ArticleLiterature Review

Ontario's internationally educated nurses and waste in human capital: Opinion Piece of International Interest

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Abstract

To analyse critically the waste in human capital of Ontario's internationally educated nurses resulting from unemployment or underemployment. Globalization of the nursing workforce is resulting in more and more internationally educated nurses migrating to Canada every year. In Ontario, internationally educated nurses represent 11% of the total nursing workforce but many are unable to become registered in Ontario. According to the College of Nurses of Ontario (CNO), 40% of internationally educated nurse applicants never complete the application process and thus never become Registered Nurses in Ontario. Systemic barriers that prevent registration in Ontario can result from any of the seven requirements for completing the application process. The inability of internationally educated nurses to become registered is significant, considering the national and global nursing shortage. In addition, the inability to become registered results in tremendous waste of human capital, especially in developing countries that have invested financially in educating nurses. Although several programmes have been implemented in Ontario for internationally educated nurses, barriers exist in the design and administration of these programmes, and these are described. An opinion piece of international interest and a human interest piece. Internationally educated nurses face significant barriers, which prevent their integration into the Ontario healthcare system. Several policy and management strategies are outlined that could be implemented to ease their integration into the Ontario healthcare system.

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... 24,25 However, for health professionals trained outside of Canada, relocating to Canada has not automatically translated to working in Canada. [26][27][28][29][30] Issues with the integration of IEHPs impact health delivery more broadly, as locally trained physicians are unable to meet the service demands. Although much has been written about the integration of IEHPs, [31][32][33][34][35][36][37] there is a gap in the literature to understand how professionalizing systems that a ect the licensing process of IEHPs intersect with socioeconomic and political realities such as globalization to (re)produce inequalities in health care between those trained locally and those trained abroad. ...
Article
Purpose: There is a gap in the literature to understand how professionalizing systems intersect with socioeconomic and political realities such as globalization to (re)produce social inequities between those trained locally and those trained abroad. In this critical review, the question of how systemic racism is reproduced in health care is addressed. Method: Electronic databases and non-traditional avenues for searching literature such as reference chaining and discussions with experts were employed to build an archive of texts related to integration of internationally-educated health care professionals (IEHP) into the workforce. Data related to workplace racialization were sought out, particularly those that utilized anti-racist and post-colonial approaches. Rather than an exhaustive summary of the data, a critical review contributes to theory building and a spatial analysis was overlayed on the critical literature of IEHP integration to conceptualize the material effects of the convergence of globalization and professional systems. Results: The critical review suggests that professions maintain their value and social status through discourses of "Canadianness" that maintain the homogeneity of professional spaces through social closure mechanisms of credential non-recognition and resocialization. Power relations are maintained through mechanisms of workplace racialization/spatialization and surveillance which operate through discourses of "foreign-trainedness." Conclusions: Movement of professionals supports a professional system that on the surface values diversity while maintaining its social status and power through the (re)production of the discourse of "Whiteness." The analysis shows how in the process domestic graduates are emplaced as the "rightful" citizens of professional paces while IEHPs are marginalized in the workforce.
... However, these agreements do not necessarily translate into a smoother or expedited process for having credentials recognized and obtaining nursing registration ). Kolawole (2009) argues that the ethical challenge of 'brain waste' or the waste that comes about when IENs, as newcomers, are unable to have their knowledge and skills recognized or because of difficulties in workplace integration -is an important issue and requires more attention in Canada. ...
... More workshops, training, and conferences can be offered through collaborative training and international exchanges in order to support current faculty and attract more nurses to the faculty role (Rosenkoetter & Nardi, 2007). There should be more cooperation between educational institutions across nations so that nursing students can transfer credit from one academic bridging program to another if they move or migrate to other countries (Kolawole, 2009). Oulton (2006the chief executive of the ICN in 2006, called for a globally unified nursing voice in order to create stronger alliances to combat the nursing shortage and insufficient numbers of faculty. ...
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In addition to a global shortage of nurses, there is also a shortage of academically qualified faculty available to teach in schools of nursing. A systematic review examined proposed solutions to the global shortage of nursing faculty. Metasynthesis was used to compare and critically appraise strategies offered for solving or ameliorating the global nursing faculty shortage by premier nursing organizations. 181 recommendations in 62 publications were categorized into eight major themed solutions, including centralizing data management, international collaboration in nursing research, and increased funding for full-time faculty positions in nursing programs. The nursing faculty shortage is due to a confluence of factors, including the global migration of nurses, a seeming persistent devaluation of faculty by academic programs, disincentives, and an overall reduction in full-time equivalent faculty positions. Results point to a needed change in direction and approach to solving the nursing faculty shortage. By designing new education models that fit global healthcare needs and pooling teaching resources, designing and using the same databases across organizations to track and project faculty needs, and collaborating between schools and businesses to create mutually beneficial agreements for services, nursing faculty capacity can be enhanced, and nursing's capacity to meet global healthcare needs can be expanded. The results of this systematic review can be used as a rubric for the design and development of strategies to end the nursing faculty shortage and expand global nursing capacity.
... Studies with a wide approach explore the impacts of nursesÕ education (e.g. Graf 2006, Kolawole 2009) and training (Rondeau et al. 2009) on human capital. NursesÕ migration and the loss of human capital (Palese et al. 2010) and economic perspectives (Roy et al. 2009) have been studied from this angle as well. ...
Article
To analyse the challenges that nurse managers meet in project management. Project management done by nurse managers has a significant role in the success of projects conducted in work units. The data were collected by open interviews (n = 14). The participants were nurse managers, nurses and public health nurses. Data analysis was carried out using qualitative content analysis. The three main challenges nurse managers faced in project management in health-care work units were: (1) apathetic organization and management, (2) paralysed work community and (3) cooperation between individuals being discouraged. Nurse managers' challenges in project management can be viewed from the perspective of the following paradoxes: (1) keeping up projects-ensuring patient care, (2) enthusiastic management-effective management of daily work and (3) supporting the work of a multiprofessional team-leadership of individual employees. It is important for nurse managers to learn to relate these paradoxes to one another in a positive way. Further research is needed, focusing on nurse managers' ability to promote workplace spirituality, nurse managers' emotional intelligence and their enthusiasm in small projects.
... In the absence of data systems to track the immigration and integration of IENs, it is impossible to determine the exact number of IENs who are not registered with a regulatory college and to explain why some are unable to practise in Canada. When IENs cannot practise nursing, Canada loses valuable health human resources (Kolawole, 2009). ...
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The purpose of this scoping review was to map key themes in the Canadian literature on the professional integration of internationally educated nurses (IENs), identify the types and sources of and gaps in evidence, and offer recommendations for research. The work was guided by a 6-step methodological framework for scoping reviews. The search and selection of academic and grey literature for the period 2000-13 resulted in a sample of 157 papers for full-text screening. Themes derived from the literature reflect stages of IENs' professional integration: pre-immigration and early arrival, professional recertification, workforce integration, and workplace integration. Data were extracted, coded, and collated using electronic charts. Numerical and qualitative thematic summaries were used to analyze the data. Recommendations for research are as follows: create data systems to track IEN immigration and integration; determine the effectiveness of programs and policies for IENs; and examine the influence of language proficiency on professional recertification, workplace integration, and patient safety.
... Studies identify the numerous barriers IENs face during their transition into clinical work in their destination countries. These barriers include fear of lawsuits and litigation [8]; unfamiliar technology [28]; clinical differences [29]; cultural differences and competencies [30,31]; verbal, written, and general language communication challenges [27, 30, 32Á34]; marginalization and cultural dissonance [34]; challenges due to differences in local healthcare systems and practices [31]; racism and discrimination [35]; lack of assertiveness and differences in beliefs that influence clinical practice [35]; psychological stress [37]; social isolation and deskilling in low-level jobs [38]; lack of supportive leadership and differences in patient care [8]; and the stress of passing the licensure examination [31,36]. ...
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Introduction: To explore the information seeking behavior of Internationally Educated Nurses (IENs) and to investigate their exposure to libraries and library training in both their home countries and after being hired in Saskatchewan. Methods: This two-phase multi-method project was carried out in Saskatchewan, Canada. A questionnaire was developed based on survey instruments used in previously conducted studies on the topic. Librarians in two academic institutions assisted with validation of the survey. In Phase 1, data were collected via an online questionnaire from IENs in three health regions: Saskatoon, Regina, and Sunrise. In Phase 2, the study was expanded to IENs in all the health regions in the province. The same questionnaire from Phase 1 was used during telephone interviews with participants. Results: A total of 17 IENs responded (Phase 1, n 0 9, Phase 2, n 0 8). Results show that IENs, although interested in looking for information for their practice, are hindered by a lack of knowledge of how and where to seek relevant clinical information as well as a lack of library training. As a result, their main source of information is the Internet (Google). Discussion: Despite barriers such as time to information seeking, results revealed that given the opportunity IENs would like to receive library training to enhance their information seeking skills.
... When IENs develop the human capital attributes of professional competencies, behaviours, and attitudes, as well as the cultural capital attributes of language proficiency and professional vocabulary required of Canadian registered nurses, they expand their employment opportunities, increase their earning ability, and facilitate their integration into society (Boudarbat, Lemieux, and Riddell 2010). In turn, the health care system profits by gaining valuable health human resources and a culturally diverse nursing workforce (Kolawole 2009). Additionally when IENs are able to practise their profession in Canada, they contribute to the local economy and the growth of their communities (Hall and Sadouzai 2010). ...
Article
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We used interview data to explore internationally educated nurses’ perceptions of the factors that facilitated their integration into the registered nursing workforce in Canada. The participants perceived that a variety of interrelated factors facilitated their integration. The identified factors seem to reflect forms of capital. Economic capital (availability of financial resources) and cultural capital (language proficiency and competency in professional vocabulary) enabled the participants to use other forms of capital to become registered and employed in Canada. Providing financial resources and interventions to develop their language skills may assist internationally educated nurses with more rapidly integrating into the country’s nursing workforce. Dans cet article, nous utilisons des données obtenues grâce à des interviews pour examiner comment des infirmières et des infirmiers ayant obtenu leur diplôme à l’étranger perçoivent les facteurs qui ont facilité leur intégration dans cette profession au Canada. Selon les participants, plusieurs facteurs entrent en jeu, et ces facteurs semblent refléter des formes de capital. Le capital économique (ressources financières disponibles) et le capital culturel (compétences linguistiques et connaissance du vocabulaire de la profession) leur ont permis de mettre à profit d’autres formes de capital afin de pouvoir faire officiellement partie de la profession et trouver ainsi du travail. Par conséquent, offrir aux infirmières et aux infirmiers ayant obtenu leur diplôme à l’étranger des ressources financières et des moyens de développer leurs compétences linguistiques pourrait les aider à avoir plus rapidement accès à la profession et à trouver un emploi au Canada.
... The market-based model, shown at left, proposes (i) to regulate medical workforce numbers through demand (i.e., the effects of institutional reputation and performance management on attracting patients, as shown at bottom left) for agreed evidence-based and cost-effective treatments, rather than through restricting provider supply as at present (top right); and (ii) to maintain the safety and quality and quality of medical work through employer-and/or insurer-led audit of relevant clinical indicators (top left) rather than relying upon adherence to centrally-administered educational programmes as currently practised (bottom right). regulations affecting their employability [38,39] ; highlytrained staff often face official barriers in gaining employment at anywhere near their pre-migration skills level, often ending up in relatively menial or junior roles [40]; while oscillations of national workforce oversupply and shortage are further complicated by migration fluxes [41,42]. The latter issue is politically delicate, involving as it often does the movement of health professionals from poorer to richer countries, leaving the former more in need [43]. ...
Article
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Background Traditional top-down national regulation of internationally mobile doctors and nurses is fast being rendered obsolete by the speed of globalisation and digitisation. Here we propose a bottom-up system in which responsibility for hiring and accrediting overseas staff begins to be shared by medical employers, managers, and insurers. Discussion In this model, professional Boards would retain authority for disciplinary proceedings in response to local complaints, but would lose their present power of veto over foreign practitioners recruited by employers who have independently evaluated and approved such candidates' ability. Evaluations of this kind could be facilitated by globally accessible National Registers of professional work and conduct. A decentralised system of this kind could also dispense with time-consuming national oversight of continuing professional education and license revalidation, which tasks could be replaced over time by tighter institutional audit supported by stronger powers to terminate underperforming employees. Summary Market forces based on the reputation (and, hence, financial and political viability) of employers and institutions could continue to ensure patient safety in the future, while at the same time improving both national system efficiency and international professional mobility.
... However, these agreements do not necessarily translate into a smoother or expedited process for having credentials recognized and obtaining nursing registration ). Kolawole (2009) argues that the ethical challenge of 'brain waste' or the waste that comes about when IENs, as newcomers, are unable to have their knowledge and skills recognized or because of difficulties in workplace integration -is an important issue and requires more attention in Canada. ...
Article
Full-text available
Internationally Educated Nurses (IENs) have been one of the key solutions to dealing with the nursing shortage in Canada and other western nations. IENs are registered nurses or registered practical nurses who have obtained their basic nursing education in a country different from the one in which they are practicing. While investments have been made by governments and employers towards initiatives that support the orientation and transition of IENs into the profession, there is limited understanding of the concept of workplace integration for IENs within health care. This paper presents a recent synthesis of existing works related to integration of IENs. Based on a critique of the nursing and healthcare literature, publications from immigrant and refugee studies were reviewed for relevant notions of the concept of integration of newcomers. For more than a decade, there has been a growing interest in the nursing and healthcare literature about IENs, mostly out of the United Kingdom, United States of America, Australia and Canada. The paper will focus on three major areas: (i) policies and ethical issues in recruitment of IENs to address the health human resource planning challenges in high-income countries; (ii) experiences of IENs while going through the regulatory process to achieve registration and when transitioning into the nursing workplace; and (iii) transition supports or programs for IENs. This paper will conclude with a discussion of the implications of these works for research and clinical practice in the context of long term integration of IENs into the healthcare workforce.
... Atılan diğer adımlarla birlikte, yabancı hemşire istihdamının hemşire açığını kapatmakta etkili olacak uygulamalar arasında yer alacağı düşünülmektedir. [13] Literatürde bu konuda yapılan çalışmaların daha eski yıllarda "yabancı hemşire" kavramı [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] kullanılarak yapıldığı ve konunun bu kavram etrafında ele alındığı görülmekteyken, daha yenilerde, özellikle de son beş yılda yapılan çalışmalarda ise "uluslararası eğitimli hemşire" kavramının [29][30][31][32][33][34][35][36] kullanıldığı görülmektedir. Burada özellikle Avusturalya, Yeni Zelanda, Kanada ve Amerika Birleşik devletleri gibi nüfusun büyük bölümünün göçmenlikle ilgili yasalara tabi olduğu ülkelerde giderek daha fazla uluslararası eğitimli hemşire kavramının ele alındığı dikkat çekmektedir. ...
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Z Amaç: Bu çalışmanın amacı hemşirelerin yabancı hemşire istihdamına ilişkin tutumlarını belirlemek üzere geçerli ve güvenilir bir ölçme aracı geliştirmektir. Yöntem: Metodolojik tipteki bu çalışmanın örneklemi klinik alanda çalışan 339 hemşireden oluştu. Ölçeğin kapsam geçerliği, Lawshe tek-niği ile incelendi. Zamana karşı geçerliği test re-test ile gösterildi. Gü-venirlik için madde toplam puan korelasyon analizleri yapıldı. Faktör yapısını belirlemede açımlayıcı faktör analizi ve son olarak iç tutarlık analizinde de Cronbach's alpha analizleri kullanıldı. Bulgular: Analizler sonucunda; madde korelasyon değerleri 0.530-0.798 arasında, faktör yükleri 0.489-0.861 arasında ve iç tutarlıkları da 0.848-0.960 arasında değişen, dört faktörde toplam 25 maddelik ölçek yapısı oluşturuldu. Sonuç: Yabancı Hemşire İstihdamına Yönelik Tutum Ölçeği'nin geçerli ve güvenilir bir ölçek olduğu belirlendi. ABSTRACT Aim: To develop a valid and reliable measuring tool in order to determine nurses' attitudes towards the employment of foreign nurses. Methods: The sample of this methodological study comprised 339 nurses. Content validity of the scale was evaluated via Lawshe's content validity technique. The stability of the scale was demonstrated via test-retest. Item total score correlation analyses were run to evaluate reliability. Exploratory factor analysis was used to determine factor structure and Cronbach's alpha coeff cient values were used for internal-consistency analysis. Results: The scale was developed with 25 items in 4 factors in which item total correlations were found between 0.530-0.798, factor loadings were found between 0.489-0.861 and internal consistency values were found between 0.848-0.960. Conclusion: The Attitudes towards Employment of Foreign Nurses Scale was found to be a valid and reliable data collection tool.
... However, research suggests a potential mismatch p.212) states that 'language was reported to be a significant barrier to nurse migration' in the international recruitment of nurses to fill nursing shortages in the USA, UK, and Australia (Kingma 2001). Many international nurse registering authorities have demonstrated concerns regarding English language testing, indicating this is a universal problem (Hawthorne 2001;Kolawole 2009;Walker 2009). ...
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ABSTRACT For health professionals, English language proficiency has increasingly been identified as important to public safety by Australian regulatory authorities. The purpose of English language testing is to evaluate the effectiveness of communicating in a nursing setting. The Nursing and Midwifery Board of Australia (NMBA) (2010) outlines the current assessment requirements for nurses from non-English speaking backgrounds (NESB) are to attain either an overall band score of 7 in each of the four components (Reading, Writing, Listening, Speaking) of the International English Language Testing System (IELTS) (give reference) or a band score of A or B in each of the same four components of the Occupational English Test (OET) (give reference). Either the OET or IELTS must be re-sat in full until the applicant achieves at least the minimum score for all sections in one sitting. The appropriateness of the administration of the current testing process for the purpose of fitness for nursing registration in Australia has not been examined. Additionally, the adoption of the required scores for these tests as English language skills registration standards by the NMBA appears arbitrary. Many nurse registering authorities have demonstrated concerns regarding English language testing with the academic nature of these tests being identified as a barrier to registration for these nurses in Australia (O’Connor 2008; Walters 2008; Deegan and Simkin 2010). Kingma (2001 p.212) states that ‘language was reported to be a significant barrier to nurse migration’ in the international recruitment of nurses to fill nursing shortages in the UK, USA and Australia (Kingma 2001). The National Council of State Boards of Nursing (NCSBN) in the United States sought to develop a nursing specific IELTS standard that would be legally defensible (O’Neill et al. 2007). A passing standard is a reflection of the values of those professionals who participate in establishing what they determine as an appropriate score, and these sets of values can be quite diverse so “ultimately, the passing standard established by a policy-making body is a judgment-based decision” (O’Neill et al. 2007 p.5). To demonstrate this point, O’Neill et al. (2007 p.19) collated the various passing standards in other English speaking countries and identified that Australia and New Zealand have adopted a higher IELTS passing standard for NESB nurse registration than other English speaking countries. Differences in such policies become more significant as the flow of nurses between countries increases. The Centre for Canadian Language Benchmarks (CCLB 2004) conducted a multi-phase project, Benchmarking the Nursing Profession across Canada which investigated how the language proficiency of nurses is measured for registration and then designed a nursing specific test, the Canadian English Language Benchmark Assessment for Nurses (CELBAN). The CELBAN is similar in its conception to the OET except with the advantage that it is entirely nursing specific whereas the OET is only nursing specific in speaking and writing modules, with the reading and listening modules applying to all the medical professions. Qualitative studies have found some nurses with strong English language backgrounds who have been unable to get the scores required in the OET or IELTS for registration in Australia (Walters 2008; Hawthorne 2001). The current study aims to investigate the appropriateness of the administration of the current English language testing process for the purpose of determining fitness for nursing registration in Australia. The main objective of this study is to further understand the issue of the relatively unexplored area of English language testing requirements for registration of migrant nurses and whether there are any predictors for success, such as English language background, in achieving the scores required. This research project aimed to answer the following questions about non-English speaking background (NESB) nurses attempting to meet the English language requirements of the Nursing and Midwifery Board of Australia (NMBA) for nursing registration in Australia: Is there an association between demographic characteristics and test success? What is the relationship between English language background and test success? What is the relationship between education and work experience of participants and test success? How did successful candidates perceive their experiences with the English tests? Keywords: Registered nurse, Foreign nurse, Migrant, Licensed nurse, Nursing board.
... When IENs can practice their profession in their new countries, the healthcare systems profit by gaining valuable health human resources who can provide culturally sensitive patient care [58]. IENs as new immigrants also benefit by earning the financial resources needed to care for their families and to contribute economically to their new communities and country [59]. ...
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Background Global trends in migration accompanied with recent changes to the immigrant selection process may have influenced the demographic and human capital characteristics of internationally educated nurses (IENs) in Canada and in turn the assistance required to facilitate their workforce integration. This study aimed to describe the demographic and human capital profile of IENs in Canada, to explore recent changes to the profile, and to identify predictors of IENs’ workforce integration. Methods A cross-sectional, descriptive, correlational survey design was used. Eligible IENs were immigrants, registered and employed as regulated nurses in Canada. Data were collected in 2014 via online and paper questionnaires. Descriptive statistics were used to examine the data by year of immigration. Logistic regression modeling was employed to identify predictors of IENs’ workforce integration measured as passing the licensure exam to acquire professional recertification and securing employment. Results The sample consisted of 2280 IENs, representative of all Canadian provincial jurisdictions. Since changes to the immigrant selection process in 2002, the IEN population in Canada has become more racially diverse with greater numbers emigrating from developing countries. Recent arrivals (after 2002) had high levels of human capital (knowledge, professional experience, language proficiency). Some, but not all, benefited from the formal and informal assistance available to facilitate their workforce integration. Professional experience and help studying significantly predicted if IENs passed the licensure exam on their first attempt. Bridging program participation and assistance from social networks in Canada were significant predictors if IENs had difficulty securing employment. Conclusions Nurses will continue to migrate from a wide variety of countries throughout the world that have dissimilar nursing education and health systems. Thus, IENs are not a homogenous group, and a “one size fits all” model may not be effective for facilitating their professional recertification and employment in the destination country. Canada, as well as other countries, could consider using a case management approach to develop and tailor education and forms of assistance to meet the individual needs of IENs. Using technology to reach IENs who have not yet immigrated or have settled outside of urban centers are other potential strategies that may facilitate their timely entrance into the destination countries’ nursing workforce.
... However, many universities have not incorporated mandatory courses in global health and/or have not documented their experience. The Canadian Nurses Association highlights the lack of discussion and documentation of initiatives to include global health content into nursing curricula (26).Language fluency is also a barrier for internationally educated nurses working in Ontario and they represent 11% of the total nurse workforce (27). ...
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Objective Literature has reported that language is the most common barrier in a health care setting and a risk factor associated with negative outcomes. The present study reports the differences between nursing students who speak one language and nursing students who speak two or more languages (self-reported language proficiency) and their skills and learning needs in global health. Method An observational cross-sectional study was performed among nursing students from five Ontario universities. A survey was designed to measure knowledge, skills and learning needs in global health. Results Students who speak more than two languages are more likely to have more interest in learning global health issues, such as health risks and their association with travel and migration (p=0.44), and social determinants of health (p=0.042). Conclusion Language training is needed for nursing students to be able to face language barriers in health care settings and improve global health, locally and internationally.
... But for nurses who enter under the LCP, they had to first complete the mandatory 2 years of work before they were eligible to apply for licensure. At best, this invariably meant that fulfilling other time-sensitive licensure requirements posed an immense challenge (Kolawole 2009;Salami and Nelson 2014). ...
Article
The twenty-first century has witnessed a number of significant demographic and political shifts that have resulted in a care crisis. Addressing the deficit of care provision has led many nations to actively recruit migrant care labour, often under temporary forms of migration. The emergence of this phenomenon has resulted in a rich field of analysis using the lens of care, including the idea of the Global Care Chain. Revisions to this conceptualization have pushed for its extension beyond domestic workers in the home to include skilled workers in other institutional settings, particularly nurses in hospitals and long-term care settings. Reviewing relevant literature on migrant nurses, this article explores the labour market experiences of internationally educated nurses in Canada. The article reviews research on the barriers facing migrant nurses as they transfer their credentials to the Canadian context. Analysis of this literature suggests that internationally trained nurses experience a form of occupational (im)mobility, paradoxical, ambiguous and contingent processes that exploit global mobility, and results in the stratified incorporation of skilled migrant women into healthcare workplaces.
... The effect of these barriers is adverse and systematic, preventing many IENs from re-establishing their professional careers (Blythe et al., 2009). The assessment of an IEN's foreign credentials (the evaluation of education equivalency and skills qualifications) is often cited as one of the most common barriers that significantly delays or prevents IENs from completing their licensure process altogether (Kolawole, 2009). IENs who are already residing in Canada are being effectively deskilled if they desire but fail to complete their nursing licensure. ...
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Using a gendered lens, we examine the balance between the contribution that migrant women make to global economic and social development through their labour, especially in the care and global service economy, with the health impacts and costs incurred by this group of migrants.
... The salient access issues identified by recent immigrants highlight the realities of establishing oneself in a new country, a major challenge to the process of migration [31]. There is evidence that barriers to employment influence integration and resettlement of immigrants in Canada [32,33]; and in some cases has a negative impact on health [34,35]. Putting such issues in context helps explain why some immigrants may have certain experiences with care and not others. ...
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French speakers residing in predominantly English-speaking communities have been linked to difficulties accessing health care. This study examined health care access experiences of immigrants and non-immigrants who self-identify as Francophone or French speakers in a mainly English speaking province of Canada. We used semi-structured interviews to gather opinions of recent users of physician and hospital services (N = 26). Language barriers and difficulties finding family doctors were experienced by both French speaking immigrants and non-immigrants alike. This was exacerbated by a general preference for health services in French and less interest in using language interpreters during a medical consultation. Some participants experienced emotional distress, were discontent with care received, often delayed seeking care due to language barriers. Recent immigrants identified lack of insurance coverage for drugs, transportation difficulties and limited knowledge of the healthcare system as major detractors to achieving health. This study provided the groundwork for future research on health issues of official language minorities in Canada.
Article
Internationally educated health professionals (IEHPs) have always been an important part of the Canadian health workforce. A particularly important aspect related to the role of IEHPs is their distribution across different sectors of the healthcare system and various geographical regions. Several provinces and territories have implemented strategies that restrict the initial practice of IEHPs to areas that have long-standing workforce shortages. While the outcomes of these approaches are mixed, some evidence suggests that IEHPs remain in place only as long as their contractual requirements stipulate. However, studies also indicate that IEHPs are increasingly practising in care settings that are perceived to be less attractive by their Canadian-trained counterparts. Whether the contribution of IEHPs is framed in terms of short- or long-term sustainable solutions, their role will continue to be an important component of health service across Canada.
Article
The overall goal of this study was to elicit and describe the lived experiences of internationally educated nurses (IENs) who work in a multi-hospital medical centre in the urban USA. Since World War Two, US health care agencies have addressed the nursing shortage by hiring IENs. While other countries have produced substantial research findings about their IENs, much less research has been done about IENs in the USA. Findings from the limited US studies suggest that more research is needed and first-hand reports of lived experiences must be added. Using a phenomenology of practice study design and Giorgi's principles of data analysis, narratives from the guided interviews with 20 new immigrant IENs who had migrated from the countries of the Philippines, Nigeria and India to the USA, were collected and studied for themes. Six themes that emerged from the stories of IENs together describe a trajectory of lived experiences that the IENs encountered during their adjustments to living and working in the USA. The emergent themes were dreams of a better life, a difficult journey, a shocking reality, rising above the challenges, feeling and doing better and ready to help others. Study findings are similar to studies done in other countries and highlight the needs of IENs. The study findings provide important first-hand insights from the subjective perspectives of the IENs in US hospitals and will guide recruitment and retention of a diverse nursing workforce. Findings will enrich orientation and transition programs for IENs as well as strengthen the cohesiveness of a diverse nursing workforce in the USA.
Article
PALESE A., CRISTEA E., MESAGLIO M. & STEMPOVSCAIA E. (2010) Italian–Moldovan international nurse migration: rendering visible the loss of human capital. International Nursing Review57, 64–69 Aim: To describe the process of the migration of Moldovan nurses to Italy. Background: Formerly a part of the Soviet Union, the Republic of Moldova gained independence in 1991. Currently, there are 25 848 nurses (60.6 per 10 000 inhabitants) working mainly in the public health system. Each year, around 2000 nurses leave the country in search of better working conditions and a better quality of life. Methods: A longitudinal study design was adopted (2006–2007). In the first phase, we contacted all known nurses living in Moldova and their available colleagues following a snowball sampling strategy. Inclusion criteria were nurses who had decided to migrate to Italy and had already prepared the migration documents and/or were awaiting their departure. In the second phase, we interviewed the same sample of nurses on arrival in Italy. Findings: After one year, only 25 nurses out of the 110 initially interviewed (22.7%) had arrived in Italy; none were working as nurses. The cost of the migration process incurred by each nurse was around 3278 euros, and the waiting time from the decision to leave until arrival was around 24 months. Conclusions: All Moldovan nurses involved in this study, once they arrived in Italy, ceased to exist from an official perspective. Policy and recommendations need to be developed to ensure the integration of Moldovan-educated nurses into the health-care system and to monitor the amount of human capital (in terms of care drain, brain drain and youth drain) that this process risks wasting.
Article
suhonen m. &paasivaara l. (2011) Journal of Nursing Management19, 246–253 Factors of human capital related to project success in health care work units Aim To explore factors of human capital related to project success that employees expect from nurse managers. Background Human capital refers to those resources that managers working with projects possess, such as abilities, knowledge and qualities of character. Method The data were collected by open interviews (n = 14) with nurses, public health nurses and nurse managers working in primary health care and a hospital. Data analysis was carried out using qualitative content analysis. Results The main factors of human capital related to project success proved to be as follows: (1) management of enthusiastic project culture, (2) management of regeneration and (3) management of emotional intelligence. Conclusions Future research is needed on the kind of means nurse managers use in human capital management in projects and how they see their possibilities in managing human capital. Implications for nursing management Human capital management skills should be underlined as an important competence area when recruiting a nurse manager. The success of health care projects cannot be improved only through education or by training of nurse managers; in addition, projects need nurse managers who understand workplace spirituality and have high emotional intelligence.
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Highly qualified individuals are leaving the Caribbean and relocating to the United States and other developed countries. Researchers describe this resulting flight of human capital, or brain drain, from the Caribbean as a problem which has no clear definition or immediate solution. This phenomenological study explored perceptions of government senior executives in the United States Virgin Islands (USVI) of the cause and impact of brain drain. Burns' and Bass's transformational and transactional leadership theories were used as the framework for this study. Data were collected through a demographic questionnaire and semistructured interviews with a snowball sample of 10 participants. Data were analyzed using the phenomenological method of thematic coding. Data indicated that leaders perceived a lack of opportunities for educated individuals in the USVI. Government senior executives acknowledged an imbalance in the workforce as the majority of workers are older individuals. Government senior executives recommended an increased budget allotment to educate, retain, and attract younger Virgin Islanders to decrease and prevent brain drain. These results indicate that policymakers and organizational leaders can create positive social change by creating job opportunities and improving the island's physical and social infrastructures, thus, ensuring future organizational success.
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Much research has been conducted on the problems relating to the current international nursing shortages (Hawthorne 2001; Buchan 2006; Choy 2010). This has included the need for Health Services to manage their nursing shortages by recruiting qualified nurses from other countries (Buchan 2006). The past few decades has seen a large increase in the levels of skilled immigration to Australia from non-English speaking background (NESB) countries and many of these come from within the nursing profession (Preston 2009).The role of nursing and midwifery registering authorities is to protect public safety by establishing policies for the regulation of the profession. Therefore the purpose of English language testing is to evaluate the effectiveness of communicating in a nursing setting with patient safety as the main objective. However, research suggests a potential mismatch between linguistic criteria assessed by language professionals and clinical communication deemed relevant by health professionals (O'Hagan et al. 2011; Jacoby & McNamara 1999). Kingma (2001 p.212) states that 'language was reported to be a significant barrier to nurse migration' in the international recruitment of nurses to fill nursing shortages in the USA, UK, and Australia (Kingma 2001). Many international nurse registering authorities have demonstrated concerns regarding English language testing, indicating this is a universal problem (Hawthorne 2001; Kolawole 2009; Walker 2009). A bibliographical database search was undertaken (Health Source: Nursing, PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), Linguistics & Language Behavior Abstracts (LLBA), Scopus and Ebsco) along with national and international nursing websites. Search terms included migrant nurse, international nurse, migration, experience, cultural safety, globalization, nurse migration, nurse recruitment, Australia, nurse registration and research. The search was limited to texts published in English and peer-reviewed research-based articles.
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This knowledge synthesis report examines how migrant transition programs (status conversion from temporary to permanent) inform nursing labour force planning in Canada with a specific focus on Ontario.
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IMRC Policy Points provide current and relevant policy briefings and recommendations drawn from scholarly research carried out by our Associates and Affiliates worldwide. Follow our series at: www.imrc.ca.
Article
Market-based migrant intermediaries play an important role in skilled migration. Skilled workers, especially in regulated professions such as nursing, face increasingly complex testing and credential assessment systems. ‘Regimes of skill’ control and filter membership to these professions by reproducing already existing power imbalances in the global regulation of skilled labour. This paper examines these processes in the case of Indian trained nurses who use educational brokers to enrol in Canadian postgraduate programmes with the intention of practising in the Canadian health care system. The study elaborates on the ‘regime of skill’ in nursing, revealing its maintenance through interactional and transnational connections between intermediaries, educators and regulators in terms of codifying and translating skills and competencies between jurisdictions with different cultural and professional histories and norms of nursing. Findings reveal that intermediaries operate transnationally in a symbiotic manner with more powerful actors in order to exploit regimes of skill and expand their market share.
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Z Amaç: Bu çalışmanın amacı hemşirelerin yabancı hemşire istihdamına ilişkin tutumlarını belirlemek üzere geçerli ve güvenilir bir ölçme aracı geliştirmektir. Yöntem: Metodolojik tipteki bu çalışmanın örneklemi klinik alanda çalışan 339 hemşireden oluştu. Ölçeğin kapsam geçerliği, Lawshe tek-niği ile incelendi. Zamana karşı geçerliği test re-test ile gösterildi. Gü-venirlik için madde toplam puan korelasyon analizleri yapıldı. Faktör yapısını belirlemede açımlayıcı faktör analizi ve son olarak iç tutarlık analizinde de Cronbach's alpha analizleri kullanıldı. Bulgular: Analizler sonucunda; madde korelasyon değerleri 0.530-0.798 arasında, faktör yükleri 0.489-0.861 arasında ve iç tutarlıkları da 0.848-0.960 arasında değişen, dört faktörde toplam 25 maddelik ölçek yapısı oluşturuldu. Sonuç: Yabancı Hemşire İstihdamına Yönelik Tutum Ölçeği'nin geçerli ve güvenilir bir ölçek olduğu belirlendi. ABSTRACT Aim: To develop a valid and reliable measuring tool in order to determine nurses' attitudes towards the employment of foreign nurses. Methods: The sample of this methodological study comprised 339 nurses. Content validity of the scale was evaluated via Lawshe's content validity technique. The stability of the scale was demonstrated via test-retest. Item total score correlation analyses were run to evaluate reliability. Exploratory factor analysis was used to determine factor structure and Cronbach's alpha coeff cient values were used for internal-consistency analysis. Results: The scale was developed with 25 items in 4 factors in which item total correlations were found between 0.530-0.798, factor loadings were found between 0.489-0.861 and internal consistency values were found between 0.848-0.960. Conclusion: The Attitudes towards Employment of Foreign Nurses Scale was found to be a valid and reliable data collection tool.
Article
New Zealand, like many other Western countries, is struggling to cope with increasing demands for nursing services. Registered nurses are being actively recruited internationally and New Zealand has become a popular destination for nurses who wish to emigrate, including those from India. These nurses have unique cultural, professional and educational needs yet it is unclear how to best support them as they move to their destination countries. The issues around nursing migration and its effects have been discussed in many forums, but there is evidence of a gap in understanding the issues around acculturation and socialization. This selected literature review sought to identify the significant factors that impact on migrating nurses becoming competent and confident registered nurses in the New Zealand practice environment. A bibliographical database search was undertaken (Web of Knowledge, Web of Science, CINAHL, Medline, Academic Search Elite, and Ebscohost EJS) along with national and international nursing websites for the period 2002-2009. Search terms included Indian nurse, international nurse, migration, experience, cultural safety, globalization, nurse migration, nurse recruitment, New Zealand and research. The search was limited to texts published in English, with preference given to peer-reviewed research-based articles. A significant volume of literature was located. The key themes that arose were migration, education, language, nursing skills, competence, cultural safety and reflection on practice. Literature considered to best reflect these main themes, and of most relevance to New Zealand, was selected for this review, with preference given to research reports and official nursing publications. Strategies such as providing ongoing professional education, ensuring cultural safety and offering mentoring in practice environments will contribute to a safe passage for migrating nurses. Further research is required into the acculturation and socialization of Indian nurses, especially those moving to New Zealand.
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Past attempts to estimate the cost of migration were limited to education costs only and did not include the lost returns from investment. The objectives of this study were: (i) to estimate the financial cost of emigration of Kenyan doctors to the United Kingdom (UK) and the United States of America (USA); (ii) to estimate the financial cost of emigration of nurses to seven OECD countries (Canada, Denmark, Finland, Ireland, Portugal, UK, USA); and (iii) to describe other losses from brain drain. The costs of primary, secondary, medical and nursing schools were estimated in 2005. The cost information used in this study was obtained from one non-profit primary and secondary school and one public university in Kenya. The cost estimates represent unsubsidized cost. The loss incurred by Kenya through emigration was obtained by compounding the cost of educating a medical doctor and a nurse over the period between the average age of emigration (30 years) and the age of retirement (62 years) in recipient countries. The total cost of educating a single medical doctor from primary school to university is 65,997 US dollars; and for every doctor who emigrates, a country loses about 517,931 US dollars worth of returns from investment. The total cost of educating one nurse from primary school to college of health sciences is 43,180 US dollars; and for every nurse that emigrates, a country loses about 338,868 US dollars worth of returns from investment. Developed countries continue to deprive Kenya of millions of dollars worth of investments embodied in her human resources for health. If the current trend of poaching of scarce human resources for health (and other professionals) from Kenya is not curtailed, the chances of achieving the Millennium Development Goals would remain bleak. Such continued plunder of investments embodied in human resources contributes to further underdevelopment of Kenya and to keeping a majority of her people in the vicious circle of ill-health and poverty. Therefore, both developed and developing countries need to urgently develop and implement strategies for addressing the health human resource crisis.
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The migration of health professionals trained in Africa to developed nations has compromised health systems in the African region. The financial losses from the investment in training due to the migration from the developing nations are hardly known. The cost of training a health professional was estimated by including fees for primary, secondary and tertiary education. Accepted derivation of formula as used in economic analysis was used to estimate the lost investment. The total cost of training an enrolled nurse-midwife from primary school through nurse-midwifery training in Malawi was estimated as US$ 9,329.53. For a degree nurse-midwife, the total cost was US$ 31,726.26. For each enrolled nurse-midwife that migrates out of Malawi, the country loses between US$ 71,081.76 and US$ 7.5 million at bank interest rates of 7% and 25% per annum for 30 years respectively. For a degree nurse-midwife, the lost investment ranges from US$ 241,508 to US$ 25.6 million at 7% and 25% interest rate per annum for 30 years respectively. Developing countries are losing significant amounts of money through lost investment of health care professionals who emigrate. There is need to quantify the amount of remittances that developing nations get in return from those who migrate.
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The medical "brain drain" has been described as rich countries "looting" doctors and nurses from developing countries undermining their health systems and public health. However this "brain-drain" might also be seen as a success in the training and "export" of health professionals and the benefits this provides. This paper illustrates the arguments and possible policy options by focusing on the situation in one of the poorest countries in the world, Malawi. Many see this "brain drain" of medical staff as wrong with developed countries exploiting poorer ones. The effects are considerable with Malawi facing high vacancy rates in its public health system, and with migration threatening to outstrip training despite efforts to improve pay and conditions. This shortage of staff has made it more challenging for Malawi to deliver on its Essential Health Package and to absorb new international health funding.Yet, without any policy effort Malawi has been able to demonstrate its global competitiveness in the training ("production") of skilled health professionals. Remittances from migration are a large and growing source of foreign exchange for poor countries and tend to go directly to households. Whilst the data for Malawi is limited, studies from other poor countries demonstrate the power of remittances in significantly reducing poverty. Malawi can benefit from the export of health professionals provided there is a resolution of the situation whereby the state pays for training and the benefits are gained by the individual professional working abroad. Solutions include migrating staff paying back training costs, or rich host governments remitting part of a tax (e.g. income or national insurance) to the Malawi government. These schemes would allow Malawi to scale up training of health professionals for local needs and to work abroad. There is concern about the negative impacts of the medical "brain-drain". However a closer look at the evidence for and against the medical "brain-drain" in Malawi suggests that there are potential gains in managing medical migration to produce outcomes that are beneficial to individuals, households and the country. Finally we present several policy options.
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To describe nurse migration patterns in the Philippines and their benefits and costs. The Philippines is a job-scarce environment and, even for those with jobs in the health care sector, poor working conditions often motivate nurses to seek employment overseas. The country has also become dependent on labor migration to ease the tight domestic labor market. National opinion has generally focused on the improved quality of life for individual migrants and their families, and on the benefits of remittances to the nation. However, a shortage of highly skilled nurses and the massive retraining of physicians to become nurses elsewhere has created severe problems for the Filipino health system, including the closure of many hospitals. As a result, policy makers are debating the need for new policies to manage migration such that benefits are also returned to the educational institutions and hospitals that are producing the emigrant nurses. There is new interest in the Philippines in identifying ways to mitigate the costs to the health system of nurse emigration. Many of the policy options being debated involve collaboration with those countries recruiting Filipino nurses. Bilateral agreements are essential for managing migration in such a way that both sending and receiving countries derive benefit from the exchange.
Article
By 2005, 19.2% of the Canadian population was foreign-born, the world’s highest proportion following Australia (24.6%). As early as the 2001 Census, the nation included 3,374,057 degree-qualified2 immigrants and 3,801,118 with post-secondary diplomas or certificates. Between 1996 and 2001, newly arriving immigrants were more than twice as likely as the Canadian-born to be degree qualified (37% compared to 15%). While male immigrants to Canada were much more highly educated than females (41% with degrees compared to 33%), both far exceeded the credential norm for the domestic workforce (15% of males and 16% of females respectively). As Kustec et al. show in this volume, credential recognition matters disproportionately to such skilled immigrants. Within the past decade, 1.2 million immigrants have reached Canada with the intention to work. Of the one-third who hold professional qualifications, at least 50% target fields requiring some type of training or formal credential. While just 15% of Canadians work in regulated occupations, this proportion rises to 34% when we look at the landed immigrants who arrived by 1996 and 2005 and for whom intended occupation is known.
Article
Korean nurses’ adjustment to hospitals in the United States of America Due to shortage of nurses, more nurses from other countries are employed in health care settings in the United States of America (USA). Little attention has been paid to understanding how culturally different international nurses adjust to USA hospitals. The purpose of this study was to investigate how Korean nurses adjust to USA hospital settings. Grounded theory method was used for sampling procedure, data collection and analysis in order to describe Korean nurses’ experiences from their perspective and to develop a substantive theory that explains their process of adjustment. Data were collected using semi-structured formal interviews with a purposive sample of 12 Korean nurses. The interviews were audio-taped and transcribed. Analysis of data, using the constant comparative method, revealed ‘adjustment to USA hospitals’ as the basic social psychological process. Five categories composed the process: (1) relieving psychological stress; (2) overcoming the language barrier; (3) accepting USA nursing practice; (4) adopting the styles of USA problem-solving strategies; and (5) adopting the styles of USA interpersonal relationships. These five categories capture the essential aspects of the adjustment process and each category contains a set of sub-categories that describe Korean nurses’ day-to-day experiences that are critical and also problematic to their adjustment. The process evolves in two stages. In the initial stage, the first three of the five categories greatly influenced the nurses’ adjustment. From the perspective of the nurses in the study, the initial stage lasts about 2 to 3 years. The remaining two categories are principal components of the later stage. It takes an additional 5 to 10 years to complete this stage. This model highlights both distress and accomplishments of Korean nurses during their adjustment to USA hospitals. The results of the study may help USA nurses gain insight in designing and implementing orientation programmes to facilitate and support Korean nurses’ adjustment to USA hospitals.
Article
The worldwide shortage of health-care workers has led to a brain drain that is negatively affecting the health-care systems of less affluent countries. The authors study the factors encouraging nurses and doctors to migrate, measure the costs and benefits of such migration and analyse methods of foreign recruitment. They then look at the theories that help explain this phenomenon: human capital theory, theories of neo-colonialism and of globalization. They conclude with a policy discussion of possible strategies, which include addressing the "push" factors motivating migration, focusing training on local health-care needs, signing bilateral agreements that limit migration, etc.
Article
Few studies have examined the impact of international migration and remittances on poverty in a broad cross-section of developing countries. The authors try to fill this gap by constructing a new data set on poverty, international migration, and remittances for 74 low- and middle-income developing countries. Four key findings emerge: 1) International migration-defined as the share of a country's population living abroad-has a strong, statistical impact in reducing poverty. On average, a 10 percent increase in the share of international migrants in a country's population will lead to a 1.9 percent decline in the share of people living in poverty ($1.00 a person a day). 2) Distance to a major labor-receiving region-like the United States or OECD (Europe)-has an important effect on international migration. Developing countries that are located closest to the United States or OECD (Europe) are also those countries withthe highest rates of migration. 3) An inverted U-shaped curve exists between the level of country per capita income and international migration. Developing countries with low or high per capita GDP produce smaller shares of international migrants than do middle-income developing countries. The authors find no evidence that developing countries with higher levels of poverty produce more migrants. Because of considerable travel costs associated with international migration, international migrants come from those income groups which are just above the poverty line in middle-income developing countries. 4) International remittances-defined as the share of remittances in country GDP-have a strong, statistical impact in reducing poverty. On average, a 10 percent increase in the share of international remittances in a country's GDP will lead to a 1.6 percent decline in the share of people living in poverty.
Article
Each organization should seek to maximize its human capital investments, which ultimately lead to increased profits and asset efficiency. Service companies utilize less capital equipment and more human productivity, customer service, and/or delivery of service as the product. With the measurement of human capital, one can understand what is happening, exercise some degree of control, and make positive changes. Senior management lives or dies by the numbers and if Human Resources (HR) really wants to be a strategic business partner, HR must be judged by the same standards as everyone else in the health care organization.
Article
To describe the push and pull factors of migration in relation to international recruitment and migration of nurses. Review of literature on nurse migration, examination of effects of donor and receiving countries, and discussion of ethical concerns related to foreign nurse recruitment. The primary donor countries are Australia, Canada, the Philippines, South Africa, and the United Kingdom (UK); the primary receiving countries are Australia, Canada, Ireland, the UK, and the United States (US). The effects of migration on donor countries include the loss of skilled personnel and economic investment; receiving countries receive skilled nurses to fill critical shortages with less economic investment. Ethical concerns include the potential for exploitation of foreign nurses. Nurses migrate to seek better wages and working conditions than they have in their native countries. Given the current conditions, developed countries continue to actively recruit foreign nurses to fill critical shortages. Migration is predicted to continue until developed countries address the underlying causes of nurse shortages and until developing countries address conditions that cause nurses to leave.
Article
The purpose of this paper is to examine what is known about the nurse workforce and nursing education in China in order to assess the likely potential for nurse migration from China in the future. There is a severe shortage of nurses in China (only one nurse per thousand in population), but at the same time there is a very high level of unemployment and underemployment of nurses. China's nursing education system is huge in size (about 500,000 nursing students in 2005), but weak in quality and career development. As a result of lack of limited job opportunities, low salary, and low job satisfaction, many talented Chinese nurses intend to switch occupation or work outside China. Commercial recruiters have expressed a strong interest in recruitment of nurses in China, but to date there are few examples of successful ventures. Even if the Chinese government were to implement health care financing reforms that led to an increase in nursing jobs and improved work conditions, some level of surplus will remain. As such, it is likely that China will become an important source of nurses for developed nations in the coming years.
Article
Little research has been conducted that examined the intended effects of nursing care on clinical outcomes. The objective of this study was to evaluate the impact of different nurse staffing models on the patient outcomes of functional status, pain control, and patient satisfaction with nursing care. A repeated-measures study was conducted in all 19 teaching hospitals in Ontario, Canada. The sample comprised hospitals and adult medical-surgical and obstetric inpatients within those hospitals. The patient's functional health outcomes were assessed with the Functional Independence Measure (FIM) and the Medical Outcome Study SF-36. Pain was assessed with the Brief Pain Inventory and patient perceptions of nursing care were measured with the nursing care quality subscale of the Patient Judgment of Hospital Quality Questionnaire. The proportion of regulated nursing staff on the unit was associated with better FIM scores and better social function scores at hospital discharge. In addition, a mix of staff that included RNs and unregulated workers was associated with better pain outcomes at discharge than a mix that involved RNs/RPNs and unregulated workers. Finally, patients were more satisfied with their obstetric nursing care on units where there was a higher proportion of regulated staff. The results of this study suggest that a higher proportion of RNs/RPNs on inpatient units in Ontario teaching hospitals is associated with better clinical outcomes at the time of hospital discharge.
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