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Picking Out the PiecesPicking Out the PiecesEthical Issues in International Nurse MigrationEthical Issues in International Nurse Migration
Sat Ananda Hayden, MSN, RNDoctoral Student, Public Policy
Lutchmie Narine, Ph DDirector, Masters of Health Administration
Associate Professor, College of Health and Human Services
Rose Marie Tong, Ph DDistinguished Professor in Health Care Ethics
Director, Center for Professional and Applied Ethics
Department of Philosophy
University of North Carolina, Charlotte
Sat Ananda Hayden, MSN, RNDoctoral Student, Public Policy
Lutchmie Narine, Ph DDirector, Masters of Health Administration
Associate Professor, College of Health and Human Services
Rose Marie Tong, Ph DDistinguished Professor in Health Care Ethics
Director, Center for Professional and Applied Ethics
Department of Philosophy
University of North Carolina, Charlotte
June 27, 2005 Ethical Issues of International Nurse Migration 2
Why Nursing Density Matters
Why Nursing Density Matters
Source: WHO (Make Every Mother and Child Count)
http://www.who.int/emc-hiv/global_report/slides/slide15.html latest available data
There are an estimated 136 million births/year worldwide
June 27, 2005 Ethical Issues of International Nurse Migration 3
Nursing Density Worldwide
Nursing Density Worldwide
Minimum: 5.4
Maximum : 2171.2839 Mean : 338.03
Standard Deviation : 356.51
http://www.who.int/GlobalAtlas/InteractiveMap/MainFrame2.asp (latest available data)
June 27, 2005 Ethical Issues of International Nurse Migration 4
Density of Source and Destination Countries
Density of Source and Destination Countries
Sources: WHO (latest available); India, UK, Nigeria, Australia, Canada, NZ, UK, Australia from Aiken et al, 2005
050
100150200250300350400450500550600650700750800850900950
All nurses per 100,000 population
BangladeshChadChinaCubaDREcuadorEgyptEl SalvadorEthiopiaGhanaIndiaJamaicaMalawiMalaysiaMexicoNicaraguaNigeriaPakistanPhilippinesSwazilandUgandaUruguayZimbabweSouth AfricaSaudi ArabiaAustraliaCanadaNZUKUSA
050
100150200250300350400450500550600650700750800850900950
All nurses per 100,000 population
BangladeshChadChinaCubaDREcuadorEgyptEl SalvadorEthiopiaGhanaIndiaJamaicaMalawiMalaysiaMexicoNicaraguaNigeriaPakistanPhilippinesSwazilandUgandaUruguayZimbabweSouth AfricaSaudi ArabiaAustraliaCanadaNZUKUSA
June 27, 2005 Ethical Issues of International Nurse Migration 5
Study QuestionsStudy Questions
What are the ethical themes in current International Nurse Migration literature?
Are those themes different for Source and Destination countries?
What are the ethical and moral implications of Brain Drain?
Should Health Professionals be treated differently than other professional migrants?
What is the best way to frame the ethical discourse about nurse migration?
What are the ethical themes in current International Nurse Migration literature?
Are those themes different for Source and Destination countries?
What are the ethical and moral implications of Brain Drain?
Should Health Professionals be treated differently than other professional migrants?
What is the best way to frame the ethical discourse about nurse migration?
June 27, 2005 Ethical Issues of International Nurse Migration 6
Study Design & SampleStudy Design & Sample
Content Analysis of published and unpublished
documents between 2000 and 2005
Sample: 212 documents
Inclusion Criteria
All documents pertaining to nurse migration, global nursing shortage, nurse migrants, foreign nurse recruitment
All documents pertaining to Brain Drain of HRH
All documents pertaining to ethical recruitment of foreign nurse graduates
Content Analysis of published and unpublished
documents between 2000 and 2005
Sample: 212 documents
Inclusion Criteria
All documents pertaining to nurse migration, global nursing shortage, nurse migrants, foreign nurse recruitment
All documents pertaining to Brain Drain of HRH
All documents pertaining to ethical recruitment of foreign nurse graduates
June 27, 2005 Ethical Issues of International Nurse Migration 7
MethodologyMethodology
Content Analysis
Theories
Policy Approaches
Ethical Implications of International Nurse Migration (INM)
Codes of Ethics for International Recruitment of Nurses (IRN)
N = 150
Content Analysis
Theories
Policy Approaches
Ethical Implications of International Nurse Migration (INM)
Codes of Ethics for International Recruitment of Nurses (IRN)
N = 150
June 27, 2005 Ethical Issues of International Nurse Migration 8
FindingsFindings
Theoretical frameworks are not typically explicated
Policy frameworks are implicit rather than explicit
Ethical discussions are at a high level of abstraction and limited to such areas as
Social Justice
Distributive Justice
Tensions between source and destination countries
The number of published documents on the topic increased fourfold between 2000 and 2004
Theoretical frameworks are not typically explicated
Policy frameworks are implicit rather than explicit
Ethical discussions are at a high level of abstraction and limited to such areas as
Social Justice
Distributive Justice
Tensions between source and destination countries
The number of published documents on the topic increased fourfold between 2000 and 2004
June 27, 2005 Ethical Issues of International Nurse Migration 9
Nurse Migration Articles by Discipline & Year of Publication
0
2
4
6
8
10
12
14
16
18
2000 2001 2002 2003 2004
Nu
mb
er
of
Art
icle
s
Nursing Policy Economics Health Sector Other
Increased International Interest
Increased International Interest
June 27, 2005 Ethical Issues of International Nurse Migration 10
Source Countries
Push factors
Stick factors
Professional preparation
Wage differentials
Structure of health sector
Exploitation
Remittances and other Diaspora Effects
Source Countries
Push factors
Stick factors
Professional preparation
Wage differentials
Structure of health sector
Exploitation
Remittances and other Diaspora Effects
Destination Countries
Pull factors
Stick Factors
Immigration Policy
Structure of health sector
Supply and demand
Ethical treatment of migrants
Destination Countries
Pull factors
Stick Factors
Immigration Policy
Structure of health sector
Supply and demand
Ethical treatment of migrants
Shared Themes
June 27, 2005 Ethical Issues of International Nurse Migration 11
Different Views of “Ethical”
Different Views of “Ethical”
Source Countries
Ethical Recruitment refers to
Poaching, looting, siphoning, stealing, neo-colonial subsidization of health care in destination countries
Destination Countries
Ethical Recruitment refers to responsibility without accountability
Codes of Ethical Recruitment Codes for Ethical Treatment of Nurse Migrants No coordination or oversight of recruitment
Source Countries
Ethical Recruitment refers to
Poaching, looting, siphoning, stealing, neo-colonial subsidization of health care in destination countries
Destination Countries
Ethical Recruitment refers to responsibility without accountability
Codes of Ethical Recruitment Codes for Ethical Treatment of Nurse Migrants No coordination or oversight of recruitment
June 27, 2005 Ethical Issues of International Nurse Migration 12
Major Ethical ThemesMajor Ethical Themes
Individual Welfare vs. Professional Values
Human Rights vs. Utilitarian Principals
Source Country Rights vs. Destination Country Rights
Health Professionals vs. Other Skilled Migrants
Global vs. Local Professional Competencies
Individual Welfare vs. Professional Values
Human Rights vs. Utilitarian Principals
Source Country Rights vs. Destination Country Rights
Health Professionals vs. Other Skilled Migrants
Global vs. Local Professional Competencies
June 27, 2005 Ethical Issues of International Nurse Migration 13
Dominant DiscourseDominant Discourse
Codes of Ethical Recruitment
Medical Exceptionalism (Alkire & Chen, 2004)
Local rather than Global Competencies
Brain Drain
Exploitation
Codes of Ethical Recruitment
Medical Exceptionalism (Alkire & Chen, 2004)
Local rather than Global Competencies
Brain Drain
Exploitation
June 27, 2005 Ethical Issues of International Nurse Migration 14
Rights-based ApproachRights-based Approach
First Generation: Source countries
Political Freedom
Civil Rights
Second Generation: Destination Countries
Distributive Justice
Allocation of Resources
First Generation: Source countries
Political Freedom
Civil Rights
Second Generation: Destination Countries
Distributive Justice
Allocation of Resources
June 27, 2005 Ethical Issues of International Nurse Migration 15
How Ethical Discourse Informs Policy
How Ethical Discourse Informs Policy
Foreign Policy
Structure aid policies to support stick and stay factors
Structure aid & development policies to support source country self-determination
Elevate Global HRH capacity planning at G8 level
Global funding and tracking of health professional migration
Credits for INM working in-country
Foreign Policy
Structure aid policies to support stick and stay factors
Structure aid & development policies to support source country self-determination
Elevate Global HRH capacity planning at G8 level
Global funding and tracking of health professional migration
Credits for INM working in-country
June 27, 2005 Ethical Issues of International Nurse Migration 16
How Ethical Discourse Informs Policy
How Ethical Discourse Informs Policy
Domestic Policy
Assess HRH impact of proposed policies
Engage in coordinated HRH capacity planning and resource tracking
Restructure Health Sector
Education:
Increase educational capacity and funding subsidies based on capacity planning
Domestic Policy
Assess HRH impact of proposed policies
Engage in coordinated HRH capacity planning and resource tracking
Restructure Health Sector
Education:
Increase educational capacity and funding subsidies based on capacity planning
June 27, 2005 Ethical Issues of International Nurse Migration 17
How Ethical Discourse Informs Policy
How Ethical Discourse Informs Policy
Economic Policy
Structure policies to support stick and stay factors
Wage adjustments for nursing salaries Incentives for returning nurses
Disincentives for HCOs that use INM
Eliminate designations of HRH shortage areas as basis for incentives
Economic Policy
Structure policies to support stick and stay factors
Wage adjustments for nursing salaries Incentives for returning nurses
Disincentives for HCOs that use INM
Eliminate designations of HRH shortage areas as basis for incentives
June 27, 2005 Ethical Issues of International Nurse Migration 18
How Ethical Discourse Informs Policy
How Ethical Discourse Informs Policy
Trade Policy
Calculate impact of trade agreements on HRH
Include reciprocal reinvestment in HRH for trading partners
Determine impact of Trade Policies on domestic health sector
Trade Policy
Calculate impact of trade agreements on HRH
Include reciprocal reinvestment in HRH for trading partners
Determine impact of Trade Policies on domestic health sector
June 27, 2005 Ethical Issues of International Nurse Migration 19
ConclusionConclusion
Source countries view INM from a neo-colonial perspective
Destination countries view INM from economic and individual rights perspective
Brain Drain, Brain Waste, and Brain Effect can be incorporated into managed migration plans
Medical exceptionalism is a palatable solution for some
Ethical discourse can be successfully incorporated into policy
Source countries view INM from a neo-colonial perspective
Destination countries view INM from economic and individual rights perspective
Brain Drain, Brain Waste, and Brain Effect can be incorporated into managed migration plans
Medical exceptionalism is a palatable solution for some
Ethical discourse can be successfully incorporated into policy
June 27, 2005 Ethical Issues of International Nurse Migration 20
Final ThoughtFinal Thought
If we are headed for a “flat world” model, what does that mean for professional status and
standards of care?
If we are headed for a “flat world” model, what does that mean for professional status and
standards of care?
June 27, 2005 Ethical Issues of International Nurse Migration 21
Corresponding Author
Sat Ananda Hayden
Political Science Department
University of North Carolina, Charlotte
9201 University City Blvd
Charlotte, NC 28223
Corresponding Author
Sat Ananda Hayden
Political Science Department
University of North Carolina, Charlotte
9201 University City Blvd
Charlotte, NC 28223
