Caribbean nurses migrating to the UK: a gender-focused literature review

Intersectionality in nursing research: A systematic review

AIM

This systematic literature review aimed to identify, appraise and synthesize available research studies that apply intersectionality in nursing research.

DESIGN

Systematic review.

DATA SOURCES

Empirical and theoretical nursing studies published before February 2022 were identified from the PubMed and CINAHL databases. Studies were eligible for inclusion if they substantially covered the topics of intersectionality and nursing, had undergone peer-review, and were written in English.

REVIEW METHODS

The PRISMA 2020 statement for reporting systematic reviews was used to report findings. The Joanna Briggs Institute Critical Appraisal tools were used to assess the quality of the included research studies.

RESULTS

Out of 331 identified studies, 60 studies were substantially about nursing and intersectionality, and were included in the review. There are a myriad of ways that the concept of intersectionality has been adopted in nursing research. Furthermore, there was great heterogeneity in the definition and application of the concept of intersectionality, and only a few studies were empirical.

CONCLUSION

There is a need for robust and clear framing of how the concept of intersectionality is defined and understood in nursing research. There is also a need for more empirical research effectively adopting the concept of intersectionality to enhance our understanding of how health inequities operate within the field of nursing.

NO PATIENT OR PUBLIC CONTRIBUTION

No patients, service users, caregivers or members of the public were involved in this work.

Exploring migration intention among registered pharmacists in Kerala: a mixed-methods study

OBJECTIVES

This study investigated the intention to migrate among pharmacists in Kerala and explored the factors driving pharmacist migration in Kerala.

METHODS

A sequential mixed-methods study was carried out to explore the intention to migrate among pharmacists in Kerala, India. A survey of 256 registered pharmacists and in-depth interviews with 15 pharmacists having high migration intentions were undertaken. Quantitative data were analysed employing univariate approaches and binary logistic regression. Qualitative data were analysed employing thematic analysis.

KEY FINDINGS

About 44.5% (n = 114) of pharmacists expressed a high intention to migrate. Younger age of up to 30 years (AOR = 8.31, 95% CI = 2.24-30.82), more opportunities abroad (AOR = 4.28, 95% CI = 1.87-9.80), better salaries (AOR = 2.48, 95% CI = 1.04-5.95) and a general negative outlook towards a pharmacy career in Kerala (AOR = 2.83, 95% CI = 1.22-6.56) predicted a high level of intention to migrate among pharmacists. Lower incomes, working conditions, respect and recognition in the society, professional conflict and social connections were observed to be major push factors influencing pharmacists' migration intentions.

CONCLUSIONS

Just under half of the registered pharmacists in Kerala has a high intention to migrate abroad. Economic factors, workplace factors, lack of opportunities, social status and so on, were influencers of the intention to migrate among pharmacists. Ensuring implementation of equitable wage policies, preventing unlicensed pharmacy practice, improving societal awareness and providing clear job roles for pharmacists with PharmD and MPharm degrees are needed.

Palliative care integration: a critical review of nurse migration effect in Jamaica

BACKGROUND

Provision of palliative care to individuals with late-stage serious illnesses is critical to reduce suffering. Palliative care is slowly gaining momentum in Jamaica but requires a highly skilled workforce, including nurses. Out-migration of nurses to wealthier countries negatively impacts the delivery of health care services and may impede palliative care capacity-building. This critical review aimed to explore the evidence pertaining to the nurse migration effect on the integration of palliative care services in Jamaica and to formulate hypotheses about potential mitigating strategies.

METHODS

A comprehensive search in the PubMed, CINAHL, and ProQuest PAIS databases aimed to identify articles pertinent to nurse migration in the Caribbean context. Grant and Booth's methodologic framework for critical reviews was used to evaluate the literature. This methodology uses a narrative, chronologic synthesis and was guided by the World Health Organization (WHO) Public Health Model and the Model of Sustainability in Global Nursing.

RESULTS

Data from 14 articles were extracted and mapped. Poorer patient outcomes were in part attributed to the out-migration of the most skilled nurses. 'Push-factors' such as aggressive recruitment by wealthier countries, lack of continuing educational opportunities, disparate wages, and a lack of professional autonomy and respect were clear contributors. Gender inequalities negatively impacted females and children left behind. Poor working conditions were not necessarily a primary reason for nurse migration. Four main themes were identified across articles: (a) globalization creating opportunities for migration, (b) recruitment of skilled professionals from CARICOM by high income countries, (c) imbalance and inequities resulting from migration, and (d) mitigation strategies. Thirteen articles suggested education, partnerships, policy, and incentives as mitigation strategies. Those strategies directly align with the WHO Public Health Model drivers to palliative care integration.

CONCLUSION

Emerged evidence supports that nurse migration is an ongoing phenomenon that strains health systems in Caribbean Community and Common Market (CARICOM) countries, with Jamaica being deeply impacted. This critical review demonstrates the importance of strategically addressing nurse migration as part of palliative care integration efforts in Jamaica. Future studies should include targeted migration mitigation interventions and should be guided by the three working hypotheses derived from this review.

Hiding in plain sight: the absence of consideration of the gendered dimensions in 'source' country perspectives on health worker migration

BACKGROUND

Gender roles and relations affect both the drivers and experiences of health worker migration, yet policy responses rarely consider these gender dimensions. This lack of explicit attention from source country perspectives can lead to inadequate policy responses.

METHODS

A Canadian-led research team partnered with co-investigators in the Philippines, South Africa, and India to examine the causes, consequences and policy responses to the international migration of health workers from these 'source' countries. Multiple-methods combined an initial documentary analysis, interviews and surveys with health workers and country-based stakeholders. We undertook an explicit gender-based analysis highlighting the gender-related influences and implications that emerged from the published literature and policy documents from the decade 2005 to 2015; in-depth interviews with 117 stakeholders; and surveys conducted with 3580 health workers.

RESULTS

The documentary analysis of health worker emigration from South Africa, India and the Philippines reveal that gender can mediate access to and participation in health worker training, employment, and ultimately migration. Our analysis of survey data from nurses, physicians and other health workers in South Africa, India and the Philippines and interviews with policy stakeholders, however, reveals a curious absence of how gender might mediate health worker migration. Stereotypical views were evident amongst stakeholders; for example, in South Africa female health workers were described as "preferred" for "innate" personal characteristics and cultural reasons, and in India men are directed away from nursing roles particularly because they are considered only for women. The finding that inadequate remuneration was as a key migration driver amongst survey respondents in India and the Philippines, where nurses predominated in our sample, was not necessarily linked to underlying gender-based pay inequity. The documentary data suggest that migration may improve social status of female nurses, but it may also expose them to deskilling, as a result of the intersecting racism and sexism experienced in destination countries. Regardless of these underlying influences in migration decision-making, gender is rarely considered either as an important contextual influence or analytic category in the policy responses.

CONCLUSION

An explicit gender-based analysis of health worker emigration, which may help to emphasize important equity considerations, could offer useful insights for the health and social policy responses adopted by source countries.

A mixed-methods study of health worker migration from Jamaica

BACKGROUND

This study sought to better understand the drivers of migration, its consequences, and the various strategies countries have employed to mitigate its negative impacts. The study was conducted in four countries-Jamaica, India, the Philippines, and South Africa-that have historically been 'sources' of health workers migrating to other countries. The aim of this paper is to present the findings from the Jamaica portion of the study.

METHODS

Data were collected using surveys of Jamaica's generalist and specialist physicians, nurses, midwives, and dental auxiliaries, as well as structured interviews with key informants representing government ministries, professional associations, regional health authorities, healthcare facilities, and educational institutions. Quantitative data were analyzed using descriptive statistics and regression models. Qualitative data were analyzed thematically. Multiple stakeholder engagement workshops were held across Jamaica to share and validate the study findings and discuss implications for the country.

RESULTS

Migration of health workers from Jamaica continues to be prevalent. Its causes are numerous, long-standing, and systemic, and are largely based around differences in living and working conditions between Jamaica and 'destination' countries. There is minimal formal tracking of health worker migration from Jamaica, making scientific analysis of its consequences difficult. Although there is evidence of numerous national and international efforts to manage and mitigate the negative impacts of migration, there is little evidence of the implementation or effectiveness of such efforts. Potential additional strategies for better managing the migration of Jamaica's health workers include the use of information systems to formally monitor migration, updating the national cadre system for employment of health personnel, ensuring existing personnel management policies, such as bonding, are both clearly understood and equitably enforced, and providing greater formal and informal recognition of health personnel.

CONCLUSION

Although historically common, migration of Jamaica's health workers is poorly monitored and understood. Improved management of the migration of Jamaica's health workers requires collaboration from stakeholders across multiple sectors. Indeed, participating stakeholders identified a wide range of potential strategies to better manage migration of Jamaica's health workers, the implementation and testing of which will have potential benefits to Jamaica as well as other 'source' countries.

Does migration 'pay off' for foreign-born migrant health workers? An exploratory analysis using the global WageIndicator dataset

BACKGROUND

This study used the global WageIndicator web survey to answer the following research questions: (RQ1) What are the migration patterns of health workers? (RQ2) What are the personal and occupational drivers of migration? (RQ3) Are foreign-born migrant health workers discriminated against in their destination countries?

METHODS

Of the unweighted data collected in 2006-2014 from health workers aged 15-64 in paid employment, 7.9 % were on migrants (N = 44,394; 36 countries). To answer RQ1, binary logistic regression models were applied to the full sample. To answer RQ2, binary logistic regression was used to compare data on migrants with that on native respondents from the same source countries, a condition met by only four African countries (N = 890) and five Latin American countries (N = 6356). To answer RQ3, a multilevel analysis was applied to the full sample to take into account the nested structure of the data (N = 33,765 individual observations nested within 31 countries).

RESULTS

RQ1: 57 % migrated to a country where the same language is spoken, 33 % migrated to neighbouring countries and 21 % migrated to former colonizing countries. Women and nurses migrated to neighbouring countries, nurses and older and highly educated workers to former colonizing countries and highly educated health workers and medical doctors to countries that have a language match. RQ2: In the African countries, nurses more often out-migrated compared to other health workers; in the Latin American countries, this is the case for doctors. Out-migrated health workers earn more and work fewer hours than comparable workers in source countries, but only Latin American health workers reported a higher level of life satisfaction. RQ3: We did not detect discrimination against migrants with respect to wages and occupational status. However, there seems to be a small wage premium for the group of migrants in other healthcare occupations. Except doctors, migrant health workers reported a lower level of life satisfaction.

CONCLUSIONS

Migration generally seems to 'pay off' in terms of work and labour conditions, although accrued benefits are not equal for all cadres, regions and routes. Because the WageIndicator survey is a voluntary survey, these findings are exploratory rather than representative.

10 Best resources on… intersectionality with an emphasis on low- and middle-income countries

Intersectionality has emerged as an important framework for understanding and responding to health inequities by making visible the fluid and interconnected structures of power that create them. It promotes an understanding of the dynamic nature of the privileges and disadvantages that permeate health systems and affect health. It considers the interaction of different social stratifiers (e.g. ‘race’/ethnicity, indigeneity, gender, class, sexuality, geography, age, disability/ability, migration status, religion) and the power structures that underpin them at multiple levels. In doing so, it is a departure from previous health inequalities research that looked at these forms of social stratification in isolation from one another or in an additive manner. Despite its potential use and long history in other disciplines, intersectionality is uncommonly used in health systems research in low- and middle-income countries (LMICs). To orient readers to intersectionality theory and research, we first define intersectionality and describe its role in public health, and then we review resources on intersectionality. We found that applications in public health mostly increased after 2009, with only 14 out of 86 articles focused on LMICs. To arrive at 10 best resources, we selected articles based on the proportion of the article that was devoted to intersectionality, the strength of the intersectionality analysis, and its relevance to LMICs. The first four resources explain intersectionality as a methodology. The subsequent six articles apply intersectionality to research in LMIC with quantitative and qualitative analysis. We provide examples from India, Swaziland, Uganda and Mexico. Topics for the studies range from HIV, violence and sexual abuse to immunization and the use of health entitlements. Through these 10 resources, we hope to spark interest and open a needed conversation on the importance and use of intersectional analysis in LMICs as part of understanding people-centred health systems.

Cultural immersion through international experiences among Japanese nurses: Present status, future intentions, and perceived barriers

AIM

Given limited exposure to various ethnicities, languages, and cultures, providing health care to an increasing foreign population in Japan will likely be challenging for Japanese nurses. This study aimed to examine past and intended future international experiences of Japanese nurses to assess their cultural immersion level.

METHODS

A cross-sectional electronic survey was conducted among 2029 nurses in 2010. Participants were categorized by travel purpose, and the frequency of non-holiday travel was analyzed. To examine participants' desire for and perceived feasibility of future non-holiday international experiences by background characteristics, logistic regression analyses were performed.

RESULTS

Of 1039 participants, 10.1% had past non-holiday international experiences, with 80% having traveled to high-income, English-speaking countries. The median value for travel frequency was once, and the median duration of travel was less than 1 month. The most common purpose of travel was participation in short-term programs (e.g. professional training, language study). Fifty-one percent of female nurses reported a desire for future non-holiday international experiences. Of these, 37.2% considered such experiences feasible. Age of the youngest child, having nursing specialization, English proficiency, and past international experience were significant predictors for feasibility.

CONCLUSION

Japanese nurses with foreign experience were considered valuable human resources for culturally appropriate care. Efforts should be made to integrate them into the Japanese healthcare setting. The present study revealed room for improvement in foreign language proficiency and cross-cultural training with a focus on non-English-speaking and developing countries. A supportive workplace environment should be created that allows nurses to pursue the international experiences they desire.

Estimating nurse migration from the Bahamas between 1994 and 2005: an exploratory descriptive study using a social network identification methodology

The purpose of this study was to collect primary data on the migration patterns of Bahamian nurses who had registered as nurses during the period 1994-2005. We used an established social network identification method developed by Delanyo Dovlo to determine whether (and to where) Bahamian nurses had migrated. We reviewed nursing registrants' records from the Nursing Council of the Commonwealth of the Bahamas. We telephoned two nurses per cohort of registration and graduation year, asking the interviewee to identify the current location of colleagues registered in their same cohort. Between 1994 and 2005, a total of 18 out of 282 nurses were either confirmed or probably migrated (6%). Ninety-six per cent of those nurses registered during the study time frame were located during the exercise, partially because of an improvement on the Dovlo method--calling a nurse leader who could locate nursing classmates and colleagues beyond his or her own year of graduation. Nurse migration in the Bahamas appears lower than in surrounding countries, posing a research opportunity to investigate the causes for this positive deviation. Future studies employing this method should include interviews of nurse leaders who can confirm the location of a much wider range of people than can the average participant.