Researchers argue that a failure to quantify both the number of and reasons for nurses emigrating means medical manpower is not being adequately planned, which could cause states problems, as a cohort of older nurses is about to retire
Instituto de Higiene e Medicina Tropical,
Universidade Nova de Lisboa, Lisbon, Portugal
Queen Margaret University, Edinburgh, Scotland
The authors are grateful to Claudia Maier and to Willy Palm for their support
There is no single source compiling validated, up-to-date and comparable quantitative information on the supply of nurses in the EU. There is only fragmentary information on the demographic structure (sex, age) of the profession. Furthermore, information on migratory flows, a phenomenon of interest to policy-makers and managers, is at best, patchy. There is also a related issue which is that there is no clear accepted EU-wide definition of ‘nurse’.
The Health For All (HFA) data show various trends. In Portugal, the number of nurses rose by 26.5% between 1997 and 2005, an increase to which migration flows from Spain and to a lesser extent from Portuguese-speaking African countries contributed.[1,2] A similar increase is observed in the UK, also partly explained by the entry of nurses from abroad, mainly India, the Philippines and the Caribbean.
A difference appears to exist between the 15 members of the EU before 2004, and the 12 that joined later (Figure 1). Between 1997 and 2006, density in post-2004 accession countries declined, particularly after 2001, and increased in the 15 other.
It seems unlikely that the reduction in the post-2004 countries can be due only, or indeed mainly to migration facilitated by accession, as the observed decrease started before their entry. Possible interpretations include that health care reforms in specific countries may have contributed to reducing the supply, that emigration was already taking place, and that there were losses to retirement and other attrition factors, such as nurses moving into other jobs, not compensated by an equivalent production of new graduates.
The health workforce, in general, has a larger proportion of workers aged 45 and above. Recent data from the NHS Scotland Information Service (2008) show that 60.9% of the active nurse population is between 40 and 60 years of age, and only 12.5% are under 30. The trend observed in Scotland is present in several European countries. In Iceland and Denmark, the nurse average age is 44 and 43.8 respectively. There are exceptions, like, Romania, where 67% of nurses are under 45 years of age.
Migratory flows across the EU
There is a major lack of comprehensive regional data on migratory flows of health workers, including nurses, in the EU. The OECD reported in 2008 that, in the first part of the present decade, the foreign-born labour workforce, including nurses, grew in Southern European countries (Italy, Spain, Greece and Portugal), as well as in the UK, Ireland and Finland.
In Austria, Belgium and France, Luxembourg and Germany, the overall number of foreign-born health workers is important, but it has either stagnated or declined. In 2006, in Ireland, 57% of the new nurses who registered with the Irish Nursing Board were trained outside Ireland, of whom one-fifth came from the European Union. In 1986, 50% of nurses trained that year did not enter the register and presumably emigrated.
A 2008 OECD report on health worker migration compiled country-specific studies, which used diverse methodologies and data sources. Although not homogenous, these data allow comparing countries with a high intake of foreign nurses, such as Ireland and the UK, with those with a lower ratio of foreigners in the nursing workforce (Table 1).
In 2000, the UK (22,601), the Czech Republic (9,628), Sweden (6,400), and Austria (4,018), were the most important EU destination countries for nurses. The UK is traditionally the largest recruiter of international nurses (from whatever source country) in Europe, and also experienced a greater inflow of doctors and nurses in 2004, in part because it was, together with Sweden and Ireland, one of the three countries not to impose restrictions on labour migrants from the new European accession countries.
Why can the supply of nurses diminish?
Nurse outflows are mostly caused by three sets of processes: normal retirement, which can be measured and planned, attrition, which refers to the exit of nurses before retirement, and emigration. Monitoring the flow of nurses by the OECD in 2000 revealed that an estimated 58,000 nurses moved from one EU country. Ireland (14,445), France (4,460), the UK (4,392) were the countries exporting most nurses across Europe for the year of reference. This has probably changed after the accession of 12 more countries, but updated data are not yet available.
Emigrants can be accounted for when they appear in the statistics of the country where they emigrated. For instance, in Hungary, 577 nurses sought verification between 2004 and 2007 from the local regulatory body to work abroad, 80% of them under 40 years of age. In Romania, approximately 5% of the nursing workforce requested verification between January 2007 and December 2008. Again, this is interesting information, but it does not inform on whether the nurse emigrated or to which country.
The flows of nurses across European countries are not unidirectional. In the UK, 8.3% of newly registered nurses were foreign trained in 2001; on the other hand, it was estimated that between 0.9 and 1.4% of British nurses left the country during the same year. In Ireland, 3,000 nurses were recruited from abroad in a one-year period (2004-05), while in the same period 1,800 nurses left the Irish Health Service to work in the UK, Australia and Canada. Ireland is currently a net importer of nurses, mostly from Asia, South Africa and the US. This may now be reversed, given the new economic conditions. In 2001 in Norway, which has an agreement with the other Scandinavian countries on free movement of nurses, 228 foreign nurses were recruited from abroad that year and 54 nurses left.[9,11]
There seems to be general consensus from the OECD and in the literature that the level of income and wage differentials is the single most important determinant of nurse migration across Europe.[5,12] Since the EU Directive on mobility removes legal obstacles to migrating, these market factors can be expected to exercise a significant influence.
Information about salaries shows important differentials among EU countries, and between them and the US, the most important potential recruiter of nurses. A shortage of 800,000 full-time equivalent (more than one million individuals) nurses is predicted by 2020, if no significant increase of domestic production takes place.13 In 2005, UK nurses’ median salary was 70% of what they can expect to earn in the US. Nurses from Portugal earned a little less than 70% of what their UK colleagues earned, those from Poland and from the Czech Republic, respectively 50% and 40% (Table 2).
At the lower end of the scale, nurses from Lithuania and Romania earned 24% of the UK figure. Nurses in Hungary earned 43% of what they could earn in neighbouring Austria. However, the literature also seems to point out that there is much more to working conditions than nominal wages, as tax deductions and country-specific cost of living may erode apparently more favourable wages.
A valuable asset
The limited data available shows that north
European countries tend to have a higher nurse density. Since 1997, nurse density appeared to have increased in the pre-2004 EU member states, and to have decreased in the new accession countries.
The European nursing workforce is predominantly female, and on average older than other professions; this is likely to exacerbate shortages in the near future, as the cohort who approaches retirement age is bigger than the one that follows, and recruitment of new students is more competitive than ever. Training output in Europe appears to have been increasing steadily until recently, but it may have reached a ceiling. In relation to nurse migration, not surprisingly higher-income countries have attracted migrant nurses, and lower-income ones have been a stimulus for emigration.
In view of its critical role in the delivery of health services, the nursing workforce deserves to be treated as a valuable asset and to be managed appropriately. In the EU, most countries have an ad hoc management approach (responding to crisis), not connected to a comprehensive approach to health workforce planning and policy development. There is need for a mid- to long-term vision of what services will be needed and demanded, and of what type of workforce – nurses and others – will be required to deliver them. Addressing migration issues needs to be done in the context of such an approach.
If a country experiences nursing shortages, it should look at all its options before recruiting abroad: incentives to improve retention, increase of domestic production, attraction of those who have left the market and would be prepared to return if they have access to retraining, to part-time contracts, and also reintegration policies/ mechanism for returning migrant health workers.
Adopting such an approach requires valid and up-to-date information on the current situation; one major issue, beyond the technical difficulties of collecting data, is that of the differences from country to country in the definition of what is a ‘nurse’. These differences are more than semantic; they also reflect major differences as regards the scope of practice of nursing personnel.
In Europe, there is as yet no process of harmonisation of the definition of tasks which a nurse can perform, although there are some factors which support a trend in that direction, such as the Bologna process, which aims at harmonising higher education in the EU, and the mobility of labour directive, which creates an incentive to make qualifications comparable. Another requirement is a strong policy analysis and development capacity – for instance, for mobilising the numerous stakeholders from the various sectors involved (finance, education, civil administration, health). This is lacking at present in most countries and building the database and the analytical capacity should be priority areas of investment. Beyond that, the most important ingredient in better policy-making is probably the commitment of the main political and professional actors to developing a workforce which will deliver services accessible to populations and responsive to their needs and expectations.
This paper draws from work for the European Observatory on Health Systems and Policies in support of a series of Policy Dialogues Funded by the European Commission and the European Parliament.
1. Alves da Silva A M, Pires Fernandez R M. Foreign nurses in Portugal. 2008; Ordem de Enfermeiros. Lisbon. International Affairs Office.
2. Ferrinho P, et al. Cahiers de sociologie et de démographie médicales 2007:47(3);377-91.
3. Gattuso C. Le numerus clausus sera porté à 6,200 étudiants en 2005. Le Quotidien du Médecins, 2004. www.quotimed.com/journal
4. McNair S, Flynn M. Managing an Ageing Workforce in Health and Social Care. 2006; Department for Work and Pensions, Leeds, UK.
5. Buchan J. Health Systems and Policy Analysis: How can the migration of health service professionals be managed so as to reduce any negative effects on supply? WHO European Ministries Conference on Health Systems, 25-27 June 2008.
6. Vladescu C et al. Romania: Health system review. 2008; Health Systems in Transition, European Observatory of Health Systems and Policies, Brussels, WHO.
7. Humphries N. International recruitment of Nurses – The Irish Case 2009; Royal College of Surgeons of Ireland.
8. Dumont JC, Zurn P. Immigrant Health Workers in OECD Countries in the Broader Context of Highly-skilled Migration. International Migration Outlook, Part III, OECD, Paris, 2007; pp.162-228.
9. Wiskow C. Health worker migration flows in Europe: Overview and case studies in selected CEE countries – Romania, Czech Republic, Serbia and Croatia. 2006; ILO Working papers No.245. Sectoral Activities Programme.
10. Eke E. The Hungarian Country Case Study on Migration of Health Professionals. 2008; WHO Regional Office for Europe. Human resources for Health Program.
11. Simoens S. Tackling nurses shortages in OECD countries. 2005; OECD Working Papers N.19. Directorate for employment, labour and social affairs.
12. Vujicic M, Zurn P. International Journal of Health Planning and Management 2006;21(2):101-15.
13. Brush BL et al. Health Affairs 2004;23,no.3:78-87.