ICN Action:

To support its position on retention and migration, ICN actively:

• Encourages the development of national and international workforce databases.

• Disseminates data on nursing employment worldwide, including information on nursing personnel needs and resources and the development of fulfilling nursing career structures.

• Provides negotiation training opportunities and advocates adherence to international labour standards.

• Fosters human resources planning, management and development in nursing.

• Advocates for safeguards that protect nurses’ interests and acquired rights when career moves, transfers and international migration occur.

 

ICN also actively encourages national nurses associations to:

• Disseminate information on the working conditions of nurses and migration issues in an effort to inform nurses and health sector stakeholders, including the public.

• Promote the important link between positive practice environments and retention.

• Cooperate with decision-making bodies, governmental and nongovernmental, to achieve appropriate human resources planning, ethical recruitment strategies, and sound national policies on the immigration and emigration of nurses.

• Promote research on the shortage, mal-distribution and mis-utilisation of nurses at the national and regional level; analyse data within the social, political and economic situations specific to their area; and, apply findings in human resources planning.

• Alert nurses to the fact that diplomas, qualifications or degrees earned in one country may not be recognised in another.

• Provide orientation for migrant nurses on the local cultural, social and political values, and on the health system and national language of the country.

• Ensure that migrant nurses have conditions of employment as favourable as those of the nurses of the country, in posts requiring the same level of competence and involving the same duties and responsibilities.

• Ensure that no distinctions are made among migrant nurses from different countries.

• Provide an advisory service to help nurses interpret contracts and assist foreign nurses with personal and work-related problems, including eventual repatriation.

 

Background

Worldwide, quality health care depends on an adequate supply of qualified nursing personnel. In almost every country nurses provide the majority of health services – up to 80% in some cases. Still, most member states of the World Health Organization (WHO) report a shortage, mal-distribution and mis-utilisation of nurses. This workforce crisis is undermining the goals of health systems globally and challenging society’s ability to meet the needs of its citizens.

Nurse supply and demand

Global nursing workforce imbalances have emerged from a complex web of supply and demand factors. (For a comprehensive list of these factors see the ICN Position Statement on Ethical Nurse Recruitment.) In short, a decreased supply of nurses cannot meet an increased demand for nursing services.

Factors driving an increased demand for nursing services include: an ageing population; a growing burden of chronic and non-communicable diseases; shorter hospital stays, resulting in increased acuity of care; and an expanded labour market.

Coupled with increased demand is a decreased supply of nurses. The reasons for this decreased supply include: an ageing nursing workforce; increased career opportunities for women; decreased funding of nursing schools and a heavier financial burden on students; a poor image of nursing as a career; and unfavourable work environments that include excessive workloads, violence, stress, wage disparities and little involvement in decision-making.

To address nurse shortages, some jurisdictions have moved to replace registered nurses with lesser-qualified staff, which ICN considers a threat to patient safety. Claiming financial constraints, meanwhile, some governments have closed health facilities, frozen nursing positions and reduced student positions, despite the need for nursing services.

Competition for nursing human resources

The combined pressures of increased demand and decreased supply have led to heightened competition for nurses, both within and among countries. Emphasis has been placed on recruitment strategies and ways to curb nurse migration, although retention strategies are equally, if not more, important and effective.

Retention. The poor quality of nurses’ practice environments is one of the main factors limiting nurse retention. That is why increasing attention is focused on the need to foster positive practice environments. Such environments support excellence and decent work. In particular, they strive to ensure the health, safety and personal well-being of staff; support quality patient care; and improve the motivation, productivity and performance of individuals and organisations.

Research has shown that nurses are attracted to and remain at their place of employment when opportunities exist that allow them to advance professionally, gain autonomy and participate in decision-making, while being fairly compensated.[1] Further, when health professionals are satisfied with their jobs, rates of absenteeism and turnover decrease (reducing associated costs), staff morale and productivity increase, and work performance as a whole improves.[2]

The term magnet hospitals is often used to refer to facilities that can attract and retain a staff of well qualified nurses and consistently provide quality care. Nurses in magnet hospital environments have lower burnout rates, higher job satisfaction and better patient outcomes.[3] Magnet hospital criteria that are applicable to all work environments range from the general (e.g. a reputation for quality care and being a good place to work) to the specific (e.g. retention and turnover rates, adequate staff, flexible schedules, strong leadership and adequate salaries).[4]

Migration. While there is increased focus on keeping nurses in their places of work, nurse migration is a growing international phenomenon. Migration flow tends to be from rural to urban areas, from lower to higher income urban neighbourhoods and from developing to industrialised countries.

Nurses have always seized the opportunity to move across national borders in search of better pay, career opportunities, working conditions and quality of life. Yet the movement of nurses, especially from developing to developed countries, has been accelerating and is expected to continue. Nurses in developing countries are often driven out by ‘push’ factors like low pay and poor employment conditions in the source country, and attracted by the existence of ‘pull’ factors like better salaries and conditions of employment in the destination country.

Overall, migration is facilitated by: globalisation; the liberalisation of trade; easier transport and communications; and active recruitment by some developed countries facing domestic issues of supply and demand. Aggressive, sometimes unethical, recruitment campaigns are on the increase. (See the ICN Position Statement on Ethical Nurse Recruitment.)

Losing highly skilled nurses to developed countries is compromising the capacity of developing countries to achieve health systems improvements and to meet national and global health targets. For developed countries, massive recruitment campaigns for foreign nurses delay local measures that would improve recruitment, retention and long-term human resources planning.

ICN supports the right of nurses to pursue professional achievement and attempt to better the circumstances in which they live and work. Career moves often enable nurses to achieve personal career goals and contribute to the nursing profession by raising the competence of its members. There is evidence, however, that career moves may negatively affect nurses’ lives during employment and retirement. For example:

• Internationally migrating nurses may be particularly vulnerable given the difficulty of verifying a work contract’s basic terms of reference and the employment situation in another country.

• Discriminatory treatment (e.g. pay, working conditions) may occur between national and migrant nurses and between migrant nurses from different countries.

• International recognition of nursing diplomas, post-basic studies or degrees is not yet widely established and may be a source of frustration for nurses emigrating to work or pursuing educational programmes abroad.

• In some countries, nurses do not receive the same privileges offered other professionals wishing to work abroad (e.g. leave without pay). This practice discourages nurses from returning to their native countries (e.g. job insecurity, skills developed abroad are not recognised in assigning return migrants their new position or determining remuneration).

• Migration and repatriation may result in the loss of benefits (e.g. pension, seniority).

Nurses’ professional and career development need to evolve within the context of the health system as a whole, allowing for horizontal as well as vertical career mobility. In many countries the career structures for nurses are inappropriate. Some governments have not addressed identified deficiencies relating to hours of work, ongoing education, re-entry programmes, staffing levels, attitudes of administrators, security, housing and daycare services.

Many internationally recruited nurses report that rather than migrate they would prefer to remain in their home country and culture, close to family and friends. Before migration will decrease significantly, however, the quality of work life in many countries needs to improve.