December 4, 2007 | Volume 4, Issue 4

Unbalanced Care

Nurse Migration in the Philippines

by Annie Gorman

Nurse Scarcity in the U.S.

The state of nurse staffing in the United States, and its future prognosis, is best illustrated by statistics such as the following:

• The U.S. Bureau of Labor Statistics predicts that healthcare services will account for 1 out of 6 new jobs from 2002 to 2012.¹
• In a 2003 study conducted by the American Hospital Association, 75% of open positions across member hospitals were for registered nurses (RNs).²
• The percentage of the American population that is aged 65 and older will double between 2000 and 2030 – but the number of women aged 25–54, who have “traditionally formed the core of the nursing workforce,” will remain virtually unchanged.³
• Due to decreasing enrollment at American nursing schools, approximately 40% of U.S. trained RNs will be over 50 years old by 2010.⁴
• The American Nurses Association found in a 2001 survey of RNs that 55% of respondents would not recommend nursing to their children or friends and 23% would actively seek to dissuade someone else from entering the profession.⁵

Taken together, these statistics paint a bleak picture. The aging U.S. population is characterized by a historically high level of disposable income and higher rates and frequencies of participation in the health-care system. A wave of retirement will affect the current population of U.S. nurses at the same time as demand for their services is expected to soar.⁶ The declining enrollment trend at nursing schools is due both to waning interest in this career and an increasing shortage of teaching faculty. These factors force many schools to turn away qualified applicants⁷ – one 2003 estimate for this figure was 11,000 per year.⁸ Retention of trained RNs is also an issue. Surveys show that increasing dissatisfaction levels among employed nurses are correlated with their desire to leave the profession. The health-care industry’s push to maximize profits via shorter patient hospital stays and less time per patient spent with physicians means that there is more work for nurses to do and less time in which they can do it. A 2002 survey conducted among acute-care hospitals in Washington State found that better working conditions were a more significant factor in improved recruiting and retention of nurses than higher salaries and better nurse-to-patient ratios.⁹ In a 1999 survey, more than 40% of hospital nurses expressed overall dissatisfaction with their jobs.¹⁰ The national turnover rate among hospital nursing staff was 26% in 2000, up from 12% in 1998.¹¹

Internationally Educated Nurses

The policy challenge developed countries are facing is to find a way to sustain their nursing workforce in the face of decreasing rates of enrollment in nursing schools.¹² Historically, the United States has found it more efficient to address the recruitment issue by importing internationally educated nurses (IENs) rather than solving the retention problem that has, in recent years, shrunk the pool of U.S. trained nurses (USNs). From 1998 to 2002, the proportion of IENs of the total number of working nurses in the U.S. more than doubled and it is estimated that this group accounted for about a third of the increase in employed nurses since the mid-1990s.¹³ This policy has alleviated the U.S. nursing shortage, but, in many of the IENs’ home countries, has left health-care systems in a state of advancing crisis.

The Philippines has long been a leader in the export of nurses due in part to a series of deliberate government policies discussed below. The impact of migration on that country’s nursing work force and its domestic health-care system. More recently, Nigeria, Korea, India, and other African nations have increased their participation in this economy. In 2000, more than 500 nurses left Ghana, more than double the number of new nursing graduates in that country that year.¹⁴

According to the World Health Organization’s World Health Report 2003, “the most critical issue facing health systems is the shortage of people who make them work.”¹⁵ This shortage trickles down from poor nations to poorer nations. Buchan and Stochalski bluntly note that “recruiting nurses from overseas often serves to only to redistribute the shortage to a country less well equipped to deal with it.”¹⁶ Jamaica, for instance, has lost so many nurses to migration that it has recently begun recruiting Cuban nurses.¹⁷ At the 2004 World Health Assembly, African ministers noted that in smaller countries with populations under one million, the loss of even one skilled nurse is significant because nurse-to-patient ratios are already so dire.¹⁸ Thus, the loss of one skilled nurse leads to a self-perpetuating migration trend that is the crux of the issue for many less-developed countries. When nurses leave for work elsewhere, the nurses left behind must care for more patients and make a greater contribution to administrative work, thus the quality of care that they are able to offer is increasingly compromised. With one fewer nurse, patients must wait longer to receive care and many of the remaining nurses feel obliged to work longer hours to ensure that they receive treatment. If an additional nurse eventually migrates due to the stress of an unreasonable workload, this only compounds the workload of the remaining nurses.

A nurse’s decision to leave their home country and seek employment overseas is the result of a number of factors including unsafe and/or politically unstable conditions at home, far higher salaries, better working conditions, and opportunities for professional development.¹⁹ Riskier working conditions are also a factor. Kline notes that in Zimbabwe, the 26% HIV infection rate translates into a heavy workload and care burden for nurses as well as a high risk that they will become infected in the course of doing their jobs.²⁰

The Philippines, which contributes 32% of the world IEN pool,²¹ is a special case in the analysis of nurse migration. In 1974, in response to high domestic unemployment, then-president Ferdinand Marcos made labor export a national economic development strategy, implementing government-controlled structures for recruiting and marketing workers. By some standards his strategy worked excessively well, and by 1995 attention to the high social costs of migration led President Fidel Ramos to seek initiatives to keep mothers at home, saying he did not want to promote migration at the expense of families. Worker migration slowed for a few years, but by 2002 it became apparent that the Philippine economy was suffering from the reduction in remittances. President Gloria Arroyo reversed course and encouraged workers, including mothers, to stay abroad as long as possible.²² Today, 2,300 Philippine citizens go overseas for work every day; 10% of them are abroad at any given time and in 2005 their aggregate remittances totaled $8 billion,²³ or 11% of total national GDP.²⁴

Some suggest that as the work eligible Philippine population is growing faster than the number of retirees, it is essential to continue sending workers abroad to prevent the domestic economy from collapsing. But the government’s export policy has hit its health-care system particularly hard. A researcher found five hospitals in the Mindanao island grouping, one of three that make up the Philippines, with no doctors or nurses.²⁵ Government-regulated health-care salaries are so low that an estimated 100,000 Philippine nurses work outside the profession as they can earn more in other professions.²⁶ Even Philippine doctors, lawyers, and engineers can boost their salaries by retraining as nurses and going to work abroad.²⁷ One study 2004 estimates that 80% of doctors at rural hospitals are retraining to become nurses so that they can emigrate.²⁸ What was an effective short-term economic solution for the Philippines is set to have lasting detrimental effects both economically and on domestic health care system.

In Mishra’s calculus, the quantifiable loss to an economy from emigration equals the reduction in welfare measured in terms of GDP that occurs when the workers who migrate receive a wage rate lower than the value of their marginal product.²⁹ With the migration of skilled workers, this effect is compounded by the adverse productivity impact on some segments of the labor force left behind. Hosein notes that there is also a loss to the public education subsidy due to the lost domestic wages.³⁰ In other words, the greater and more sustained is worker migration, the worse a country’s education system becomes. This should be a sobering consideration for the Philippines because at the point at which its education system ceases to produce young people whose skills and knowledge make them attractive among global competition, the remittance-reliant economy will collapse. Kigma also considers native countries’ lost investment in helping professionals develop their skills – as those skills will now be deployed in the service of another country’s economy – and the related opportunity costs to the native governments. Total losses due to migration can be summarized as simple emigration loss, the externality effect, reduced government expenditure, and fiscal losses on account of foregone tax revenues.

Costs and Benefits

Hiring IENs provides some obvious benefits to the host country. IENs tend to be skilled workers who can immediately enter the workforce – 49.7% of IENs have bachelor’s degrees or higher, compared to 37.6% of USNs.³¹ Also, because so many IENs come from countries and regions that have suffered social and political upheaval, they are perceived resilient and calm, and not as not susceptible to stress. IENs as a group are often younger than USNs because they started and completed their nursing training at a younger age and/or attended fewer years of school. [32] The effect is a longer, more productive career, a greater return on investment to employers and thus a greater per-capita effect on relieving the U.S. nursing shortage.³³ Initially, bringing in IENs is a much less expensive way to fill nursing positions than recruiting domestically. One Kentucky hospital recruited 50 Filipina nurses at a total cost of $300,000, less than one typical month’s spending on non-staff (i.e., temporary agency) nurses.³⁴ IENs average higher salaries than USNs with comparable education levels, and some researchers surmise that the hurdles to U.S. employment that they have had to clear have made them more determined and tenacious workers.³⁵

However, the costs, particularly to the IENs’ home countries, can be extensive. Glaessel-Brown notes that reliance on IENs as “readily available, expendable workers postpone sustained efforts to resolve professional problems leading to a more stable work force and self-sustaining cycle.”³⁶ Several of the United Nations’ Millennium Development Goals relate to health issues such as improving maternal health and combating HIV infection and AIDS. In several African countries, programs in support of the Millennium Development Goals have been funded, but they are in abeyance because of lack of personnel.³⁷ Botswana’s unprecedented commitment to providing free antiretroviral therapy, in a country with a 17.3% HIV infection rate, is suffering not because of lack of financing but because of lack of personnel.³⁸

Nurse migration also exacts a cost to USNs as it drives down their income in the aggregate and on the per-hour level. The widening income gap between IENs and USNs is due to IENs’ tendency to consistently work more hours more and to concentrate in higher paying urban hospitals and ICUs.³⁹ A study conducted by the Texas Nurses Association in 1998 measured the impact of the entrance of about 500 IENs in one local market at a time when several health-care facilities were downsizing and consolidating. The prevailing wage fell from $14 to $11 per hour. Since all the IENs were eventually discovered to be in the country fraudulently, it was later possible to determine that lost salary opportunities for U.S. nurses totaled $13 million over three years.⁴⁰ Two states, California and New Mexico, will hire Philippine nurses who have not taken or have not passed the Philippine national nursing board exam and have merely passed the U.S. licensing exam. This is a lower standard than the one to which USNs are subject in these states. [41]

IENs tend to concentrate in less desirable jobs, which makes them vulnerable to poor working conditions.⁴² Kingma refers to this as “de-skilling,” the loss of skills due to regular practice or active use. One widely cited instance of de-skilling occurred when an experienced midwife was put in charge of her ward’s bed-making. Many IENs have reported a lack of recognition of their skills, which one described as “both an emotional and a professional insult.⁴³

The proportion of IENs working in management or supervisory roles has decreased since 1977 compared to USNs. Considering their higher education level, Xu sees circumstantial evidence of discrimination. This is supported by DiCicco-Bloom’s more anecdotal findings in which IENs describe being denied promotions.⁴⁴ Hosein has found that IENs tend to be afraid of complaining about their employers, even when they feel it is warranted. Kline cites a number of cases illustrating the exploitation of IENs, including a case in which the Catholic Archdiocese of Chicago was forced to pay almost $400,000 in back pay to a group of Filipina nursing home nurses that had been paid on the nursing-aide scale. In 2001 a group of Washington, D.C. area hospitals credited overseas nurses with only half of their years of experience.

IENs not yet fluent in English report difficulties in understanding slang or humor, feeling or being the object of derision among other nurses, not being able to speak as directly with doctors as native-born nurses can, and feeling timid in questioning patient care regimens.⁴⁵ IENs see fealty to hospital supervisors, administrators, and supervisors as the way to get ahead and they feel that this attitude does not come naturally to them.⁴⁶ Trossman notes that “many employers know that foreign-educated nurses will not speak up about poor working conditions or unfair treatment,” partly due to their culture and partly due to real or perceived vulnerability of their employment.⁴⁷ She points out that this affects both patient care and these IENs’ own careers.

Kingma quotes a Philippine nurse: “The situation for many people, including nurses, makes immigration not a choice but a necessity. The failure to improve those conditions leads to a depopulation of professionals that is causing havoc in the Philippine health system.” The overall quality of available care has indeed suffered in the Philippines because of high turnover – nurses take jobs in Philippine hospitals, stay to acquire the bare minimum of experience required to apply for jobs abroad, then leave.⁴⁸

For IENs leaving their home countries, the social costs are very high. They must put down new roots, learn different routines, adapt to new medical technologies and administrative procedures at work, and learn a new culture. Many of them bear the responsibility of providing for family members or entire families left behind at home. Kingma observes that the countries that contribute the largest numbers of IENs tend also to be those in which leaving one’s children behind or being separated from aging parents is not supported in the culture. “Even if surrogate parents function well, asking women to place the economic survival of the family ahead of the bond with their children is a significant social demand.” [49] Although children remaining at home may suffer from weakened family ties and a lack of parental discipline, IENs bringing them to the new country, especially those with inferior English skills may have difficulty negotiating child care, or school. The conflicting cultural norms and value systems of the home country and the new country may lead to feelings of guilt on the part of the IEN or outright conflict.⁵⁰ In the Caribbean, one study found, children separated from their migrant parents were more than twice as likely to have emotional problems as other children.⁵¹ The same issue can affect the relationships of married IENs, especially if the wife is earning a higher income and/or has a more prestigious job. For unmarried IENs not working in cities that have a large immigrant population, there may be a lack of exposure to potential marriage partners from the same culture.⁵²

Many IENs report tensions with colleagues because of the perception that they are being recruited at the expense of attention paid, and funds devoted, to the concerns and needs of veteran USNs. They may also have difficulty forming social bonds because of the same cultural differences referenced above, and some report that they perceive their nursing skills to be compromised by their on-the-job exclusion from social groups. It is common in Philippine culture for women IENs to gradually bring over family over the course of several of years.⁵³ Thus the social cost is reduced for the IEN, but the economic cost to the Philippines is multiplied.

IENs are typically matched with vacant developed world nursing positions by for-profit recruiting agencies, some of which have ties to nursing schools. These ties and the economic incentives they create can lead to conflicts of interest. In August 2006, the president of the Philippine Nurses Association, who also owns a nursing review center, was accused by his students of leaking the national board exam to them ahead of time.⁵⁴ A New York Times article emphasized that their high scores would have meant more income to his review center from nursing agencies, but the article did not explicitly connect nurses’ inflated exam scores and the potential risk to patients who would later be in their care.

Governments typically do not monitor or track the recruitment of nurses. Buchan and Stochalski note that nurse recruiting agencies tend to target countries that have the weakest controls on the process.⁵⁵ The Philippines government benefits from nurse recruitment as it is able to higher new nurses at lower wage levels than their experienced and emigrating counterparts.⁵⁶ Governments have also thwarted some organizations’ micro-level efforts to build more ethical models for nurse recruitment. For instance, one Swiss nursing school was sensitive to French outcry over Switzerland’s poaching of new French nursing graduates. (Salaries in Switzerland are almost twice as high as in France, and the nurse-to-patient ratio is the lowest in the world.) The school proposed subsidizing the nursing school tuition of French students in exchange for some years’ work upon their graduation. Politicians rejected the proposal because it was cheaper to continue working with agencies to recruit abroad.
No international body regulates or monitors international nurse recruitment. These issues underscore the complexity of devising multinational policy approaches. It is unknown how many recruiting agencies there are, either at a per-country level or in total. There are thousands in the Philippines alone. Nurses seeking overseas placement are thus often targets for exploitation.

Recruitment agencies often garnish wages for the first few months an IEN is in her new position⁵⁷, and some Indian agencies have charged would-be IENs thousands of dollars for access to their job listings.⁵⁸ In the Philippines, recruiting agencies must, by law, derive their income from the hospitals that hire nurses and not from the nurses themselves. But these laws are not enforced, thus nurses must pay for the privilege of being recruited. Transportation and relocation expenses are negotiated, but recruitment agencies tend to deduct these costs from nurses’ paychecks, sometimes with exorbitant interest fees added. In one unadjudicated case, Philippine nurses were required to pay $750, the equivalent of four months’ in-country nursing salary, for two interviews with recruiting hospitals and no guaranteed job.⁵⁹ Another IEN signed an agreement that brought her family to Washington State and paid for her U.S nursing license in return for a six-year contract. When her hourly wage after a year was $12 compared to USNs’ $50, she sought to escape the contract and learned that buying it out would cost $50,000.⁶⁰ Pyle notes that according to the United Nations definition of the term, “trafficking occurs not only when women are physically forced to migrate but also when they migrate voluntarily, based upon recruiters’ deceptions, into unforeseen exploitation” and points out that these agencies could be subject to U.N. sanctions.⁶¹ Despite the efforts of some activists to force the issue, the U.N. has declined to consider such cases.

In response to harsh criticism from Nelson Mandela over its aggressive recruitment of African nurses, the United Kingdom Department of Health published an ethics code prohibiting the National Health Service from directly recruiting African nurses. But there is a simple workaround: African nurses now come to the United Kingdom via for-profit recruitment agencies and move to the National Health Service when their contracts are up. This was a lost opportunity for the United Kingdom to initiate an international dialogue, supported by someone of Mandela’s stature, on the effects of nurse migration and possible solutions to the issue. Although, as Kingma notes, at the time Mandela made his comments 78% of rural physicians in South Africa were citizens of other African countries.⁶²

The lack of regulation of the recruitment of health care professionals may become a national- or international-security issue, as illustrated by the June 2007 attempted car bombings in London and Glasgow. All eight of those arrested were doctors or medical workers. Recruitment agencies are not equipped to conduct comprehensive background checks on those they recruit, nor are they required to by law. A statement from a recruiting concern in the aftermath of the attempted bombings said, “We would expect an employer to ask a doctor who is being appointed from overseas to bring their own evidence of police clearance in their home country.”⁶³ It is not clear that documentation of this clearance would be double-checked. It is certainly possible that it could be forged.

It does seem clear that IEN-importing countries also bear some culpability for creating the conditions that induced nurses to migrate. Ann-Louise Colgan, quoted in Kingma, suggests that “the past two decades of World Bank and IMF structural adjustment in Africa have led to greater social and economic deprivation” that has been felt especially in terms of a deterioration in health and in health care services. Monetary austerity means that workers’ real income declines; reduced government spending necessitates cuts in the health-care sector; and the slow or stagnant growth of the private sector has meant that jobs lost in the public sector will stay lost. The result is harder work and poorer working conditions for those who remain in the public sector, while those workers moving to the private sector have generally seen their contracts renegotiated with lower salaries, reduced training opportunities and benefits, and poor job security.

Policy Solution and Conclusions

In establishing the framework by which a policy solution to the problem of nurse migration can be addressed, home countries and recruiting countries have different issues to resolve.

Policy Questions for Home Countries

1. Should home countries endorse, oppose, or remain neutral to the migration of nurses and health care professionals?
2. Should nurse migration be reduced? If so, by what means and according to what criteria?
3. Should recruitment agencies be regulated?
4. How should the migration of nurses be monitored?

Policy Questions for Recruiting Countries

1. Is the inflow of migrant nurses sustainable?
2. Is there a way to address the current nursing shortage that uses a higher proportion of domestic nursing labor?
3. Should recruiting agencies be regulated?
4. How should the inflow of migrant nurses be monitored?

There are two overarching questions here: How will these questions be answered? And, Who will have the authority to answer them?

These questions must be answered with data. Because nurse migration and nurse recruitment is almost exclusively a private-sector phenomenon, there is no means to set standards for data collection on its prevalence and growth; to fund, monitor, and enforce this data collection; and to keep it appropriately accessible and appropriately secure. There is no agreement, either, on what data dimensions are the minimum for productive analysis. In many countries, including the U.S., private-sector health-care organizations need not disclose the type of information that is categorically necessary to establishing a data set on nurse migration. According to Kingma, in the countries where the public health systems have been hardest hit by nurse migration, health statistics tend to occur along a spectrum from unreliable to unavailable.⁶⁴ In many of these countries, information systems and infrastructure are sorely lacking. But making projections that will guide planning and policy demands the ability not only to analyze data but to monitor trends over time.⁶⁵ Even if these data-collection roadblocks were resolved immediately, it would be a few or several years before the collected data could be useful to policy makers. There needs to be a commitment by a politically powerful – but not politically affiliated – international organization to changing data-reporting laws wherever possible and immediately begin collecting data in the places where the main roadblocks have been logistical. This organization must have the resources to fund the data collection where necessary, and it must have the experience with large-scale statistical processes to understand the importance of terminological definitions: for instance, what is a “nurse”? How does the meaning of this word differ from country to country?⁶⁶

A nonprofit organization with a mission encompassing international public health should have the authority to answer these questions. The guiding involvement of organizations like the World Bank is dubious for reasons noted above. The United Nations is perceived by many less developed nations as representing the interests of rich countries. Organizations like the American Nurses Association and the International Council of Nurses exist to promote the interests of nurses as a group and as individuals, which may be counter to the interest of public health. An organization like Doctors Without Borders or the Gates Foundation would be a good choice to lead the data collection effort while promoting its importance for global heath care and health care policy. The Peace Corps could be a valuable partner, providing volunteers who serve as data collectors in remote regions.

There are several factors that would contribute to an international climate in which addressing the inequities of nurse migration becomes possible, and the scope of this paper necessitates mentioning only a few. First, if the IMF and World Bank relaxed the financial restrictions to which developing countries were subjected, these countries could theoretically make necessary investments in health care education, institutions, and professionals. Countries that have lost health care providers due to migration should consider such programs as one that the government of South Africa created in which its national health department works with local nonprofit groups to recruit and train community health workers, who receive three months of training and are then qualified to perform public-health advocacy, counseling, and in-home care for the infirm.⁶⁷ Countries that have gained health care providers due to migration should fund the development of these programs. The Australian Nursing Federation is lobbying for a chief nurse position at the federal level to advise national leadership on nursing issues, and other countries should follow that lead.

The U.S. can take steps of its own to address its declining nurse retention. Nursing is a field with very high wage compression – that is, most of a nurses’ salary growth occurs early in their careers; the longer they remain in nursing, the more financially attractive other careers look by comparison. Reducing wage compression, perhaps with the aid of nursing unions, will keep nurses on the job longer and help to preserve institutional knowledge. Most hospitals are not investing in information technology in a way that support nurses’ work. Since nurses cite poor working conditions as leading factors in their dissatisfaction, hospitals should survey nurses to find out what asset investments would be perceived as contributing to a better work environment. Hospitals should also pursue working arrangements that give nurses more stability and more consistent schedules. The Baylor Plan, which creates a pool of nurses who work exclusively on weekends and are paid at a premium, has improved nurse retention in several hospitals where it has been introduced. Reducing reliance on non-staff nurses and offering better benefits to full-time hospital nursing staff has had similar results. Hospitals should work with nursing groups – and groups of nurses – to find out what kind of working arrangements they would like to have and be willing to try to attain them.

Nurse migration rates continue to rise in countries that have historically supplied the U.S. with IENs, to the extent that some academics question whether the arrangements are nearing their tipping point. About a quarter of the total nurses employed in Philippine hospitals in 2001 left to work abroad that year. India, China, and some of the former Soviet states have been examining the Philippine model of labor export as a balm to their own economic troubles.⁶⁸ However, if these countries allowed the establishment of education, nursing exam preparation, and recruitment systems that are as unregulated as those in the Philippines, this would create another huge population that was vulnerable to exploitation, and it could drive down the quality of IEN care provision. It is a critical moment in the history of nurse migration for an internationally policy making body to intervene.

It is also a critical moment for one or more of the nations that have benefited from the import of IENs to assume a role of ethical leadership in the development of such policies. In the British Commonwealth, 22 countries have committed to researching a formula in which “developed nations which use overseas trained staff should compensate the developing nations for their loss” – but Great Britain, which leads the Commonwealth in terms of the proportion of IENs in its nursing workforce, will not participate. Some 22 Commonwealth countries have signed up to such an approach, but not the UK. But a 2005 survey of IENs working in London, conducted by the British Royal College of Nursing, found that 40% of them were considering a move to another country that offers better pay.⁶⁹ Globalization provided Great Britain and the U.S., among others, with a solution to their shortages of nurses. But as these countries’ fortunes change and other countries become more able to compete in the market for nurse labor, globalization could destroy what it had previously built.

Works Cited

¹ Lowell, B. Lindsay and Stefka Gerova (2004). Immigrants and the Healthcare Workforce: Profiles and Shortages. Work and Occupations 31, 474–498.

² Kline, Donna S. Push and Pull Factors in International Nurse Migration. Journal of Nursing Scholarship 35 (2), 107–111.

³ United States General Accounting Office. July 2001. Nursing Workforce: Emerging Nurse Shortage Due to Multiple Factors. GAO-01–944.

⁴ United States General Accounting Office.

⁵ O’Sullivan, Anne. 2001. “Statement for the Governmental Affairs Subcommittee on Oversight of Government Management, Restructuring, and the District of Columbia on Addressing Direct Care Staffing Shortages.” http://nursingworld.org/gova/federal/legis/testimon/2001/govaref.htm. Accessed July 8.

⁶ Pindus, N., Tilly, J., and Weinstein, S. (2002). Skill shortages and mismatches in nursing related health care employment. Washington, DC: The Urban Institute. 

⁷ Lowell and Gerova.

⁸ Aiken, Linda H. The hospital workforce: Problems and prospects. Washington, DC: Council on the Economic Impact of Health System Change. 

⁹ Schneider, Jodi. July 28, 2003. “Getting Nurses Back on Board.” U.S. News and World Report. http://health.usnews.com/usnews/health/articles/030728/28nurses.htm. Accessed June 23, 2007.

¹⁰ Aiken, Linda H., James Buchan, et al. (2004). Trends in international nurse migration. Health Affairs 23 (3), 69–77.

¹¹ Hospital and Healthcare Compensation Service, Hospital Salary and Benefits Report, 2000–2001 (Oakland, N.J: Hospital and Healthcare Compensation Service, 2000).

¹² Buchan, J., and J. Sochalski. 2004. The Migration of Nurses: Trends and Policies. Bulletin of the World Health Organization 82(8): 587–594

¹³ Aiken and Buchan

¹⁴ Buchan and Stochalski

¹⁵ World Health Organization. The World Health Report 2003. Via http://www.who.int/whr/2003/en/. Accessed July 8, 2007.

¹⁶ Buchan and Stochalski

¹⁷ Winkelmann-Gleed, Andrea. Migrant Nurses: Motivation, Integration, and Contribution. Radcliffe Publishing Ltd, 2006, Seattle.

¹⁸ Kingma, Mireille. Nurses on the Move: Migration and the Global Health Care Economy. ILR Press: Ithaca, NY, 2006. 

¹⁹ Ibid.

²⁰ Kline

²¹ Lowell and Gerova

²² Pyle, Jean. Globalization and the Increase in Transnational Health Care. Globalizations 3, 297–315.

²³ Kingma

²⁴ Williams, Scott. April 11, 2005. “A Proud Nursing Heritage: Focus on the Philippines.” NurseWeek. http://www.nurseweek.com/news/Features/05–04/NursingHeritage_SC.asp. Accessed June 23, 2007.

²⁵ Cruz

²⁶ Hoppe, Ron. February 2005. “A Response to the National Public Radio (NPR) Program Number of Philippine Nurses Emigrating Skyrockets.” http://www.nurseimmigrationusa.com/Downloads/CoreFiles/NPR_Ron_Hoppe_rebuttal.htm. Accessed June 23, 2007.

²⁷ Hosein, Roger and Clive Thomas (2006). CSME and the Intra-Regional Migration of Nurses: Some Proposed Opportunities. Draft paper from the International Forum on the Social Sciences-Policy Nexus (2006), UNESCO.

²⁸ Conde, Carlos H. October 19, 2004. “Filipino Nurses’ Exodus.” International Herald Tribune. http://www.iht.com/articles/2004/10/18/news/phil.php. Accessed June 23, 2007.

²⁹ Micha, Prashi. January 2006. Emigration and Brain Drain: Evidence from the Caribbean. International Monetary Fund working paper. http://www.imf.org/external/pubs/ft/wp/2006/wp0625.pdf. Accessed June 23, 2007.

³⁰ Hosein

³¹ Lowell and Gerova

³² Winkelmann-Gleed

³³ Xu et al.

³⁴ Kline

³⁵ Lowell and Gerova

³⁶ Glaessel-Brown, F. 1998. Use of immigration policy to manage nursing shortages. Journal of Nursing Scholarship 30, 318–340.

³⁷ Kingma

³⁸ Aiken and Buchan

³⁹ Xu, Y. and Kwak, C. 2007. Comparative Trend Analysis of Characteristics of Internationally Educated nurses and U.S. Educated Nurses in the United States. International Nursing Review 54: 78–84

⁴⁰ American Nurses Association. 1998. “American and Foreign Nurses Abused by Massive Visa Fraud.” http://nursingworld.org/pressrel/1998/foreign.htm. Accessed July 8, 2007

⁴¹ (Filipino Nurses 2 US). December 6, 2006. “If You Failed The Board Exam.” http://www.filipinonurses2us.com/filipino_nurses_2_us/recruitment/index.html. Accessed June 23, 2007.

⁴² Lowell and Gerova

⁴³ Ibid.

⁴⁴ DiCicco-Bloom, Barbara. “The Racial and Gendered Experiences of Immigrant Nurses of Kerala, India.” Journal of Transcultural Nursing 15 (1): 26–33.

⁴⁵ Winkelmann-Gleed

⁴⁶ Kingma

⁴⁷ Trossman, Susan. 2002. “The Global Reach of the Nursing Shortage.” American Journal of Nursing 102(3). http://www.nursingworld.org/ajn/2002/mar/issues.htm. Accessed July 8, 2007.

⁴⁸ Conde.

⁴⁹ Kingma

⁵⁰ Ibid.

⁵¹ Jones, A., Sharpe, J., and Sjogren, M. 2004. Children’s Experience of Separation from Parents as a Consequence of Migration. Caribbean Journal of Social Work 3: 89–109.

⁵² Ibid.

⁵³ Ibid.

⁵⁴ Conde, Carlos H. August 21, 2006. “Scandal Over Nurses’ Exam Stirs Unease in Philippines.” The New York Times. http://www.nytimes.com/2006/08/21/world/asia/21nurses.html?ex=1184904000&en=1bc80bf041416fb2&ei=5070. Accessed June 23, 2007.

⁵⁵ Buchan and Stochalski.

⁵⁶ Kingma

⁵⁷ Pyle

⁵⁸ Winkelmann-Gleed

⁵⁹ Kingma

⁶⁰ Alvarado, Lourdes. March 23, 2007. “Immigrants Step in to Fill U.S. Nursing Shortage.” The (Washington) Daily Olympian. http://www.theolympian.com/109/story/72007.html. Accessed June 23, 2007.

⁶¹ Pyle

⁶² Kingma

⁶³ Landler, Mark, and Sarah Lyall. July 4, 2007. “7 Doctors Tied to British Plots.” http://www.nytimes.com/2007/07/04/world/europe/04britain.html?ex=1184904000&en=e3789e0972826ce1&ei=5070. The New York Times. Accessed July 4, 2007.

⁶⁴ Kingma

⁶⁵ Buchan and Stochalski

⁶⁶ Aiken and Buchan

⁶⁷ Ka Mzolo, Bhungani. “One Nation’s Response to Nurse Migration: The View from South Africa.” http://nursingsociety.org/RNL/1Q_2006/features/feature3.html. Accessed June 23, 2007.

⁶⁸ Aiken and Buchan

⁶⁹ Dean, Malcolm. March 18, 2005. “The NHS Goes Global.” The Guardian. http://society.guardian.co.uk/comment/column/0,,1485880,00.html. Accessed June 23, 2007.

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