by Mireille Kingma
288 pages, Cornell University Press
US$24.95 paper, US$49.95 cloth

Administrators and nursing leaders understand the need for strategies to address the anticipated global nursing shortage and ensure the quality and safety of patient care now and into the future. Understanding, however, does not necessarily translate into action. Worldwide, nurses continue to face challenges in the work environment, economically, socially and, sometimes, politically. For some, migration has seemed a solution; others see it as part of the problem.

In her book, Nurses on the Move, Mireille Kingma argues that international nurse migration is a symptom of a long-term problem that has been inadequately dealt with through too many short-term solutions. She makes her case through a well-researched synthesis of key national and international literature, drawing from major reports and studies undertaken over the past decade.

This book also provides clear insight into migration's broader implications. By integrating data and policy reviews with the personal stories of nurse migrants, the author puts a human face on this complex issue and illustrates the social costs of migration - the impact of leaving family, friends and community and establishing oneself in another country and culture.

Kingma begins by citing data on nursing migration in the context of globalization, the characteristics of the migrant nurse and the reasons nurses might choose this route. She introduces the notion of "push-pull factors," the conditions that force nurses from their home country and the incentives that draw them to another.

For example, Fatima - a member of a minority ethnic community in her home country - was frequently the butt of intolerable discrimination from her colleagues and hospital leadership. Despite a desperate shortage of nurses in her country, she was unable to secure full-time status, even after 11 years as a nurse and many efforts to advance her qualifications through continuing education. Ultimately, Fatima emigrated to Sweden and fulfilled her career aspirations. "The decision to move was mine, and I would do it again," she says.

Other nurses describe such pull factors as the aggressive tactics of recruitment agencies that offer major financial and transition incentives, which sometimes fail to materialize once the nurse arrives in the destination country. Some nurse migrants have been forced to work in less attractive clinical areas, accept cuts in pay and even shoulder responsibility for the processes and expenses associated with securing registration or licensure. Paradoxically, when incentives do materialize, migrant nurses often experience abuse from local nurses, who may perceive reverse discrimination since the perks are given only to migrants.

Kingma also lays bare the business opportunities that have arisen out of nurse migration, such as private education programs established primarily for preparing nurses for migration, the lucrative opportunities in facilitating licensure and international banking and, inevitably, the opportunities for fraud. She describes the economic burden on home countries that have invested in educating nurses only to see them leave, and the reduction in quality of patient care when expert nurses leave settings where nurse-to-patient ratios are already as high as one to 60 or 80.

The issues can be even more complex. Some countries produce and export nurses for economic advantage, since remittances are sent back to the home country. Other countries have many unemployed nurses while patients fail to receive adequate care. In politically unstable countries, nurses may be forced to leave for reasons of personal safety.

Kingma also examines the ethical issues in nurse migration. For example, it would seem unethical to engage in aggressive recruitment to lure nurses from developing countries where shortages already exist. On the other hand, what of the rights of nurses to leave an intolerable work environment? Nurses choose to leave when they are not respected as professionals, and when they are denied an adequate living for themselves and their families. Nursing leaders need to come to terms with these ethical dilemmas.

In the final chapter, Kingma argues that the root of the problem is the international community's reluctance to address the conditions that push nurses away. Furthermore, the historical tendency has been to utilize short-term solutions, such as migration, when the core issue is attracting and retaining nurses within a positive environment where they feel satisfied with the care they are able to provide.

One dimension of the problem, Kingma contends, is the inability or unwillingness of many countries to address social factors and the economics of nursing. "Any attempts to regulate the workforce environment and avoid periodic shortages or surpluses have tended to be cosmetic and short term," she writes. She repeatedly cites the absence of well-founded human resources planning and management in the current crisis.

Despite Kingma's criticisms of international healthcare policy, she relays many positive stories of nurses who received the support and mentoring they required to make the transition to a new country and culture. Some migrant nurses have advanced professionally to become role models. But there is still much for us to learn.

In Canada, we need to review our transition processes to ensure a streamlined journey for the migrant nurse. Such a review would begin with the evaluation of qualifications, continue with programs that enable the achievement of Canadian standards and competencies and conclude with the process of registration.

Further challenges occur once migrant nurses enter the clinical setting, when they need support and mentoring. Beyond the normal orientation to a new clinical environment, they are making the transition to a new culture, a new language and, perhaps, a new model or approach to care. We need to sensitize Canadian healthcare providers to the issues and challenges these nurses face. Migrant nurses are a positive addition to Canada's multicultural model, which values diversity. We should welcome this opportunity to gain new perspectives on different cultures and traditions of care.

Kingma argues for more creative and innovative models for international nursing. For example, when Canadian nurses want to experience healthcare provision in another part of the world, why don't we offer a leave of absence so that they will more readily return to the Canadian setting? Our healthcare system would benefit, as such nurses would return with new learning and be richer for the experience.

This book underlines the potential crisis in healthcare if the root causes that lead to nurse migration are not addressed. As Kingma suggests, most nurses would prefer to remain home if the conditions were right. Similarly, many would not leave the profession if they believed that, at the end of the day, they accomplish something significant for their patients.

Economic factors may hinder the introduction of remedies that have been identified in many research studies and reports. Strategies that would stabilize the nursing workforce are perceived to be expensive. Kingma argues that we cannot afford not to implement these solutions. If we fail to acknowledge the potential for a global crisis in healthcare, there may be greater economic consequences for the world. It is time to move towards an integrated national and international nursing human resources strategy.

Nurses on the Move should be required reading in several sectors - for all nurses considering migration, and also nursing leaders, CEOs, human resources professionals and policy makers across government portfolios. This book has the potential to influence policy and provide direction for a long-term strategic plan for nursing human resources.

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