© Borgis - New Medicine 4/2013, s. 140-146
*Attila Matiscsák
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
Summary
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.
Introduction
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.
Discussion
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 endangered | 146 | 31.35 |
| Is in a state of burnout | 53 | 22.15 |
| Requires healing | 2 | 0.42 |
| Total | 481 | 100 |
Fig. 2. Factor influencing choice of career (average values, N = 48).
Potential solutions
I.
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.
One of the challenges of the future consists in civil society organizations taking an active role in health promotion, given that citizens’ health literacy can largely be influenced and enhanced by measures outside the health care system. Disseminating healthy lifestyles and turning them into general social norms, among others through stimulating good health behaviour patterns would decrease the incidence of cardiovascular disease and cancer, representing a dominant percentage of diseases and fatalities, or to delay their occurrence, thus significantly increasing the number of years lived in health. Mental health promotion and the reduction of the rate of substance abuse must be considered priority tasks. Improving the health status of marginalized groups along with promoting health-conscious behaviour, possibly through volunteer programs, is a primordial task.
It would be useful to involve educational institutions in such programs, given that health behaviour is optimal if it is formed early in life, since then it becomes a generic pattern that does not require special attention to be paid. In order to improve the health status of the population, it would be advisable to establish a citizens’ health program. Local governments or the local health institutions could coordinate the program, potentially uniting a variety of NGOs and social organizations and institutions, promoting partnership among them, exploring and utilizing community resources.
Cross-border cooperation is an opportunity to reduce disadvantages in the border regions and improve the living conditions of the population. There is an administrative county in Hungary which shares a border with the Slovak Republic on more than a hundred kilometres. Harmonizing health care in the border areas would be an important progressive step.
The above considerations are intended to draw attention to the prevention process, not without reason. Maintaining the basic health care system is far more expensive and difficult than launching prevention and health promotion programs and connecting them with other social sub-systems, as in this case actors of several sectors will be involved in development – including private, non-profit and community programs.
In the coming years, nursing will unavoidably face new challenges in connection with the elderly as well as patients suffering increasingly frequent chronic and mental diseases. Prevention, rehabilitation, and health promotion will play an increasingly crucial role in these circumstances. With the increase in age, the number of people in need of nursing can be expected to rise as well. There will be more demand for home and community nursing due to a reduction in hospital inpatient capacities (9).
The institutional systems of care are not sufficiently prepared to meet this increased demand. This is confirmed by the 2009 EurHOMAP report underlining the need for the development of home nursing care (10). Instead of uniform institutional care, there is growing demand for care and nursing tailored to the individual and centred on the family. Moreover, it is reasonable to expect social impact in family composition and health care. More and more people will require nursing care, which on the one hand will increases the demand for nurses, while on the other hand creates opportunities for Hungarian and foreign private capital to invest in establishing institutions providing health care in Hungary (9).
The process will not only be observed in Hungary, but it is already present in Western European countries, which is one of the most important factors behind the migration of Hungarian nurses – especially through the channels that do not require professional registration. Investment into the social and health care systems should be brought to Hungary, to be developed into a aprticular sector of the national economy alongside health tourism.
II.
International studies have explored why students fail to complete their studies and also why they choose not to pursue a career in nursing upon graduation. Significant differences by researchers and by countries were recorded in the actual drop-out rates. Factors given for student attrition included a perceived lack of competence, a perceived lack of support by mentors, teachers and nursing staff, stress, the lack of career advancement, as well as social and gender issues of the work environment. Positive reinforcement by mentors, staff and patients significantly contributed to long-term career commitment. Ongoing support by the educational institution was considered a strong force of retention, contributing to completing the studies and to choosing nursing as a career.
The educational institutions where professionals are trained might cushion the intention to migrate, given that a significant portion of the students prefer working abroad already at the time they begin their studies.
Based on previous surveys, professional support provided by the university seems to be the strongest predictor of graduating consequently remaining in the profession (5).
Being satisfied by the clinical experiences and the clinical staff positively influenced the decision to graduate and subsequently to get employment.
Pressure to leave nursing exerted by family members working in the health care profession, family and peers negatively influenced the decision to acquire a degree. Having family members working in health care reduces the likelihood of graduation, compared with those who had no such family members. The higher the pressure on the student from family and peer groups to quit nursing training, the less likely it is that these students complete their studies. The more prior nursing experience students had (number of years worked in the profession), the less they seemed to be willing to pursue a career in nursing upon graduation. Interestingly, those students who had considered the possibility of working abroad have shown a greater willingness of pursuing nursing careers after obtaining their degrees.
The problem of burnout in the nursing profession also deserves serious consideration as early as in the phase of academic training. Prevention of burnout can be initiated already during the training through the development of the professional personality, through better delineating the boundaries of the professional role, and through better illuminating the work requirements, specifically, the emotional requirements inherent in the health profession. Support for further professional training, lifelong learning, adult education, and autonomous study is crucial since higher qualifications correlate with better personal efficiency and thus lower burnout levels.
Statistical data regarding applications to higher education along with the commitment by the state towards education in health care indicates that the health care profession may still be popular among the young. This phenomenon, however, can be deceptive, as signalled above, since a significant portion of prospective students apply to the institutions of higher education with the intention of working abroad in the first place.
Professional and psychological career guidance for the students is clearly a determining factor as towhetherthey will remain in the profession, or in the country, after graduation. Thequestion thus iswhether they can be offered training that develops their skills as well as their professionalknowledge. Endowed withthe abilitytoconstruct their own careers, develop their personalities as well as starting their own businesses, studentscan consciouslyplan their professional lives. Strengthening their professional commitments and their network of connections at the start of their careers may mitigate the causes behind the motivation to leave the country.
Fig. 3. Planning to work abroad (N = 48) (5).
Fig. 4. Are there health care professionals in the family? (N = 48) (5).
III.
Our research on the sociology of youth has shown that young people are fundamentally attracted to freedom, and thus to autonomy as well. Nevertheless, independently of the role played by the pursuit of autonomy in their life plans or their value orientation, the vast majority of young adults expect that they will be working as employees 10 years from now (11).
The proportion of those who want to start their own business is very low. But the most important assumption corroborated by the research was that they would on the whole not be willing to undertake greater uncertainty in exchange for a greater revenue, and would prefer working for a lower income.
The above considerations are also significant as they shed light on how dominant an issue security is in situations when decisions pertaining to migration must be made.
Our investigation on networks revealed that many acquaintances in qualified nurses’ relationship networks are already working abroad. The basic hypothesis is that an increase in the number of professionals emigrating will strengthen the integrity of the web of connections and reinforce the dominant role of these relationships, while at the same time the quality of the connections often shows no more significant correlation than their professional embeddedness.
For if the network of personal and professional relationships of young qualified nurses is strengthened and stabilized, they can rapidly transform their relational capital into social capital. Social capital will then give them the security presently lacking that is needed in order to strengthen mobility on the labour market.
The solution of course is not to weaken the power of social networks but, on the contrary, to channel key information and professional benefits into the communication flow of these networks in ways that will increase the credibility of domestic programs. Credibility in a network, on the other hand, is necessarily a function of the opinion and experience of a key member or node of the network.
Conclusions
The above reflections sought to highlight two key factors. One of these concerns the global threat of nursing shortage, which can result in extreme conditions. Albeit with differences among countries and regions, this labour shortage will definitely affect the migration processes. It follows that we need to be able to maintain the human resource capacities at the national level. The most important prerequisite is to begin to take account of the scale and the gravity of the problem. The second prerequisite is to look for solutions that are workable even at a time of recession, in both the private and civil sectors, and to observe how the people impacted respond to the crises of particular systems and allow the solutions to follow their course and work accordingly.
We should consider the young professionals, the young adults about to choose their careers as a reserve of opportunities that is waiting for exploitation. Let us achieve a social change of direction so that the generation gap does not deepen any further. In the sectors with a great emphasis on authority, the generation gap and stress levels are automatically increased. If the situation is not rectified, young people will find a safe haven in the financial and psychological security provided by a remote country much more than in the fortress of authority, erected by the older generation, without the consolation of social prestige.
Novices and professionals on the brink of burnout equally need novel patterns and fresh examples, innovative workshops and new opinion leaders who can share their vision, offer security and a decent way of life to the new generation.
Piśmiennictwo
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