Why Nursing Density Matters
There are an estimated 136 million births/year worldwide
Sat
Sat Ananda
Ananda Hayden,
Hayden, MSN,
MSN, RN
RN
Doctoral
Doctoral Student,
Student,Public
Public Policy
Policy
Picking Out the Pieces
Lutchmie
Lutchmie Narine,
Narine, Ph
Ph D
D
Director,
Director,Masters
Mastersof
of Health
Health Administration
Administration
Associate
Associate Professor,
Professor, College
College of
of Health
Health and
and Human
Human Services
Services
Ethical
Ethical Issues
Issues in
in International
International Nurse
Nurse Migration
Migration
Source: WHO (Make Every Mother and Child Count)
http://www.who.int/emc-hiv/global_report/slides/slide15.html latest available data
Rose
Rose Marie
Marie Tong,
Tong, Ph
Ph D
D
Distinguished
Distinguished Professor
Professorinin Health
Health Care
Care Ethics
Ethics
Director,
Director,Center
Centerfor
forProfessional
Professional and
and Applied
Applied Ethics
Ethics
Department
Departmentof
of Philosophy
Philosophy
June 27, 2005
University
University of
of North
North Carolina,
Carolina, Charlotte
Charlotte
Nursing Density Worldwide
2
Ethical Issues of International Nurse Migration
Density of Source and Destination Countries
Sources: WHO (latest available); India, UK, Nigeria, Australia, Canada, NZ, UK, Australia from Aiken et al, 2005
950
950
900
900
850
850
800
800
750
750
700
700
650
650
600
600
550
550
500
500
450
450
400
400
350
350
300
300
250
250
200
200
150
150
100
100
50
50
0
0
Minimum: 5.4
Maximum : 2171.2839 Mean : 338.03
Standard Deviation : 356.51
All
All nurses
nurses per
per 100,000
100,000 population
population
http://www.who.int/GlobalAtlas/InteractiveMap/MainFrame2.asp (latest available data)
June 27, 2005
Ethical Issues of International Nurse Migration
3
June 27, 2005
Study Questions
z
z
What are the ethical themes in current International
Nurse Migration literature?
z
z
Are those themes different for Source and
Destination countries?
z
z
What are the ethical and moral implications of Brain
Drain?
z
z
Should Health Professionals be treated differently
than other professional migrants?
z
z
What is the best way to frame the ethical discourse
about nurse migration?
June 27, 2005
Ethical Issues of International Nurse Migration
Bangladesh
Bangladesh
Chad
Chad
China
China
Cuba
Cuba
DR
DR
Ecuador
Ecuador
Egypt
Egypt
El
El Salvador
Salvador
Ethiopia
Ethiopia
Ghana
Ghana
India
India
Jamaica
Jamaica
Malawi
Malawi
Malaysia
Malaysia
Mexico
Mexico
Nicaragua
Nicaragua
Nigeria
Nigeria
Pakistan
Pakistan
Philippines
Philippines
Swaziland
Swaziland
Uganda
Uganda
Uruguay
Uruguay
Zimbabwe
Zimbabwe
South
South Africa
Africa
Saudi
Saudi Arabia
Arabia
Australia
Australia
Canada
Canada
NZ
NZ
UK
UK
USA
USA
Ethical Issues of International Nurse Migration
4
Study Design & Sample
z
z
Content Analysis of published and unpublished
documents between 2000 and 2005
5
z
z
Sample: 212 documents
z
z
Inclusion Criteria
z
z
All
All documents
documents pertaining
pertaining to
to nurse
nurse migration,
migration, global
global nursing
nursing
shortage,
shortage, nurse
nurse migrants,
migrants, foreign
foreign nurse
nurse recruitment
recruitment
z
z
All
All documents
documents pertaining
pertaining to
to Brain
Brain Drain
Drain of
of HRH
HRH
z
z
All
All documents
documents pertaining
pertaining to
to ethical
ethical recruitment
recruitment of
of foreign
foreign
nurse
nurse graduates
graduates
June 27, 2005
Ethical Issues of International Nurse Migration
6
1
Methodology
z
z
z
z
Findings
Content Analysis
z
z
Theoretical frameworks are not typically explicated
z
z
Theories
Theories
z
z
Policy frameworks are implicit rather than explicit
z
z
Policy
Policy Approaches
Approaches
z
z
z
z
Ethical
Ethical Implications
Implications of
of International
International Nurse
Nurse Migration
Migration (INM)
(INM)
Ethical discussions are at a high level of abstraction
and limited to such areas as
z
z
Codes
Codes of
of Ethics
Ethics for
for International
International Recruitment
Recruitment of
of Nurses
Nurses (IRN)
(IRN)
N = 150
z
z
June 27, 2005
7
Ethical Issues of International Nurse Migration
z
z
Social
Social Justice
Justice
z
z
Distributive
Distributive Justice
Justice
z
z
Tensions
Tensions between
between source
source and
and destination
destination countries
countries
The number of published documents on the topic
increased fourfold between 2000 and 2004
June 27, 2005
Nurse Migration Articles by Discipline &
Year of Publication
z
z
16
Number of Articles
14
Source Countries
10
8
6
0
Nursing
June 27, 2005
2001
Policy
2002
Economics
2003
Health Sector
z
z
Pull
Pull factors
factors
z
z
Stick
Stick factors
factors
z
z
Stick
Stick Factors
Factors
z
z
Professional
Professional preparation
preparation
z
z
Immigration
Immigration Policy
Policy
z
z
Wage
Wage differentials
differentials
z
z
Structure
Structure of
of health
health sector
sector
z
z
Structure
Structure of
of health
health sector
sector
Supply
Supply and
and demand
demand
z
z
Exploitation
Exploitation
z
z
z
z
Remittances
Remittances and
and other
other
Diaspora
Diaspora Effects
Effects
z
z
Ethical
Ethical treatment
treatment of
of
migrants
migrants
2004
Other
Ethical Issues of International Nurse Migration
9
June 27, 2005
Different Views of “Ethical”
Ethical
Ethical Recruitment
Recruitment refers
refers to
to
z
z
z
z
Poaching,
Poaching, looting,
looting, siphoning,
siphoning, stealing,
stealing, neo-colonial
neo-colonial
subsidization
subsidization of
of health
health care
care in
in destination
destination countries
countries
Destination Countries
z
z
Ethical
Ethical Recruitment
Recruitment refers
refers to
to responsibility
responsibility without
without
accountability
accountability
z
z
z
z
z
z
June 27, 2005
Ethical Issues of International Nurse Migration
10
Major Ethical Themes
Source Countries
z
z
Destination Countries
Push
Push factors
factors
4
2
z
z
z
z
12
2000
8
Shared Themes
Increased International Interest
18
Ethical Issues of International Nurse Migration
z
z
Individual Welfare vs. Professional Values
z
z
Human Rights vs. Utilitarian Principals
z
z
Source Country Rights vs. Destination Country Rights
z
z
Health Professionals vs. Other Skilled Migrants
z
z
Global vs. Local Professional Competencies
Codes
Codes of
of Ethical
Ethical Recruitment
Recruitment
Codes
Codes for
for Ethical
Ethical Treatment
Treatment of
of Nurse
Nurse Migrants
Migrants
No
No coordination
coordination or
or oversight
oversight of
of recruitment
recruitment
Ethical Issues of International Nurse Migration
11
June 27, 2005
Ethical Issues of International Nurse Migration
12
2
Dominant Discourse
z
z
Codes of Ethical Recruitment
z
z
Medical Exceptionalism (Alkire
(Alkire &
& Chen,
Chen, 2004)
2004)
z
z
Local rather than Global Competencies
z
z
Brain Drain
z
z
Exploitation
June 27, 2005
Ethical Issues of International Nurse Migration
Rights-based Approach
z
z
z
z
13
Foreign Policy
Political
Political Freedom
Freedom
z
z
Civil
Civil Rights
Rights
Second Generation: Destination Countries
z
z
Distributive
Distributive Justice
Justice
z
z
Allocation
Allocation of
of Resources
Resources
June 27, 2005
Ethical Issues of International Nurse Migration
z
z
Structure
Structure aid
aid policies
policies to
to support
support stick
stick and
and stay
stay factors
factors
z
z
Assess
Assess HRH
HRH impact
impact of
of proposed
proposed policies
policies
z
z
Structure
Structure aid
aid &
& development
development policies
policies to
to support
support source
source
country
country self-determination
self-determination
z
z
Engage
Engage in
in coordinated
coordinated HRH
HRH capacity
capacity planning
planning and
and resource
resource
tracking
tracking
z
z
Elevate
Elevate Global
Global HRH
HRH capacity
capacity planning
planning at
at G8
G8 level
level
z
z
Restructure
Restructure Health
Health Sector
Sector
z
z
Global
Global funding
funding and
and tracking
tracking of
of health
health professional
professional migration
migration
z
z
Education:
Education:
z
z
Credits
Credits for
for INM
INM working
working in-country
in-country
Ethical Issues of International Nurse Migration
z
z
15
How Ethical Discourse Informs Policy
z
z
Wage
Wage adjustments
adjustments for
for nursing
nursing salaries
salaries
Incentives
Incentives for
for returning
returning nurses
nurses
z
z
Disincentives
Disincentives for
for HCOs
HCOs that
that use
use INM
INM
z
z
Eliminate
Eliminate designations
designations of
of HRH
HRH shortage
shortage areas
areas as
as basis
basis for
for
incentives
incentives
June 27, 2005
z
z
Structure
Structure policies
policies to
to support
support stick
stick and
and stay
stay factors
factors
z
z
Ethical Issues of International Nurse Migration
June 27, 2005
Increase
Increase educational
educational capacity
capacity and
and funding
funding subsidies
subsidies based
based on
on
capacity
capacity planning
planning
Ethical Issues of International Nurse Migration
16
How Ethical Discourse Informs Policy
Economic Policy
z
z
14
Domestic Policy
z
z
June 27, 2005
z
z
z
z
How Ethical Discourse Informs Policy
How Ethical Discourse Informs Policy
z
z
First Generation: Source countries
17
Trade Policy
z
z
Calculate
Calculate impact
impact of
of trade
trade agreements
agreements on
on HRH
HRH
z
z
Include
Include reciprocal
reciprocal reinvestment
reinvestment in
in HRH
HRH for trading partners
z
z
Determine
Determine impact
impact of
of Trade
Trade Policies
Policies on
on domestic
domestic health
health
sector
sector
June 27, 2005
Ethical Issues of International Nurse Migration
18
3
Conclusion
z
z
Source countries view INM from a neo-colonial
perspective
z
z
Destination countries view INM from economic and
individual rights perspective
z
z
Brain Drain, Brain Waste, and Brain Effect can be
incorporated into managed migration plans
z
z
Medical exceptionalism is a palatable solution for
some
z
z
Ethical discourse can be successfully incorporated
into policy
June 27, 2005
Ethical Issues of International Nurse Migration
Final Thought
If we are headed for a “flat world” model, what does
that mean for professional status and standards of
care?
19
June 27, 2005
Ethical Issues of International Nurse Migration
20
Corresponding Author
Sat
Sat Ananda
Ananda Hayden
Hayden
Political
Political Science
Science Department
Department
University
University of
of North
North Carolina,
Carolina, Charlotte
Charlotte
9201
9201 University
University City
City Blvd
Blvd
Charlotte,
Charlotte, NC
NC 28223
28223
sahayden@uncc.edu
sahayden@uncc.edu
June 27, 2005
Ethical Issues of International Nurse Migration
21
4