Educational resources are virtually nonexistent and available textbooks frequently are outdated. On-line training has been nonexistent, although it has begun surfacing (Talley, 2006). Because increased training usually is linked to reward or advancement, the lack of educational opportunities decreases the potential for additional remuneration, promotion potential, and professional gratification.

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The distribution and ratio of nurses are especially significant push factors in developing countries. It is common for one nurse to care for 40 or more patients (Fudge, 2008). Staff retention and recruitment within the health service sector is a pervasive problem, especially in rural areas (Horton, 2001). In Ghana, over 50% of nurses are concentrated in major cities that hold less than 20% of the population (Ghana Ministry of Health, 2008; Kingma, 2004; Munjaja et al., 2005). While most of the urban population has access to health care, only about 6S% of the rural population does (Lavy, Strauss, Thomas, & de Vreyer, 1996). The lack of incentives to attract nurses to rural areas has left the disparity between urban and rural care unresolved.

Moving Toward a Resolution of Brain-Drain

Because the United States derives significant benefits by accepting the influx of nurses from Ghana and other developing countries, nurse leaders in this country must assume accountability for depriving developing countries of their nurses. Accurate data collection on workflows from developing countries is imperative to define the magnitude and scope of brain-drain. A global agency such as the International Centre on Nurse Migration may be able to assume this responsibility. As a collective, nurses can examine how to reciprocate the benefits gained through brain-drain. Policy changes are essential in both destination and source countries. For example:

* Hospitals, health care facilities, and international recruiters that utilize FENs could compensate source countries that have invested resources in training nurses. Perhaps a large organization such as the International Council of Nurses could oversee such a program.

* States boards of nursing could enlist a reimbursement policy to the source country before granting a license to the FEN.

* Federal and state governments could make direct, multilateral agreements with source countries to address reimbursement for using FENs, place time limits for their employment in the United States, and/or provide resources to the source country, such as training and supplies.

* Professional organizations, unions, or private foundations in the United States could fired overseas training and/or provide library resources to the source country.

[FIGURE 4 OMITTED]

[FIGURE 5 OMITTED]

Without an effective governing body, the prognosis for reversing nursing brain-drain is guarded. Improved and accurate data collection on human resource issues, such as vacancy rates, salary structures, immigration statistics, and workplace safety, is essential for policy change. Increased pay is an immediate priority to help offset the rate of brain-drain (Buchan et al., 2005). The next immediate priority would be to increase staffing (Sparacio, 2005).

Health care in Ghana would benefit by governmental allocation of funds to the nursing profession. In part, the funding could be provided by the initiatives outlined here. Additional innovations to consider include:

* Instituting a lottery targeted to benefit health care and nursing.

* Offset of the distribution disparity through compensatory incentives to attract and retain nurses in rural settings through remuneration, and provision of housing and transportation.

* Creation of a dedicated sub-division for nursing by the Ghanian Ministry of Health.

* Increased funding for private or faith-based health care organizations to alleviate the strain of an overburdened governmental agency.

Ghanaian labor laws could provide benefits by targeting issues reflected in the International Centre on Nurse Migration Summary of Positive Practice Environments, which might address the following (International Centre on Nurse Migration, 2010):

* Workplace safety.

* Fair salary and compensation formulations.

* Meritocratic promotion based on objective factors.

* In-service training linked with promotion.

Conclusion

Brain-drain is a complex global issue. An increased awareness can begin to motivate nurses in the United States to tackle issues that lead to brain-drain. Ghana has been used as an example of the concerns relevant to brain-drain; it has many of the elements representing this worldwide problem common in developing countries. The recommendations outlined in this article would strengthen the nursing profession in source countries and act as both a retention strategy and an incentive for Ghanaian nurses to return home. Recognition of the multi-faceted issues of brain-drain should foster the resolve necessary to energize nurses and governments to reverse this phenomenon.

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Richard J. Slote, MS, RN, ONC, RNC, is a Clinical Nurse II, Hospital for Special Surgery, New York, NY. He participates annually in a medical mission through the Foundation for Orthopaedics and Complex Spine (FOCOS) to Ghana, West Africa.

Acknowledgments: Dr. Oheneba Boachie-Adjei from the Foundation for Orthopaedics and Complex Spine; Marjorie G. Winters for editorial assistance; Tim Roberts, MLS, for research guidance; and Steven Portera for graphic support.

Note: The author and all MEDSURG Nursing Editorial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education article.

For more information about this topic and medical missions, contact the author at SloteRN@gmail.com
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Title Annotation:CNE SERIES
Author:Slote, Richard J.
Publication:MedSurg Nursing
Date:Jul 1, 2011
Words:5402
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