Nurse migration and health workforce planning: Ireland as illustrative of international challenges

The reported experiences of internationally qualified nurses in aged care: A scoping review

AIM

To examine the experiences of internationally qualified nurses, including those from culturally and linguistically diverse backgrounds, transitioning to and working in the aged care sector of high-income countries.

DESIGN

A scoping review.

DATA SOURCES

CINAHL, MEDLINE and PSychINFO databases were searched to find eligible literature published from January 2010 onwards.

REVIEW METHODS

This scoping review was based on the framework by Arksey and O'Malley and the PRISMA-ScR guidelines. The literature search was conducted by the first author, and all three authors reviewed the retrieved studies for eligibility and inclusion.

RESULTS

Fourteen articles were eligible. Data was categorized into three broad themes: stress of migration and transition; miscommunication, racism and discrimination; and aged care specific challenges which included two sub-themes 'shock of aged care' and 'bottom care'.

CONCLUSION

Internationally qualified nurses, particularly if they are culturally and linguistically diverse, face unique stresses and challenges in aged care and face barriers in the recognition of skills and qualifications. The under-utilization of skills is not only a loss in terms of patient care but is linked to fears of de-skilling, losing professional development and opportunities for career progression.

IMPACT

Internationally qualified nurses are positioned as a solution to aged care shortages in high-income countries; however, there is a scarcity of research exploring their experiences. In the context of the global aged care staffing crisis, an understanding of the stresses and challenges faced by internationally qualified nurses will further strengthen efforts to recruit, support and retain skilled nurses in aged care.

Understanding the factors influencing community pharmacist retention - A qualitative study

Background

Shortages in healthcare workers affects the overall delivery and effectiveness of the provision of healthcare. There are currently insufficient pharmacists working in the community sector in Ireland. While several studies have reported on the factors leading to retention in the medical and nursing profession, there is an absence of robust research examining retention within the pharmacist workforce in Ireland.

Objective

To identify and understand the range of factors currently at play in the community pharmacy sector in Ireland which influence the decision-making process for pharmacists deciding whether or not to continue to practice as a community pharmacist.

Method

A cross-sectional qualitative descriptive study was used to investigate the factors influencing community pharmacist retention as elicited from the lived experiences of 23 pharmacists. Study recruitment was undertaken using both convenience and purposive sampling. Qualitative content analysis was used to analyze the interview data to identify and explore themes.

Results

A broad and diverse range of factors were identified as affecting community pharmacist retention including working conditions, career fulfilment and progression, regulatory and administrative burden, the commercial focus within community practice, lack of representation and their overall health and well-being.

Conclusion

The findings show that there are a number of factors which either individually or cumulatively influence a pharmacist's decision to stay in or leave community practice. Various areas for change were identified, which if addressed are considered likely to improve retention in the sector. These include enhanced terms and working conditions, better acknowledgement and resourcing of professional activities, improved opportunities for career progression, reforms to the regulatory model including the personal accountability of a supervising pharmacist for all of the pharmacy's professional activities, a more streamlined model of reimbursement and more effective collective representation.

Past, Present and Future: Perspectives on an Oral History of Intellectual Disability Nursing

Thirty-one participants engaged in this oral history research study aimed at exploring the lived experience of intellectual disability nurses and healthcare assistants' knowledge of the trajectory of intellectual disability nursing over the last 30 years in the Republic of Ireland and England. This paper documents some of these experiences offering perspectives on intellectual disability nursing and what is important for the future. Findings from Ireland consider the nature of intellectual disability services and the registered nurse in intellectual disability. Findings from England focus on opportunities and restrictions in intellectual disability nursing, shared visions, the changing context within which work took place and also the internal and external supports that impacted their roles. It is evident that intellectual disability nurses must be responsive to the changing landscape of service provision and also the requirements for contemporary new roles to meet the changing needs of people with intellectual disabilities.

Co-worker relationships and their impact on nurses in Irish public healthcare settings

This article presents the findings of a secondary analysis of data arising from a quantitative study of 3769 nurses on co-worker relationships and their impact on nurses working in public healthcare settings in Ireland. The overall findings from this analysis suggest moderate to high levels of satisfaction with co-worker relationships, with an average scale mean of 77%. Statistically significant lower scale means were identified in respect of nurses whose basic nursing qualification was awarded in a country outside the EU, among students and among those working in the west of Ireland. Respondents intending to leave the healthcare workforce reported significantly lower scores (74%) on this index compared with those intending to stay (79%). Significant positive correlations between co-worker relationships and workplace engagement (0.233), job satisfaction (0.225), organisational commitment (0.221) and perception of managers (0.259) were identified. These findings have implications for the retention of nurses working in Irish public healthcare services.

A new mathematical model for determining optimal workforce planning of pilots in an airline company

This study aims to model a workforce-planning problem of pilot roles which include captain and first officer in an airline company and to make an efficient plan having maximal utilization of minimum workforce requirements. To tackle this problem, a mixed integer programming based a new mathematical model is proposed. The model considers different conditions such as employing pilots with different skill types, resignations, retirements, holidays of pilots, transitions between different skills regarding needs of the demands during the planning horizon. The application of the proposed approach is investigated using a case study with real-world data from an airline company in Turkey. The results show that a company can use transitions instead of new employment and this is a more suitable medium-term production and human resource planning decision.

Effective workforce planning: Understanding final-year nursing and midwifery students' intentions to migrate after graduation

AIMS

To examine the factors influencing final-year nursing/midwifery students' intentions to migrate following graduation.

BACKGROUND

With expanding global staff shortages, effective recruitment and retention strategies targeted at new nursing/midwifery graduates are necessary. Understanding factors that influence graduates' decisions to migrate or remain in the health care organisation that supported their education is essential but under-researched.

METHODS

A cross-sectional electronic survey was distributed to graduating nursing/midwifery students across nine higher education institutions in Ireland with a 36% (N = 407) response rate.

RESULTS

85% of Irish (n = 376) nursing/midwifery graduating students reported an intention to migrate overseas and 70% intend to return within 5 years. Pay, working conditions and career were ranked as influencing intentions to migrate. Multivariable analysis illustrated that educational opportunities and friends predict migration, while family and obligation were protective factors.

CONCLUSION

Nursing and midwifery leaders and policymakers must reconsider recruitment and retention strategies and embrace innovative and responsive approaches to address migration intentions and trends.

IMPLICATIONS FOR NURSING/MIDWIFERY MANAGEMENT

Strategic leadership is required to develop effective structures that support personal, professional and career opportunities for new graduates. Targeted recruitment innovations to entice graduates back into the health service are recommended.

The experiences of international nurses and midwives transitioning to work in the UK: A qualitative synthesis of the literature from 2010 to 2019

PURPOSE

In recent years there has been an increase in international nurses and midwives (trained outside of the European Economic Area) recruited to work in the UK. The aim of this review was to synthesise the most recent qualitative research exploring the experiences of international nurses and midwives as they transition and adapt to living and working in the UK.

FINDINGS

A systematic literature search using the databases psycINFO, CINAHL, MEDline, Web of Science, as well as Google Scholar, resulted in six studies meeting the criteria of primary qualitative research published since 2010 and focussing on the UK as the host country. A lack of research into the experiences of midwives meant that the participants in each of these six studies were international nurses. The findings of these six studies were synthesised into 4 analytical themes: (1) Cultural integration; (2) Individual challenges; (3) Support networks, and; (4) Communication issues. Participants reported difficulties adapting to their new life in the UK, including within their role as a nurse, but also in finding and building positive relationships that would help to ease their transition. Instances of discrimination, an undervaluing of international nurses' skillset, and problems around communication were all detrimental to this process.

SUMMARY

These studies are in line with earlier findings that suggest international nurses face a challenging integration process when recruited to work in the UK, indicating no improvement in international nurse experience. With an increasing number of international nurses being recruited to work in the UK, this review raises concerns based on the need to effectively support these nurses to successfully integrate into work and the wider society.

Failing to retain a new generation of doctors: qualitative insights from a high-income country

BACKGROUND

The failure of high-income countries, such as Ireland, to achieve a self-sufficient medical workforce has global implications, particularly for low-income, source countries. In the past decade, Ireland has doubled the number of doctors it trains annually, but because of its failure to retain doctors, it remains heavily reliant on internationally trained doctors to staff its health system. To halve its dependence on internationally trained doctors by 2030, in line with World Health Organisation (WHO) recommendations, Ireland must become more adept at retaining doctors.

METHOD

This paper presents findings from in-depth interviews conducted with 50 early career doctors between May and July 2015. The paper explores the generational component of Ireland's failure to retain doctors and makes recommendations for retention policy and practice.

RESULTS

Interviews revealed that a new generation of doctors differ from previous generations in several distinct ways. Their early experiences of training and practice have been in an over-stretched, under-staffed health system and this shapes their decision to remain in Ireland, or to leave. Perhaps as a result of the distinct challenges they have faced in an austerity-constrained health system and their awareness of the working conditions available globally, they challenge the traditional view of medicine as a vocation that should be prioritised before family and other commitments. A new generation of doctors have career options that are also strongly shaped by globalisation and by the opportunities presented by emigration.

DISCUSSION

Understanding the medical workforce from a generational perspective requires that the health system address the issues of concern to a new generation of doctors, in terms of working conditions and training structures and also in terms of their desire for a more acceptable balance between work and life. This will be an important step towards future-proofing the medical workforce and is essential to achieving medical workforce self-sufficiency.

Nursing qualification and workforce for the Association of Southeast Asian Nations Economic Community

International nurse migration among Association of Southeast Asian Nations (ASEAN) countries has the potential to increase the effectiveness of health services and access for the ASEAN Economic Community. Providing equivalent nursing qualifications and licensure standards and increasing the availability of the nursing workforce has become a challenge for ASEAN members. The purpose of this study is: 1) to comparatively analyze information on nursing licensing examinations (NLE) across ASEAN countries; and 2) to present information on the human resources required for a successful nursing workforce. This study reviews all documents published on the subject within the ASEAN Economic Community. NLE systems exist in all ASEAN Member States (AMSs)s except Brunei, Vietnam, and Lao PDR. Nursing education systems also vary across ASEAN countries. Language as a means of general communication and nursing examinations also differs. The availability of a qualified health workforce at the regional level is above the threshold in some areas. However, at the national level, Indonesia, Myanmar, Cambodia, and Lao PDR fall below the threshold. Professional licensure requirements differ among ASEAN nurses as a part of the process to become a qualified nurse in host and source countries. Mutual Recognition Agreements on nursing services should address the differences in NLE requirements as well as the availability of nurses.

The consequences of Ireland's culture of medical migration

BACKGROUND

In recent years, Ireland has experienced a large-scale, outward migration of doctors. This presents a challenge for national policy makers and workforce planners seeking to build a self-sufficient medical workforce that trains and retains enough doctors to meet demand. Although, traditionally, medical migration has been considered beneficial to the Irish health system, austerity has brought a greater level of uncertainty to the health system and, with it, a need to reappraise the professional culture of migration and its impact on the Irish health system.

METHODS

This paper illustrates how a culture of migration informs career and migration plans. It draws on quantitative data-registration and migration data from source and destination countries-and qualitative data-in-depth interviews with 50 doctors who had undertaken postgraduate medical training in Ireland.

RESULTS

Of 50 respondents, 42 highlighted the importance of migration. The culture of medical migration rests on two assumptions-that international training/experience is beneficial to all doctors and that those who emigrate will return to Ireland with additional skills and experience. This assumption of return is challenged by a new generation of doctors whose professional lives have been shaped by globalisation and by austerity. Global comparisons reveal the comparatively poor working conditions, training and career opportunities in Ireland and the relative attractiveness of a permanent career abroad.

CONCLUSION

In light of these changes, there is a need to critically appraise the culture of medical migration to determine if and in what circumstances migration is appropriate to the needs of the Irish health system. The paper considers the need to reappraise the culture of medical migration and the widespread emigration that it promotes.

Gone for good? An online survey of emigrant health professionals using Facebook as a recruitment tool

BACKGROUND

Health professionals, particularly doctors, nurses and midwives, are in high demand worldwide. Therefore, it is important to assess the future plans and likelihood of return of emigrating health professionals. Nevertheless, health professionals are, by definition, a difficult population to track/survey. This exploratory study reports on the migration intentions of a sample of doctors, nurses and midwives who had emigrated from Ireland, a high-income country which has experienced particularly high outward and inward migration of health professionals since the year 2000.

METHODS

Health professionals who had emigrated from Ireland were identified via snowball sampling through Facebook and invited to complete a short online survey composed of closed and open response questions.

RESULTS

A total of 388 health professionals (307 doctors, 73 nurses and 8 midwives) who had previously worked in Ireland completed the survey. While over half had originally intended to spend less than 5 years in their destination country at the time of emigration, these intentions changed over time, with the desire to remain abroad on a permanent basis increasing from 10 to 34 % of doctor respondents. Only a quarter of doctors and a half of nurses and midwives intended to return to practice in Ireland in the future.

CONCLUSIONS

The longer health professionals remain abroad, the less likely they are to return to their home countries. Countries should focus on the implementation of retention strategies if the 'carousel' of brain drain is to be interrupted. This would allow source countries to benefit from their investments in training health professionals, rather than relying on international recruitment to meet health system staffing needs. Improved data collection systems are also needed to track the migratory patterns and changing intentions of health professionals. Meanwhile, social networking platforms offer alternative methods of filling this information gap.

Applying a typology of health worker migration to non-EU migrant doctors in Ireland

BACKGROUND

Research on health worker migration in the Irish context has categorized migrant health workers by country or region of training (for example, non-EU nurses or doctors) or recruitment mechanism (for example, actively recruited nurses). This paper applies a new typology of health worker migrants - livelihood, career-oriented, backpacker, commuter, undocumented and returner migrants (European Observatory on Health Systems and Policies and WHO, vol. 2:129-152, 2014) - to the experiences of non-EU migrant doctors in Ireland and tests its utility for understanding health worker migration internationally.

METHODS

The paper draws on quantitative survey (N = 366) and qualitative interview (N = 37) data collected from non-EU migrant doctors in Ireland between 2011 and 2013.

RESULTS

Categorizing non-EU migrant doctors in Ireland according to the typology (European Observatory on Health Systems and Policies and WHO, vol. 2:129-152, 2014) offers insight into their differing motivations, particularly on arrival. Findings suggest that the career-oriented migrant is the most common type of doctor among non-EU migrant doctor respondents, accounting for 60 % (N = 220) of quantitative and 54 % (N = 20) of qualitative respondents. The authors propose a modification to the typology via the addition of two additional categories - the family migrant and the safety and security migrant.

CONCLUSIONS

Employing a typology of health worker migration can facilitate a more comprehensive understanding of the migrant medical workforce, a necessary prerequisite for the development of useful policy tools (European Observatory on Health Systems and Policies and WHO, vol. 2:129-152, 2014). The findings indicate that there is some fluidity between categories, as health worker motivations change over time. This indicates the potential for policy levers to influence migrant health worker decision-making, if they are sufficiently "tuned in" to migrant health worker motivation.

'Emigration is a matter of self-preservation. The working conditions . . . are killing us slowly': qualitative insights into health professional emigration from Ireland

BACKGROUND

Achieving a sustainable health workforce involves training and retaining sufficient staff to deliver health services. The Irish health workforce is characterised by a high level of emigration of Irish-trained staff and a heavy reliance on internationally trained staff. This paper presents qualitative findings from a mixed-method study of doctors, nurses and midwives who have recently emigrated from Ireland.

METHODS

Using Facebook, this study elicited 556 (388 completed) responses to an exploratory mixed-method online survey in July 2014. Respondents provided rich responses to two free-text questions, one on health worker return (N = 343) and another on health professional emigration (N = 209) from the source country (Ireland).

RESULTS

Respondents emigrated because of difficult working conditions in the Irish health system (long working hours, uncertain career progression), which compared poorly with conditions in the destination country. Respondents' experiences in the destination country vindicated the decision to emigrate and complicated the decision to return. Their return to Ireland was contingent upon significant reform of the Irish health system and an improvement in working conditions, expressed, for example, as: 'It's not about the money, it's about respect . . . we love working in medicine, but we love our families and health more' (RD283).

CONCLUSIONS

This paper highlights that doctors, nurses and midwives are emigrating from Ireland in search of better working conditions, clear career progression pathways and a better practice environment. The question for the source country is whether it can retain and attract back emigrant doctors, nurses and midwives by matching their expectations.

Migration Experiences of Foreign Educated Nurses

Purpose: Global nurse migration has a recognized impact on host and source countries, but the lived experience of foreign educated nurses is an important aspect of the success of this migration. A systematic review of the literature was conducted to understand the lived migration and acculturation experiences of foreign educated nurses. Design: A systematic review of the literature, based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was conducted. Primary research articles or secondary analyses were selected based on keyword and citation-based searches ( n = 44). Findings: Nurses’ experiences included migration and licensing barriers, difficulty with communication, racism and discrimination, skill underutilization, acculturation, and the role of the family. Conclusions: Barriers encountered in host countries may impede acculturation and successful nursing practice, resulting in circular migration and poor patient safety outcomes. Implications for Practice: Social support systems and cultural orientation programs can mitigate the impacts of social isolation and racism. Addressing common barriers can help minimize deskilling and allow safe and effective transitions to host countries.

A cycle of brain gain, waste and drain - a qualitative study of non-EU migrant doctors in Ireland

BACKGROUND

Ireland is heavily reliant on non-EU migrant health workers to staff its health system. Shortages of locally trained health workers and policies which facilitate health worker migration have contributed to this trend. This paper provides insight into the experiences of non-EU migrant doctors in the Irish health workforce.

METHOD

In-depth interviews were conducted with 37 non-EU migrant doctors in Ireland in 2011/2012.

RESULTS

Respondents believed they had been recruited to fill junior hospital doctor 'service' posts. These posts are unpopular with locally trained doctors due to the limited career progression they provide. Respondents felt that their hopes for career progression and postgraduate training in Ireland had gone unrealised and that they were becoming de-skilled. As a result, most respondents were actively considering onward migration from Ireland.

DISCUSSION & CONCLUSIONS

Failure to align the expectations of non-EU migrant doctors with the requirements of the health system has resulted in considerable frustration and a cycle of brain gain, waste and drain. The underlying reasons for high mobility into and out of the Irish medical workforce must be addressed if this cycle is to be broken. The heavy reliance on non-EU migrant doctors to staff the medical workforce has distracted from the underlying workforce challenges facing the Irish medical workforce.

Foreign nurse recruitment

Recruitment of nurses by industrialized nations from developing countries has been common practice for decades. Globalization, a crucial trend of the 21st century, raises the world’s awareness of the economic and social disparities between nations. The direct impact on nurse emigration emphasizes the ethical, economic, and social inequalities between source and destination countries. It is often more cost-effective for industrialized countries to recruit from developing countries; however, the depletion of source country resources has created a global healthcare crisis. Destination countries are being challenged on the ethical implications of aggressive recruitment and their lack of developing a sustainable self-sufficient domestic workforce. Similarly, source countries are confronting the same challenges as they struggle to fund and educate adequate numbers of nurses for domestic needs and emigrant replacement. This article will review the ethical, economic, and social impacts of continued unrestricted international recruitment of nurses and present a proposal for development of an international treaty addressing global sustainability.