© Borgis - New Medicine 4/2013, s. 140-146
Potential New Directions for Human Resources Development in the Nursing Profession In Light of International Migration Processes
Department of Carrier, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
Head of the Faculty: prof. Zoltán Z. Nagy, MD, PhD
There are not many countries globally that can reasonably hope to avoid facing the problem of labour shortage in the nursing profession. The motivating factors for migration and the conditions characterizing the international labour market amplify various processes acting simultaneously in parallel. The survival strategies and the solutions employed by the health care systems in a state of crisis currently do not provide system-wide responses to the labour shortages suddenly heightened to critical levels. Therefore, it has become necessary to articulate and explore the opportunities that could influence some aspects of the migration process, even if they are not sufficient to change the current state of the health system at a coherent structural level. We need to be able to provide answers to how the emigration of health experts might be mitigated in the current socio-economic context.
There are not many countries globally that can reasonably hope to avoid facing the problem of labour shortage in the nursing profession. Countries with a sufficient number of health professionals, and specifically, nurses, are in a better position to confront the crisis emerging in the form of increased shortages and limited human resources.
The scarcity of human resources in health care is a global problem, as that there are less than 2.5 health care professionals for 1000 citizens, a figure estimated as necessary to provide basic health care provisions. In fact, the data show further decline in numbers (1).
The impact of the global crisis is increased by the demand for nurses in developed countries and the fact that these countries are not capable of luring former professionals back into their jobs who either retired or left their nursing careers behind because they were not satisfied with them. The past decade saw an enormous gap in the supply of nursing professionals. While this gap mostly impacts developing countries, developed countries also face a growing shortage of qualified professionals.
Council Regulations on the freedom of movement for workers (1612/68/EEC) and the mutual recognition of professional qualifications will enable nurses, among others, to easily migrate within Europe and to get employment in any country they choose. These principles are important tools for the mobility of nurses in Europe, as the dramatic changes in the average age of nurses require massive replacements of the nursing workforce (2).
This increased demand in Europe occurs when the United States also actively strives to recruit more nurses from abroad to fill its vacant nursing positions. Considering the capacity of nursing education in Western Europe, and taking into account the rate of replacement of this workforce, part of the solution will have to consist in luring nurses from the Eastern areas of the continent or to open up more channels for migration within the European Community.
Aim of the study
Based on these considerations it is reasonable to predict that the heightened dynamics of the migration of nurses experienced today in Hungary and other Eastern European countries may be only the beginning. The motivating factors for migration and the conditions characterizing the international labour market amplify various processes acting simultaneously in parallel. The survival strategies and the solutions employed by the health care systems in a state of crisis currently do not provide system-wide responses to the labour shortages suddenly heightened to critical levels as the first steps of the fiscal restrictions policies employed by the states in recession primarily focus on spending cuts to reduce the budget deficit.
Thus nowadays the public is primarily interested in the financial policies employed, mostly concerning the issue of labour wages in what is essentially a labour intensive sector. Headcount problems in health care as well as the supply in human capital at the international level are in the focus of research internationally. By 2020, the shortage in nurses may extend to almost 1/3 of the total demand. According to a position of the International Council of Nurses dating back to 2003, „local” conditions should be improved, i.e. increasing social recognition, career opportunities in the field and proper human resource planning (3).
Local conditions have not unfortunately been remedied in the past 10 years. One cannot see the systematic structural reforms that would make one think that the reforms in economic policy are just about to reach and strengthen the health sector. Therefore, it has become necessary to articulate and explore the opportunities that could influence some aspects of the migration process, even if they are not sufficient to change the current state of the health system at a coherent structural level. We need to be able to provide answers to how the emigration of health experts might be mitigated in the current socio-economic context.
Hungary’s health indicators are among the worst in Europe. The average life expectancy at birth has increased somewhat since the regime change; nevertheless it is among the worst in Europe, with 5.1 years below the EU average. Population loss is rapid; public health conditions are despicable, mainly due to traditionally unhealthy Hungarian food, extraordinarily levels of alcohol consumption and smoking. In 2010, 31.4 per cent of the population aged 15 and over smoked regularly. This figure is lower almost everywhere else in Europe (fig. 1) (4).
Fig. 1. Life expectancy at birth, 2009 (or nearest year available), and years gained since 1960.
Source: Health at a Glance 2009, OECD.
Neither do demographic data paint a brighter picture. Hungarian society is ageing. The population pyramid is widening towards the top, which means that the number of dependents will soon exceed the active population headcount to a critical limit. The bulk of citizens born between 1950 and 1956 will retire in the period 2013-2020. According to economic estimates, there will be years when the number of people starting their pensions will be double the average figure, reaching about 350 to 400 thousand people, presenting an enormous burden to system that already shows worrying signs of instability.
Ageing of course does not only impact society in general, but also those working in the health care professions, which raises the problems of securing the next generation of professionals. Not enough young professionals enter the system to compensate for those who leave it.
Though the career choice motivations strongly predestinate young professionals to keep on working in their chosen careers according to our results, the rate of changing careers has increased, while commitments to the profession do not decrease the intention to migrate (5).
In addition, health care professionals who consider their job to be their true calling are the most threatened by the risk of burnout. Those who believe that their interaction with clients and patients should be guided by a professional code and a certain work ethic are more vulnerable.
In the short and medium run, the demographic situation of the country will bring on increased demands in the provision of nursing services, while the demographic and health status of health care professionals will lead to decreasing performance. The social consequences thereof are frightening.
It is generally held that most problems are caused by the shortcomings of the health care system. The deterioration of the health status of the population is, on the other hand, but a symptom of the lack of prevention and all-round health promotion programs. The correlation of per capita purchasing power adjusted GDP and average life expectancy at birth shows that the health status of the Hungarian population is below the level which could be expected based on the socio-economic situation in the country. Life expectancy at birth of the Hungary’s population falls behind by about 3 years compared to the values corresponding to purchasing power adjusted GDP, or the amounts spent on health life (6).
This can be accounted for by the fact that the population’s health status and life expectancy are impacted by socio-economic factors and lifestyle more than by the health care system.
If the system-wide reforms within the health sector fall through, we will not only have to face the possibility that the functioning of the health care system might reach critical levels already in the short run, but also the fact that the prevention tools of the health promotion approach will not be incorporated into the accompanying social subsystems. This will mean that the health care system will soon have to face further increasing numbers of patients parallel to declining headcounts in the health care professions.
When we examine the health status of the population, special attention must be paid to the health status of health care professionals themselves. Dealing with the issue of burnout among nurses cannot be postponed. Research data from the international literature prove that health care workers belong to a professional group characterized by high incidence of burnout (7, 8).
Table 1. Grade of intensity of burnout syndrome based on research carried out in 2005 (N = 481) (13).
|Grade of intensityof burnout syndrome||Numberof people||%|
|Is reasonably well||155||32.22|
|Some issues require attention||125||25.99|
|Is in a state of burnout||53||22.15|
Fig. 2. Factor influencing choice of career (average values, N = 48).
Wage increases are not the only measures that can be used to stop or slowed down migration. According to the 2011 country WHO report, doctors moving abroad highlighted a number of further factors almost as frequently as they mentioned the pay rate, such as working conditions, poor prospects of health care in Hungary, considerations related to their careers and the social prestige of their profession (4). These factors are almost exactly the same as our results regarding the motives for nurse migration (the target population examined in this case were domestic workers).
This demonstrates that an exclusive preference given to wage bargaining is a fundamentally flawed governmental attitude towards the health sector, since other programs fundamentally addressing the causes of migration detailed above may prove to be effective measures. Sabbaticals, flexible working hours, wide access to further professional training, providing recreational opportunities could all be instruments more economical and efficient than solely concentrating on wages.
If health care institutions try to solve the problem at the institutional level, in decentralized fashion, it seems reasonable to explore their hidden reserves in internal efficiency. As an example, one could mention further concentration in active inpatient care, as well as more efficient forms of care. One cannot ignore further opportunities to involve private capital, along with accelerating and streamlining the utilization of EU funds. There is potential to be exploited in developing patient journey management and rehabilitation, and in general, developing forms of care to replace hospital care.
The latter instances are perhaps the most important building blocks of decentralized, individual solutions. It is not only in the framework of a state-run public health program that one can conduct prevention, health promotion, or screening. The institutions of the health care system may be able to perform preventive, awareness raising and screening tasks on an ad hoc basis as well as individually. These programs may be particularly effective when merged with citizens’ and private initiatives.
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