Sat Ananda Hayden, MSN, RN
Doctoral Student, Public Policy
Picking Out the Pieces
Ethical Issues in International Nurse Migration
Lutchmie Narine, Ph D
Director, Masters of Health Administration
Associate Professor, College of Health and Human Services
Rose Marie Tong, Ph D
Distinguished Professor in Health Care Ethics
Director, Center for Professional and Applied Ethics
Department of Philosophy
University of North Carolina, Charlotte
Why Nursing Density Matters
There are an estimated 136 million births/year worldwide
Source: WHO (Make Every Mother and Child Count)
http://www.who.int/emc-hiv/global_report/slides/slide15.html latest available data
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Nursing Density Worldwide
Minimum: 5.4
Maximum : 2171.2839 Mean : 338.03
Standard Deviation : 356.51
http://www.who.int/GlobalAtlas/InteractiveMap/MainFrame2.asp (latest available data)
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Density of Source and Destination Countries
Sources: WHO (latest available); India, UK, Nigeria, Australia, Canada, NZ, UK, Australia from Aiken et al, 2005
950
900
850
800
750
700
650
600
550
500
450
400
350
300
250
200
150
100
50
0
All nurses per 100,000 population
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Ethical Issues of International Nurse Migration
Bangladesh
Chad
China
Cuba
DR
Ecuador
Egypt
El Salvador
Ethiopia
Ghana
India
Jamaica
Malawi
Malaysia
Mexico
Nicaragua
Nigeria
Pakistan
Philippines
Swaziland
Uganda
Uruguay
Zimbabwe
South Africa
Saudi Arabia
Australia
Canada
NZ
UK
USA
4
Study Questions

What are the ethical themes in current International
Nurse Migration literature?

Are those themes different for Source and
Destination countries?

What are the ethical and moral implications of Brain
Drain?

Should Health Professionals be treated differently
than other professional migrants?

What is the best way to frame the ethical discourse
about nurse migration?
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Study Design & Sample

Content Analysis of published and unpublished
documents between 2000 and 2005

Sample: 212 documents

Inclusion Criteria

All documents pertaining to nurse migration, global nursing
shortage, nurse migrants, foreign nurse recruitment

All documents pertaining to Brain Drain of HRH

All documents pertaining to ethical recruitment of foreign
nurse graduates
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Methodology


Content Analysis

Theories

Policy Approaches

Ethical Implications of International Nurse Migration (INM)

Codes of Ethics for International Recruitment of Nurses (IRN)
N = 150
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Findings

Theoretical frameworks are not typically explicated

Policy frameworks are implicit rather than explicit

Ethical discussions are at a high level of abstraction
and limited to such areas as


Social Justice

Distributive Justice

Tensions between source and destination countries
The number of published documents on the topic
increased fourfold between 2000 and 2004
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Increased International Interest
18
Nurse Migration Articles by Discipline &
Year of Publication
16
Number of Articles
14
12
10
8
6
4
2
0
2000
Nursing
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2001
Policy
2002
Economics
2003
Health Sector
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2004
Other
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Shared Themes

Source Countries

Destination Countries

Push factors

Pull factors

Stick factors

Stick Factors

Professional preparation

Immigration Policy

Wage differentials

Structure of health sector

Structure of health sector


Exploitation
Supply and demand

Ethical treatment of
migrants

Remittances and other
Diaspora Effects
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Different Views of “Ethical”
Source Countries

Ethical Recruitment refers to


Poaching, looting, siphoning, stealing, neo-colonial
subsidization of health care in destination countries
Destination Countries

Ethical Recruitment refers to responsibility without
accountability



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Codes of Ethical Recruitment
Codes for Ethical Treatment of Nurse Migrants
No coordination or oversight of recruitment
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Major Ethical Themes

Individual Welfare vs. Professional Values

Human Rights vs. Utilitarian Principals

Source Country Rights vs. Destination Country Rights

Health Professionals vs. Other Skilled Migrants

Global vs. Local Professional Competencies
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Dominant Discourse

Codes of Ethical Recruitment

Medical Exceptionalism

Local rather than Global Competencies

Brain Drain

Exploitation
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(Alkire & Chen, 2004)
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Rights-based Approach


First Generation: Source countries

Political Freedom

Civil Rights
Second Generation: Destination Countries

Distributive Justice

Allocation of Resources
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How Ethical Discourse Informs Policy

Foreign Policy

Structure aid policies to support stick and stay factors

Structure aid & development policies to support source
country self-determination

Elevate Global HRH capacity planning at G8 level

Global funding and tracking of health professional migration

Credits for INM working in-country
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How Ethical Discourse Informs Policy

Domestic Policy

Assess HRH impact of proposed policies

Engage in coordinated HRH capacity planning and resource
tracking

Restructure Health Sector

Education:

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Increase educational capacity and funding subsidies based on
capacity planning
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How Ethical Discourse Informs Policy

Economic Policy

Structure policies to support stick and stay factors


Wage adjustments for nursing salaries
Incentives for returning nurses

Disincentives for HCOs that use INM

Eliminate designations of HRH shortage areas as basis for
incentives
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How Ethical Discourse Informs Policy

Trade Policy

Calculate impact of trade agreements on HRH

Include reciprocal reinvestment in HRH for trading partners

Determine impact of Trade Policies on domestic health
sector
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Conclusion

Source countries view INM from a neo-colonial
perspective

Destination countries view INM from economic and
individual rights perspective

Brain Drain, Brain Waste, and Brain Effect can be
incorporated into managed migration plans

Medical exceptionalism is a palatable solution for
some

Ethical discourse can be successfully incorporated
into policy
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Final Thought
If we are headed for a “flat world” model, what does
that mean for professional status and standards of
care?
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Corresponding Author
Sat Ananda Hayden
Political Science Department
University of North Carolina, Charlotte
9201 University City Blvd
Charlotte, NC 28223
sahayden@uncc.edu
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