the international migration of nurses in long-term care

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The International Migration ofNurses in Long-Term CareDonald L. Redfoot PhD a & Ari N. Houser BS aa AARP Public Policy Institute , Washington, DC,20049, USAPublished online: 11 Oct 2008.

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Journal of Aging & Social Policy, Vol. 20(2) 2008Available online at http://jasp.haworthpress.com

© 2008 by The Haworth Press. All rights reserved.doi:10.1080/08959420801977681 259

WASP0895-94201545-0821Journal of Aging & Social Policy, Vol. 20, No. 2, April 2008: pp. 1–17Journal of Aging & Social Policy

The International Migration of Nurses in Long-Term Care

International ViewJournal Of Aging & Social Policy Donald L. Redfoot, PhDAri N. Houser, BS

AARP Public Policy Institute, Washington, DC

ABSTRACT. This article describes five major factors that are affectingpatterns of international migration among nurses who work in long-termcare settings:

• Demographic drivers–The aging of the populations in developed coun-tries and the low to negative growth in the working-age population willincrease the demand for international workers to provide long-term careservices.

• Gender and race–A dual labor market of long-term care workers,increasingly made up of women of color, is becoming internationalizedby the employment of migrating nurses from developing countries.

• Credentialing–The process of credentialing skilled workers creates bar-riers to entry for migrating nurses and leads to “decredentialing” whereregistered nurses work as licensed practical nurses or aides.

• Colonial history and geography–The colonial histories of many Euro-pean countries and the United States have increased migration fromformer colonies in developing countries to former colonial powers.

• Worker recruitment–Efforts to limit the recruitment of health care work-ers from some developing countries have had little effect on migration,

Donald L. Redfoot (E-mail: [email protected]) is Strategic Policy Advisor;and Ari N. Houser (E-mail: [email protected]) is Policy Research Analyst; bothare at the AARP Public Policy Institute, 601 East Street NW, Washington, DC20049.

Address correspondence to Donald L. Redfoot and Ari N. Houser at the aboveaddress.

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260 JOURNAL OF AGING & SOCIAL POLICY

in part because much of the recruitment comes through informalchannels of family and friends.

KEYWORDS. International, long-term care, workforce, nursing

OVERVIEW

What if regions of the world were like the neighborhoods of a city?What would the world look like? I’d describe it like this: WesternEurope would be an assisted-living facility, with an aging popula-tion lavishly attended to by Turkish nurses.

–Thomas L. Friedman in The World Is Flat(Friedman, 2005, p. 316)

While Friedman’s observation was meant metaphorically, his ratherunflattering portrait of Western Europe reflects the demographic realitythat the rapid aging of developed countries has major implications forfuture long-term care needs and the demand for workers to provide theservices. Growing numbers of older people will mean growing demandfor long-term care services, but declining numbers of working-age peopleare creating a growing shortfall in workers available to provide the ser-vices in many developed countries. These pressures are major contribu-tors to the increasing demand for long-term care workers from developingcountries.

The overwhelming majority of the existing literature on the interna-tional migration of health care workers focuses on acute care, especiallyhospital workers. This article will examine the variations within the inter-national labor market for nurses, specifically the labor markets for nurses inlong-term care settings and how they differ from nurses in other settings.The article is primarily focused on nurses, by whom we mean registeredand licensed practical nurses, but we also include some information onparaprofessional direct-care workers. In general, growth in demand com-bined with a low supply of workers and the relatively low prestige of thework has led to disproportionate use of international workers in the long-term care sector. Much of the information cited in this article is from theUnited States because of the availability of data, though we include datafrom other developed countries where it is available. Issues that differen-tially affect the labor market for long-term care workers include:

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International View 261

• Demographic drivers of the labor market for long-term care workers• Gender, race, and the dual labor market for long-term care workers• Skill levels, education, and credentialing• Colonial histories, geography, and patterns of migration• The role of worker recruitment

Demographic Drivers of the Labor Market for Long-Term Care Workers

Most developed countries currently have favorable demographic charac-teristics with respect to meeting workforce demands. The “dependency ratio,”reported in numbers of persons aged 65 and older plus those aged 14 andyounger for every 100 persons 15–64, is at or near historic lows (Redfoot &Houser, 2005). Current worker shortages in long-term care are occurring inspite of these favorable demographics. These shortages are likely to increasein the future because of: (1) an aging population demanding more long-termcare services, and (2) a diminishing supply of workers (mostly women) to fillthe jobs associated with long-term care. For example, the working-age popu-lation in Western and Central Europe is projected to decrease by 19.5% by2050, while the older population will increase by as much as 50% (Holzmann &Muenz, 2004). United Nations Population Division projections indicate thatthe population age 65 and older in the United States will increase by 122%between 2005 and 2050, during which time the working age population willincrease by only 27% (Redfoot & Houser, 2005).

Increased numbers of older people are likely to create increaseddemand for long-term care services–and the workforce to provide them–over the next few decades. For example, the Federal Ministry of Healthand Social Security (2005) estimates that the number of persons requiringlong-term care in Germany will increase by 63.5% between 2002 and2030, from 1.89 million to 3.09 million. The U.S. Department of Healthand Human Services (2003) projects that the number of workers provid-ing long-term care services (including nurses, aides, and personal careworkers in institutional and home-based settings) will grow from 1.9 millionto 2.7 million, a 45% increase between 2000 and 2010. Projected needs forlong-term care workers range from 3.8 million to 4.6 million by 2050–a100 to 140% increase over 2000 levels.

Demographic pressures that have increased demand for long-term careservices and policy pressures to shorten hospital stays have createddisproportionate increases in the number of professional nurses providinglong-term care services in the United States. Table 1 indicates the

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disproportionate growth in the number of nurses in long-term care facili-ties when compared to hospitals, as well as the fact that the rate of growthamong foreign-born nurses has greatly outpaced the growth rate amongnative-born nurses in all settings. The combination of the high relativegrowth in demand for nursing services in the long-term care sector andthe higher growth rate of foreign-born nurses has contributed to the sub-stantial numbers of foreign-born nurses in long-term care settings. Indeed,the percentage of foreign-born nurses in long-term care settings rose from6% in 1980 to 16% in 2003 (Redfoot & Houser, 2005). In addition, abouta quarter of the “Other Health” category, where the growth in the numberof foreign-born nurses has been particularly strong, includes home healthnurses who often provide long-term care services.

Gender, Race, and the Dual Labor Market for Long-Term Care Workers

Gender issues permeate all aspects of long-term care, from unpaid fam-ily caregiving to international labor markets for skilled care. The fact thatcaregiving, paid and unpaid, is seen as “women’s work” suggests a “duallabor market” segmented by the interacting factors of gender, ethnicity,and class (Howe & Jackson, 2005). At all skill levels, increasing amountsof long-term care in many developed countries are provided by women ofcolor from other countries.

Low wages and poor working conditions for aides and care assistantsillustrate the dual labor markets for those employed in long-term care.Harris-Kojetin etal. (2004) note high turnover rates and vacancies among

TABLE 1. Percentage Growth in the Number of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) by Setting

and Nativity, 1990–2000

Total Growth Native-Born Growth

Foreign-Born Growth

RNs LPNs RNs LPNs RNs LPNs

All health care settings +20% +35% +16% +31% +56% +99%Hospitals +9% −15% +6% −19% +39% +23%Long-term care facilities +34% +92% +23% +84% +164% +237%Other health care settings +65% +156% +62% +149% +122% +334%

Source: U.S. Census data, 2000, AARP PPI analysis.

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direct caregivers in many countries, even those with relatively high unem-ployment rates. Poor wages and working conditions attract only marginalor entry-level workers. Increased employment opportunities for womenwho might otherwise be in the traditional pool of long-term care workerscompound the shortage, creating openings for immigrants who are willingto do work that native-born women are increasingly unwilling to do.

At the professional level, women interested in pursuing careers in themore developed countries are increasingly turning to options other thannursing, contributing to serious nursing shortages (Simoens, Villenueve,& Hurst, 2005). Nursing associations around the world describe their pro-fession as one in crisis because of working conditions and low morale(Gordon, 2005; Royal College of Nursing, 2002; Aiken etal., 2001).Among registered nurses in the United States, only 69.5% expressed sat-isfaction with their jobs, compared with 85% of all workers and 90% ofother professionals. Nurses in nursing homes expressed the lowest levelof satisfaction among all settings, with only 65% expressing satisfaction(Spratley etal., 2000). Turnover rates of over 50% among nurses in manyU.S. long-term care settings reflect this low morale (National Commis-sion on Nursing Workforce for Long-Term Care, 2005).

The dual labor market that has traditionally characterized employmentopportunities for native-born women in developed countries is now beinginternationalized. The internationalization of these labor markets has racial aswell as gender implications. As other opportunities open, native-born women,especially white women, are not entering the caregiving professions at thesame rate as the past in the United States. Between 1994 and 2002, the num-ber of native-born nurses in the United States younger than age 35 declinedfrom roughly 490,000 to 380,000 (Arends-Kuenning & McNamara, 2004).

Slow growth in the number of native-born nurses has opened opportu-nities to women from developing countries, where nursing may still beone of the few professional opportunities available to them. The youngerages and high percentage of foreign-born nurses who have arrived in theUnited States within the past 10 years (see Table 2) are indicators thathigher percentages of the newly employed nurses in long-term care arecoming from other countries. Much higher percentages of foreign-bornworkers also work in central cities, generally seen as less desirable loca-tions. As the countries of origin have increasingly shifted from moredeveloped to developing countries (a trend discussed below), foreign-born nurses are also changing the racial and ethnic composition of thenursing staff in long-term care settings. Foreign-born nurses are far morelikely than native born-nurses to be non-whites, as shown in Table 2.

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Skill Levels, Education, and Credentialing

Labor market characteristics and working conditions are important fac-tors in understanding migration patterns of long-term care workers. Thelabor market for long-term care in the United States includes at least threerelatively distinct segments, each with its own dynamics:

• Registered nurses, who must navigate complex systems of creden-tialing to practice their professions after immigrating;

• Licensed practical nurses, most of whom were registered nurses intheir countries of origin; and

• Unlicensed aides and other long-term care workers, some of whomare “decredentialed” nurses seeking entry to a career in health orlong-term care.

Each country has credentialing processes defined by law and regulation.For example, while most developed countries have a similar division betweenregistered and practical (or “enrolled”) nurses, Austria, France, and Spain

TABLE 2. Select characteristics of native-born and foreign-bornnurses and licensed practical nurses in long-term care

settings in the United States, 2000

Registered Nurses Licensed Practical Nurses

Native-Born Foreign-born Native-Born Foreign-born

Median age 45 41 42 39Age <35 21% 30% 30% 34%<10 years in the

United StatesNA 41% NA 29%

Median income $33,000 $39,000 $22,800 $24,000Central City 10% 26% 11% 28%

Native-Born and Foreign-born Workers from the Following Racial/Ethnic GroupsAsian * 46% * 24%Black 10% 23% 19% 42%Hispanic 2% 8% 3% 11%White 86% 19% 75% 17%Other/mixed 2% 6% 2% 7%

*Less than 0.5%.Source: U.S. Census data, 2000, AARP PPI analysis.

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have only one category of licensed nurses. On the other had, the Netherlandshas three categories of nurse aides (Simoens, Villeneuve, & Hurst, 2005).Long-term care credentialing is generally not distinct from other health-related services except for paraprofessional direct-care workers who are oftencertified as nurse assistants for long-term care. Registered nurses are not cre-dentialed for long-term care only, so movement among nursing home, homehealth, and hospital care is quite common. Employment in the long-term caresector is often the entry to work in other health-related settings.

Nations establish education and credentialing requirements to helpassure quality of care, but these requirements also limit the number oflong-term care workers admitted to the labor market, especially amongskilled workers (Bryant, 2005). For example, Japan has some of the moststringent requirements, allowing only graduates of Japanese nursingschools to be licensed and allowing only Japanese citizens or permanentresidents to be admitted to those schools (Brasor, 2004). Bilateral negoti-ations are underway to allow a minimal number of graduates of Filipinoand other nursing schools, after demonstrating nursing and languagecompetence, to practice in Japan. But the Japanese Nurses Associationstrenuously opposes any opening to immigrant nurses (Sieg, 2004).

Efforts to limit the immigration of nurses have also used credentialingin the United States (Choy, 2003). In the 1970s, states began to require acompetency test developed by the National Council of State Boards ofNursing, at that time a branch of the American Nurses Association(ANA), which had consistently lobbied to limit the immigration of nurses.That test evolved into the National Council Licensure Examination(NCLEX®) used to this day to measure nursing competence. The failurerate was very high among foreign-trained nurses in the early years–for example, only 23% passed in 1976 (Choy, 2003). Although passrates have improved substantially, only 58.2% of foreign-trainedapplicants passed the NCLEX-RN® on their first attempt in 2004,compared to 85.3% of U.S.-educated nurses (Crawford, O’Neill,Reynolds, & White, 2005).

In 1978, the ANA and the National Council of Nurses established theCouncil of Graduates of Foreign Nursing Schools (CGFNS) to deal withongoing concerns about the quality of foreign-trained nurses and to stemthe number of foreign nurse candidates in the United States who failed thelicensing examination (Choy, 2003). The purpose of the CGFNS was todevelop prescreening tests of nursing competence and English-languagecompetence before coming to the United States to take the NCLEX® exam.While this prescreening process may protect some foreign nursing students

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from the problems associated with failing the licensing exam, it also addsanother layer of requirements and delays to the complicated process ofbecoming licensed in the United States.

Getting through the various levels of pre-testing and testing to finallicensure takes, on average, nearly two years (22.6 months) and costs morethan $2,500. According to Aiken (2005), 19,903 nurses began the processof applying for the CGFNS prescreening exam in 2001, but only 3,482received visa screen certificates. Of these, only slightly more than halfcould expect to pass the NCLEX® exam on their first attempt.

One reason for implementing the prescreening process through theCGFNS was the high failure rate of nurses who came to the United Statesto take the licensing exam and the “decredentialing” that often followed;that is, skilled professionals taking lower-skilled jobs because of the lossof their credentials. McKeon (2003) describes the concern with decreden-tialing: “Often, these nurses would be employed as lower-paid nurses’aides.” While no one has documented the exact extent of this decreden-tialing, it appears to be fairly common for foreign-trained nurses to workfor some time as nurse aides, very often in long-term care settings, whilewaiting to take or retake the licensing exam (George, 2005). Indirect evi-dence of decredentialing comes from the unusually high levels of educa-tion among foreign-born nurse aides. As Figure 1 shows, 70% of aides in

FIGURE 1. Years of Education, Nurse Aides in Long-Term Care Settingsin the United States, by Place of Birth, 2000.

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long-term care settings from the Philippines and 50% of aides from Africahave some college education, compared to only about 30% of native-bornaides.

More direct evidence of decredentialing comes from the number ofmigrating nurses who were educated as registered nurses in their homecountries but who have been licensed as practical nurses in the UnitedStates. The Commission on Graduates of Foreign Nursing Schools (2005)found that 80% of the foreign-educated practical nurses surveyed hadbeen educated and licensed as registered nurses in their home countries.These nurses either failed the NCLEX® exam for registered nurses, ortheir education was considered more comparable to that of practicalnurses in the United States. The decredentialing of practical nurses isespecially relevant to long-term care, since 50% of all internationallyeducated practical nurses found employment in long-term care settings,compared to only 16% of a similar sample of internationally educatedRNs (Commission on Graduates of Foreign Nursing Schools, 2002,2005).

British credentialing of nurses relies more on individual determinationsand emphasizes serving a clinical trial period rather than competency test-ing. But this system can be as time-consuming and difficult as that in theUnited States. Of 41,406 nurses and midwives who applied for registry inthe year ending in March 2004, 3,394 were accepted the first time, and11,352 were accepted only after a “period of adaptation” (Nursing andMidwifery Council, 2005). During this adaptation period, trained nursesoften work as “carers” in care homes for older people until they arejudged ready to register as nurses again. Many international nurses reportfeeling that the adaptation period is arbitrary and exploitative becausethey are asked to perform many of the functions of a nurse but are notpaid at that level (Allan & Larsen, 2003).

Colonial Histories, Geographic Relations, and Patterns of Migration

Histories of colonialism and geographic proximity also play majorroles in the patterns of nurse migration. The migration of nurses from thePhilippines to the United States is a prime example of the influence of acolonial past. Choy (2003) notes that the colonial history of the first halfof the 20th century laid the foundation for the migration that followed inthe second half of the century. She describes four characteristics of nursetraining established during the colonial period that continue to shape the

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migration of nurses: (1) Americanized professional nursing training, (2)English-language fluency, (3) Americanized nursing culture, and (4) gender-based notions of nursing as women’s work.

Much the same can be said for the relationship between Europeancountries and their former colonies. The education systems in formercolonies often teach in the language of the colonial power and track itseducational requirements, which can ease migration from former colonyto colonizer. Immigration rules may also be eased because of the histori-cal relationship. For example, many health care workers have migratedfrom former Portuguese colonies in Africa to Portugal (Stilwell etal.,2004), and many Latin American caregivers provide services in Spain(Johansson & Moss, 2004).

As a reflection of the colonial past, immigration of nurses to the UnitedStates and the U.K. has shifted dramatically in recent years from devel-oped countries to developing countries. As Figure 2 shows, the number ofnewly registered nurses in the U.K. who were foreign-trained tripledbetween 1998/1999 and 2003/2004, from 5,034 to 15,132 before recedingin 2004/2005 to 12,670 due to cutbacks in the National Health Service.During the entire period, the proportion of new nurses who came fromdeveloped countries in the EU or from Australia, New Zealand, UnitedStates, and Canada declined from 72 to 21%. With the major exception ofthe Philippines, virtually all of the increase in foreign-trained nurses inrecent years has come from former colonies in Africa and Asia, especially

FIGURE 2. Initial Overseas Admissions to the U.K. Nurse and MidwiferyCouncil Registry by Country, 1998–2005.

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from India (Nursing and Midwifery Council, 2005). These nursessometimes note that they came to the U.K. because of the colonial historyand British-based education system that they thought would ease theirtransition (Allan & Larsen, 2003).

The former American colony, the Philippines, continues to be the largestsupplier of registered and practical nurses in the United States (see Table 3;also Arends-Kuenning & McNamara, 2004). The increase in nurses fromthe Philippines as well as the substantial increase of nurses migrating fromIndia to the U.K. as documented in Figure 2 is not only due to a colonialconnection, but also due to deliberate public policies and private efforts toencourage migration to realize the economic benefits of remittances. Asformer Philippine President Marcos put it, “We will now encourage thetraining of nurses because as I repeat, this is a market that we should takeadvantage of. Instead of stopping nurses from going abroad why don’t weproduce more nurses? If they want one thousand nurses, we produce athousand more” (quoted in Choy, 2003, pp. 115–116, her emphasis).

Other developing countries with no colonial ties to the United Stateshave also become major suppliers of nurses. Between 1990 and 2000,Nigeria (with 343% growth), Mexico (100% growth), and Haiti (125%growth) joined the top 10 providers of foreign-born registered nurses tothe United States, as Ireland and Germany declined in relative importance(Arends-Kuenning & McNamara, 2004). The impact is even more strik-ing when looking specifically at long-term care settings. Between 1980and 2000, the percentage of foreign-born RNs in long-term settings fromdeveloping countries increased from 60 to 83%; the percentage offoreign-born LPNs from developing countries increased from 58 to 82%(U.S. Census Bureau, 2005, analysis by AARP Public Policy Institute).

TABLE 3. The Number and Percentage of Foreign-Born Nurses and Nurse Aides in Long-Term Care Settings in the United States

from the Top Five Countries of Origin, 2000

Nurses Nurse Aides

Philippines 12,500 (25%) Jamaica 14,500 (13%)Jamaica 4,800 (9%) Philippines 13,300 (12%)Haiti 3,300 (7%) Mexico 12,800 (11%)India 3,100 (6%) Haiti 11,700 (10%)United Kingdom 1,860 (4%) Puerto Rico 4,800 (4%)

Source: U.S. Census data, 2000, AARP PPI analysis.

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Regional proximity also plays an important role in the migrationpatterns of long-term care workers. The nations of Central and WesternEurope have recently seen more migration of nurses from Eastern Europeancountries in conjunction with the expansion of the European Union. Forexample, nearly all of the foreign-trained nurses in Austria are from Europeancountries, with 70% coming from the nearby countries of Bosnia, Romania,Croatia, Czech Republic, and Poland. Similarly, 60% of foreign-trainednurses in Switzerland come from the nearby countries of Germany, Bosnia,France, Albania, and Italy, and most of the rest come from other Europeancountries (Simoens, Villeneuve, & Hurst, 2005).

In general, the labor market for foreign-born skilled nurses tends to beglobal for the United States and the U.K., while the labor market for for-eign-born nurse aides tends to be more regional (Arends-Kuenning andMcNamara, 2004). Table 3 contrasts the regional origins of most foreign-born nurse aides in the United States with the more global labor marketfor nurses.

The Role of Worker Recruitment

An industry of recruiters has emerged to facilitate the flow of healthand long-term care workers from developing to developed countries.Faced with the pressures to fill staff vacancies, employers find profes-sional recruiters to be essential links to potential employees withoutincurring the costs of direct recruitment. From the perspective of migrat-ing workers, recruiters link them to potential jobs and help them navigatethe complicated process of immigration and credentialing.

Selective recruitment practices and policies affect the migration patternsof long-term care workers, especially among skilled nurses. Moreover,some recruiters have come under criticism for ethically questionable practices(International Council of Nurses, 2001). These criticisms are of twotypes. The first is misrepresentation of the types of services they willprovide or the pay and work conditions the migrating worker can expect(Choy, 2003; Allan & Larsen, 2003). The second type of criticism is thatrecruiters try to maximize the number of workers they can enlist with littleregard for their impact on health-related services in the source country(International Council of Nurses, 2001).

Recruiters are largely unregulated by either the host or source country.Nongovernmental professional organizations, including the InternationalCouncil of Nurses, have issued codes of ethics. Ethical standards havealso been issued by international organizations representing member

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states such as the Standing Committee of Nurses of the European Union(2005) and the Commonwealth (Commonwealth Secretariat, 2005).Finally, individual countries have issued guides for the recruitment ofnurses (see the Standing Committee of Nurses, 2005, for links to nationalguidelines). However, a review of eight national and international codesof practice to encourage ethical recruitment of international health careworkers found that “support systems, incentives and sanctions, and moni-toring systems necessary for effective implementation and sustainabilityare currently weak or have not been planned” (Martineau & Willetts,2004).

One of the most notable national guidelines was issued by the Depart-ment of Health in the U.K. (2004). This code prohibits the NationalHealth Service (NHS) from recruiting from certain less developed coun-tries in order to stem the “brain drain” of health care professionals fromcountries that can ill afford to lose them. But the code does not apply tonurses employed in the independent sector. As a result, 10% of the non-NHS nurses were first qualified overseas in 2002, compared to 4% ofNHS nurses.

Moreover, foreign-trained nurses were much more likely to work inindependent nursing homes: 14% of internationally qualified nursesworked in such settings compared to only 5% of white U.K. nurses (RoyalCollege of Nursing, U.K., 2002). In fact, one of every four overseasnurses qualified in the U.K. in 2002–2003 was from a country on theDepartment of Health’s proscribed list (Buchan & Dovlo, 2004), callinginto question the effectiveness of the code as a method of restrictingrecruitment of nurses from countries facing critical shortages.

South Africa was specifically targeted for relief after an appeal by NelsonMandela in 1997 to end the recruiting of nurses (Bach, 2003). SouthAfrica and the U.K. reached a memorandum of understanding to deal withthe migration of health care personnel (Mafubelu, 2004). Despite thisagreement and South Africa’s being on the proscribed list for recruiters,5,171 South Africans registered as nurses in the U.K. between 2001–02and 2003–04 (Nursing and Midwifery Council, 2005). By way of compar-ison, the number of registered nurses in South Africa grew by only 2,163between 2001 and 2003 (South African Nursing Council, 2005). The situ-ation is even more critical in much of the rest of Africa, which bears 25%of the world’s burden of disease but has only 0.6% of the world’s healthcare professionals to combat those diseases (Gbary, 2005).

The exodus of African nurses is especially relevant to long-term careemployment in the U.K. and the United States. Our analysis of 2000 U.S.

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Census data shows that an increasing percentage of foreign-born nursescomes from Africa; 17% of foreign-born nurses who work in long-termcare settings and who had been in the United States for 10 years or lesscame from Africa (Redfoot & Houser, 2005). Moreover, African nurses andnurse aides in the United States are much more likely to work in long-termcare settings than are foreign-born nurses and aides from any other region.

CONCLUSION

Much more research is needed in both developed and developing coun-tries to inform policy decisions regarding the international migration ofhealth and long-term care workers. Among the least studied issues is theimpact of immigration on the quality of services. Migrating workers fillimportant gaps in the labor force, especially in central city areas that havetrouble recruiting native-born workers. Moreover, foreign-trained nursesoften have more education and more experience than newly licensednative-born nurses. But communication issues and cultural differences inexpectations related to long-term care need more study in order to under-stand the impact of increasing numbers of foreign-born workers on theclients they serve.

Research related to developing countries might look at the role ofmigration in developing health and long-term care systems. In manycountries, the loss of health care professionals represents not only a lossof needed services but also a loss of public investments in education andtraining. Cooperative agreements with recruiting countries and agencieswithin those countries may result in more mutually beneficial approachesthat include training and retention of workers and reintegrating workerswho have spent some time abroad back into their countries of origin.

Finally, research on policies and programs that address health andlong-term care needs at the national level should not ignore the individualneeds and aspirations both of those who need long-term care and thosewho would provide that care. Long-term care and immigration policiesmust address the aspirations of individuals with disabilities who wanthigh-quality services that support their dignity and independence. Thoseprograms and policies are unlikely to work unless they also recognize andaddress the aspirations of individuals who are migrating to improve theirlives and the lives of their families. Meeting these individual aspirationsand national priorities in a period of global change is one of the major pol-icy challenges of aging societies.

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RECEIVED: 09/06REVISED: 02/07

ACCEPTED: 04/07

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the international migration of nurses in long-term care

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