Journal of Nursing Scholarship Second Quarter 2003 107 World Health A shortage of registered nurses (RNs) exists in countries throughout the world. Australia, Canada, France, Germany, Ireland, the United Kingdom (UK), and the United States (US)���all wealthy, industrialized countries��� are but a few of the countries reporting nursing shortages. Cyclical nurse shortages in many countries have usually been the result of increased demands outpacing the slower-increasing supply of nurses (Buchan, 2001). The current shortage, however, appears more serious, with demand continuing to increase while the projected supply indicates a continued reduction in the availability of nurses, especially in the US and UK, countries that are primary destinations of migrating nurses. A survey conducted by the American Hospital Association (AHA) showed that the 715 U.S. hospitals surveyed posted 168,000 open positions of those positions, 126,000 or 75% were for RNs (AHA, 2001). A recent study indicated the projected gap between supply and demand for RNs in the US to be 808,000 by the year 2020 (Bureau of Health Professions, 2002). The UK is grappling with similar nurse shortage problems. The Royal College of Nursing listed the current number of RN vacancies at about 22,000 and estimated that the National Health System (NHS) will need to recruit 110,000 RNs by 2004 (Finalyson, Dixon, Meadows, & Blair, 2002b). In addition to current shortage problems in the US, a fundamental shift occurred in the RN workforce during the last 2 decades that has been predicted to substantially affect the overall numbers of RNs available. According to Buerhaus, Staiger, and Auerbach (2000), as the opportunities for women outside nursing expanded over the last 20 years in the US, the number of young women entering the RN workforce declined. As a result, a demographic shift has occurred in the nursing workforce. The decreased number of young people choosing nursing careers has resulted in a gradually increasing average age of nurses, and thus an aging RN workforce without commensurate replacement of retiring nurses. The authors predicted that this aging will continue over the next decade when the largest percentage of RNs will be in their 50s and 60s, after which the RN workforce will become even smaller as the aging RNs retire. One means to alleviate the shortage crisis in developed countries has been to recruit foreign nurses to fill vacant Push and Pull Factors in International Nurse Migration Donna S. Kline Purpose: To describe the push and pull factors of migration in relation to international recruitment and migration of nurses. Organizing Construct: Review of literature on nurse migration, examination of effects of donor and receiving countries, and discussion of ethical concerns related to foreign nurse recruitment. Findings: 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. Conclusions: 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. JOURNAL OF NURSING SCHOLARSHIP, 2003 35:2, 107-111. ��2003 SIGMA THETA TAU INTERNATIONAL. [Key words: nurse migration, push and pull factors, nursing shortage, international] * * * Donna S. Kline, RN, MN, Nurse Manager, Seattle Veterans Affairs Puget Sound Health Care System, Seattle, WA. Correspondence to Ms. Kline, Seattle VAPSHCS���S-111, 1660 S. Columbian Way, Seattle, WA 98108. E- mail: doje@myuw.net Accepted for publication February 20, 2003.

108 Second Quarter 2003 Journal of Nursing Scholarship International Nurse Migration positions. However, not only are representatives from developed countries recruiting nurses, some of the same recruiting countries such as Australia, Canada, and the UK are losing nurses through migration. The ���brain drain��� of nurses has come under intense scrutiny in recent years with complaints from people in donor countries such as India, the Philippines, South Africa, and Zimbabwe about the loss of valuable human resources (���Record overseas numbers,��� 2002). The purpose of this analysis was to explore these issues regarding the international migration of nurses: ��� the push-pull theory of migration ��� identification of the major receiving and donor countries ��� effects of nurse migration on donor and receiving countries and ��� ethical considerations of nurse migration. The Push-Pull Theory of Migration According to Mejia, Pizurki, and Royston (1979), migration is the result of the interplay of various forces at both ends of the migratory axis. Some of these forces are political, social, economic, legal, historical, cultural, and educational. The authors classified the forces as ���push��� and ���pull��� factors. Push factors are generally present in donor countries, and pull factors pertain to receiving countries. Both forces must be operating for migration to occur. In addition, facilitating forces must be present as well, such as the absence of legal or other constraints that impede migration. Kingma (2001) discussed several reasons for nurse migration that constituted both push and pull factors. First, nurses migrated in search of professional development that was not attainable in their current job or country, demonstrating educational pull factors. The desire to practice nursing skills may have required moving from rural to urban areas or to another country where opportunities existed for them to use their knowledge and skills. Second, nurses sought better wages, improved working conditions, and higher standards of living not present in their native countries, exhibiting economic and social push and pull factors. Third, nurses sought areas to work where they would encounter less risk to their personal safety. Personal safety is an increasingly strong political and social factor in nurse migration and ���may be motivated by circumstances within the health sector or the external environment��� (Kingma, 2001, p. 207). Push factors such as concerns for personal safety are evident in African countries with high rates of HIV and other infectious diseases. For example, the World Bank reported that Zimbabwe, a donor country, has one of the highest rates of HIV prevalence in the world, with 26% of the population estimated to be infected. In addition, the number of tuberculosis cases has increased fivefold since 1995 (Zimbabwe: National Health Strategy Support, 1999). Not only does the AIDS epidemic place health workers such as nurses at risk, the demands for care by nurses in these areas are much greater than in countries with lower prevalence rates. Global Movement of Nurses Developed countries are the primary destinations of most migrant nurses. Australia, the UK, and the US are the countries receiving the largest number of migrant nurses. Australia received 11,757 foreign nurses between the years of 1995 and 2000 (Hawthorne, 2001). Between 1995 and 2000, the U.S. Immigration and Naturalization Service (INS) reported more than 10,000 foreign nurses were admitted to the US under H-1A visas (Immigration and Naturalization Service, 2000). In the 4-year period between 1998 and 2002, the UK admitted 26,286 foreign nurses into the U.K. nurse registry (���Record overseas numbers join UK nurse register,��� 2002). Countries such as Denmark, Norway, and Sweden generally recruit from other Nordic countries (Nursing Workforce Profile 2002, 2002). Saudi Arabians have long depended on foreign nurses, with as many as 40 countries represented in the nurse workforce. Estimates of foreign nurses there range from 83% to 95% and include nurses in significant numbers from Australia, Canada, Indonesia, and the US (Aboul-Enein, 2002 Marrone, 1999). Although Japan has had a homogeneous nurse workforce, the Japanese ruling Liberal Democratic Party recently approved a proposal to ease visa and residency regulations to include nurses (Lamar, 2002). Under current regulations, working visas in Japan are restricted to people deemed to have expertise in academic fields, technology, and journalism. The shift in policy is partially related to Japanese estimates that nearly 1 in 5 of its 120 million people are over 65 years of age, and the percentage is rapidly increasing (Population Aging, 2002). The Table shows the major receiving and donor countries. Major donor countries include Australia, India, Philippines, South Africa, and UK. The primary receiving countries are Australia, Canada, Ireland, UK, and US. Table. Major Donor and Receiving Countries of Migrating Nurses Receiving Australia Canada Ireland UK USA countries Donor China Ireland Australia Australia Canada countries Germany Philippines Philippines Canada Hong Kong Hong Kong UK UK Finland Japan India South Africa Germany India Ireland Ghana Mexico Malaysia Ireland Nigeria New Zealand India Philippines Philippines Kenya Puerto Rico South Africa New Zealand South Korea Sri Lanka Nigeria UK UK Pakistan Vietnam Philippines South Africa Sweden USA West Indies Zambia Zimbabwe