1. Picking Out the Pieces Ethical Issues in International Nurse Migration Sat Ananda Hayden, MSN, RN Doctoral Student, Public Policy Lutchmie Narine, Ph D Director, Masters of Health Administration Associate Professor, College of Health and Human Services Rose Marie Tong, Ph D Distinguished Professor in Health Care Ethics Director, Center for Professional and Applied Ethics Department of Philosophy University of North Carolina, Charlotte Sat Ananda Hayden, MSN, RN Doctoral Student, Public Policy Lutchmie Narine, Ph D Director, Masters of Health Administration Associate Professor, College of Health and Human Services Rose Marie Tong, Ph D Distinguished Professor in Health Care Ethics Director, Center for Professional and Applied Ethics Department of Philosophy University of North Carolina, Charlotte

2. June 27, 2005 Ethical Issues of International Nurse Migration 2 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 datahttp://www.who.int/emc-hiv/global_report/slides/slide15.html There are an estimated 136 million births/year worldwide

3. June 27, 2005 Ethical Issues of International Nurse Migration 3 Nursing Density Worldwide Minimum: 5.4 Maximum : 2171.2839 Mean : 338.03 Standard Deviation : 356.51 http://www.who.int/GlobalAtlas/InteractiveMap/MainFrame2.asphttp://www.who.int/GlobalAtlas/InteractiveMap/MainFrame2.asp (latest available data)

4. June 27, 2005 Ethical Issues of International Nurse Migration 4 Density of Source and Destination Countries Sources: WHO (latest available); India, UK, Nigeria, Australia, Canada, NZ, UK, Australia from Aiken et al, 2005

5. June 27, 2005 Ethical Issues of International Nurse Migration 5 Study 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?

6. June 27, 2005 Ethical Issues of International Nurse Migration 6 Study 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

7. June 27, 2005 Ethical Issues of International Nurse Migration 7 Methodology 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

8. June 27, 2005 Ethical Issues of International Nurse Migration 8 Findings 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

9. June 27, 2005 Ethical Issues of International Nurse Migration 9 Increased International Interest

10. 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 Shared Themes

11. June 27, 2005 Ethical Issues of International Nurse Migration 11 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

12. June 27, 2005 Ethical Issues of International Nurse Migration 12 Major 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

13. June 27, 2005 Ethical Issues of International Nurse Migration 13 Dominant 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

14. June 27, 2005 Ethical Issues of International Nurse Migration 14 Rights-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

15. June 27, 2005 Ethical Issues of International Nurse Migration 15 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

16. June 27, 2005 Ethical Issues of International Nurse Migration 16 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

17. June 27, 2005 Ethical Issues of International Nurse Migration 17 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

18. June 27, 2005 Ethical Issues of International Nurse Migration 18 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

19. June 27, 2005 Ethical Issues of International Nurse Migration 19 Conclusion 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

20. June 27, 2005 Ethical Issues of International Nurse Migration 20 Final Thought If we are headed for a “flat world” model, what does that mean for professional status and standards of care?

21. 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 sahayden@uncc.edu Corresponding Author Sat Ananda Hayden Political Science Department University of North Carolina, Charlotte 9201 University City Blvd Charlotte, NC 28223 sahayden@uncc.edu