DB3-42 - Paper Answers

IMGs and INGs, ethical considerations

Read the corresponding chapter and both current topic articles for week 3, then respond to the following discussion question:

In your opinion, what are the ethical issues that healthcare leaders and managers must consider when recruiting IMGs and INGs? Why are these issues? What role, if any, does empathy and cultural awareness training have?

· You must cite your source at the end of your post. Utilize APA format.

Labour Market Integration of Refugee Health
Professionals in Germany: Challenges and

Strategies

Sidra Khan-G€okkaya* and Mike M€osko*

ABSTRACT

Refugee health professionals are a vulnerable group in a host country’s labour market as they
experience several barriers on their path to labour market integration. This study aims to iden-
tify challenges refugee health professionals and their supervisors experience at their work-
places and strategies they have developed to overcome these barriers. Semi-structured
interviews were conducted with refugee health professionals who have been living in Germany
for an average of four years and their supervisors (n = 24). The interviews were analysed
using qualitative content analysis. Nine themes were identified: (1) recognition of qualifica-
tions, (2) language competencies, (3) differing healthcare systems, (4) working culture, (5)
challenges with patients, (6) challenges with team members, (7) emotional challenges, (8) dis-
crimination and (9) exploitation. Results indicate the need to implement structural changes in
order to improve the labour market experiences of refugee health professionals.

BACKGROUND

The global healthcare workforce is facing skilled labour shortage. The World Health Organization
(WHO) estimates a global shortage of 14.5 million health professionals by 2030 (World Health Orga-
nization, 2006). The European Commission estimates a shortfall of 1 million health workers in Europe
by 2020 (European Commission, 2012), and employment agencies in Germany predict a nationwide
lack of health professionals (Bundesagentur f€ur Arbeit, 2018). In order to address this shortage, nearly
all European countries depend on the recruitment of foreign-trained health professionals (Organisation
for Economic Co-operation and Development (OECD), 2017). Another strategy that has been imple-
mented by the German government to address this shortage is the so-called “activation of domestic
potential” (Bundesregierung, 2018). With that, the German government aims to address those groups
that have difficult access to the labour market, such as refugees in order to improve their employability
and use them to fill shortages (Bundesregierung, 2018). As the number of refugees in Germany has
increased since 2015, the German government has recognized the need to address their labour market
integration (Bundesregierung, 2016). However, refugees belong to a particularly vulnerable group in
the labour market facing unemployment or underemployment (Tanay et al., 2016).

University Medical Center Hamburg-Eppendorf, Hamburg,
This paper is part of a special issue on the “Labour Market Integration of Highly Skilled Refugees in Sweden, Ger-
many and the Netherlands”

doi: 10.1111/imig.12752

of International Organization for Migration
International Migration

ISSN 0020-7985

This is an open access article under the terms of the Crea
tive Commons Attribution-NonCommercial-NoDerivs
License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-
commercial and no modifications or adaptations are made.

http://creativecommons.org/licenses/by-nc-nd/4.0/

The barriers and difficulties that refugees face in the context of their labour market integration
are multidimensional and manifold. First, their access to the labour market in Germany is restricted
and depends on their legal status and the likelihood of getting a residency permit which in turn
depends on the country of origin (Bundesministerium f€ur Arbeit und Soziales, 2019). In Germany,
there is a ban on employment for all refugees within the first three months. After three months,
their access to the labour market is dependent on the individual residency status. As of the fourth
month, refugees need work permission from the foreign authority office in Germany and the local
employment agencies in order to work (Bundesministerium f€ur Arbeit und Soziales, 2019). Their
access to language courses depends on their legal status and the likelihood of receiving a residence
permit (Bundesministerium f€ur Arbeit und Soziales, 2019). Moreover, participating in job-related
language courses is described as challenging either due to long waiting times or course availability
(United Nations High Commissioner for Refugees-Organisation for Economic Co-operation and
Development (UNHCR-OECD), 2016). Second, refugee health professionals need to go through a
difficult and long recognition process (K€ortek, 2015; Desiderio, 2016) which is described as the
starting point for permanent downward mobility (Hawthorne, 2002). Moreover, refugees may not
be able to provide identity documents (Bucken-Knapp et al., 2019) or official documents about
their education (Bloch, 2008) due to the flight which impedes the recognition process. Third, a lack
of information about career pathways (Cohn et al., 2006), such as knowledge about job search
strategies (Willott and Stevenson, 2013) and unfamiliarity with the healthcare system of the host
country (Ong et al., 2004), are reported barriers. Fourth, due to their flight they may have had a
break in their professional career and/or experienced the loss of their professional status (Willott
and Stevenson, 2013) which is related to the loss of professional identity (Peisker and Tilbury,
2003). It may also result in deskilling (Stewart, 2003), loss of self-confidence (Willott and Steven-
son, 2013), high levels of frustration (Mozetic, 2018) and negative psychological impacts (Cohn
et al., 2006). Additionally, the lack of recognition of their previously gained experiences leads to a
feeling of being disadvantaged compared to locally trained team members (Mozetic, 2018) which
might be intensified by the experience of multiple forms of discrimination (Jirovsky et al., 2015)
and exclusion (Bloch, 2008).
Studies in Germany have also focused on the working experiences of migrant physicians and

international nurses from within the European Union as well as from non-European countries. They
report similar barriers as the above-mentioned. A study on migrant physicians (Klingler and Marck-
mann, 2016) describes difficulties in three fields. The first field refers to the organization of health-
care institutions and other institutional difficulties such as insufficient support or being assigned to
tasks below their level of expertise. Moreover, difficult career advancement opportunities and unfair
treatment of migrant physicians were mentioned as institutional difficulties. The second field relates
to experienced difficulties with own competencies such as language competencies and knowledge
about the healthcare system. The third field relates to difficulties in interpersonal relations and inter-
actions such as inadequate treatment of patients and co-workers. In this context, a study on the
workplace integration of internationally recruited nurses in Germany points out that conflicts often
arise between migrated nurses and locally trained team members. These conflicts arise because
locally trained team members either hold back or do not comprehensively share key information in
order to organize their work. Thus, the incorporation of migrated nurses into daily work routine is
impeded and the potential for conflicts in everyday work is increased (P€utz et al., 2019). These
studies illustrate that international healthcare professionals and refugee healthcare professionals
experience similar barriers at their workplaces. However, refugees were forced to flee by the cir-
cumstances of their home countries (Yarris and Casta~neda, 2015), whereas internationally recruited
health professionals may be considered as voluntary migrants. This distinction between refugees
and voluntary migrants has effects on the barriers they experience. While voluntary migrants were
most likely able to prepare for their migration, refugees had to flee under extreme conditions (Jack-
son et al., 2004). Stressors of the flight, the loss of family members, traumatic experiences and the

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

uncertainty about their residency permit (Carlsson and Sonne, 2018) may also influence their pre-
requisites to work. Rather, in comparison to other highly qualified migrants, highly qualified refu-
gees are more likely to stay in jobs they are overqualified for which mainly relates to the fact that
documentation of their education is missing (Tanay et al., 2016). Moreover, some other barriers,
such as housing, health, absence of networks or childcare, may indirectly influence employment
outcomes (OECD/UNHCR, 2018).
The European Parliament recommends qualification programmes to prepare refugees for work

and strengthen their employability (Konle-Seidl, 2016). These recommendations comprise individu-
ally tailored programmes to the specific needs of refugees. Amongst others, it is recommended to
provide (occupational specific) language courses combined with working opportunities, skills
assessment, mentoring and career advice. For highly skilled refugees, it is especially recommended
to increase availability of on the job trainings, recognize existing qualifications and offer vocational
training. However, in order to implement tailored programmes that match the host countries’ legal
and social requirements it is essential to identify and analyse the barriers refugee health profession-
als face when entering the labour market. While the legal situation of refugees and their access to
the labour market in Germany is documented through policy papers (European Commission, 2012;
Platonova and Urso, 2012; Konle-Seidl, 2016; Tanay et al., 2016; UNHCR-OECD, 2016; OECD,
2017; United Nations Department of Economic and Social Affairs Population Division, 2017;
UNHCR, 2017; Bundesministerium f€ur Arbeit und Soziales, 2019), little attention has been paid to
the challenges they face in everyday working life and their own perspective and strategies. Thus, in
this study, refugee health professionals and their supervisors across Germany were interviewed
about the challenges they faced at their workplaces as workplaces are a “key site of sociocultural
incorporation” (van Riemsdijk et al., 2016). Moreover, this paper advances this field by giving rec-
ommendations for healthcare providers and organizations based on the experiences of refugee
health professionals and their supervisors in order to implement changes on structural levels and
improve the working environment. These changes refer to establishing supporting structures as well
as measures of diversity management and anti-discrimination.

METHODS

The reporting of methods is in accordance with the consolidated criteria for reporting qualitative
research (COREQ) guidelines (Tong et al., 2007).

Researcher characteristics

Qualitative research depends on the personal qualities of the researcher and the theoretical sensitiv-
ity that the researcher brings to a research (Strauss and Corbin, 1990). Thus, it is important to
reflect on the researcher’s characteristics and its impact on the interview situation. All interviews
were conducted in person by the first author, female, person of color, PhD student of the Depart-
ment of Medical Psychology at the University Medical Center Hamburg-Eppendorf. The first author
is trained in cultural studies, international migration and intercultural studies and has several years
of training in conducting qualitative studies. For transparency reasons, participants were informed
that the study was part of a PhD study.

Recruitment

Major educational organizations and projects for the labour market integration of refugee health
professionals (RHPs) across Germany were identified through internet research. The organizations

Labour market: Refugee health professionals 3

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

(n = 15) were contacted and informed about the study. Their consent was obtained. Three of the
major organizations agreed to participate in the study. Participants were divided into RHPs and
supervisors as the refugees’ self-perception about their experiences might differ from the supervi-
sors’ perception. Since the group of RHPs comprises different professions, we decided on subdivid-
ing the stratum of RHPs into two groups: physicians and other health professions. In terms of data
saturation, it is recommended to conduct six to twelve interviews per stratum (Guest et al., 2006).
Thus, 24 interviews were conducted in three major cities in Germany (Hamburg, Hannover and
Frankfurt). All three organizations provided persons that matched the inclusion criteria with infor-
mation on this study and either arranged appointments or provided participants with the research-
ers’ contact information. Inclusion criteria for participants referred to the following aspects:
Target group1.:

• Refugees (regardless of their residency status and form of protection) who have obtained a
qualification in a health profession in their home country or a country other than Germany;

• Supervisors that were responsible for the integration of refugee health professionals, their
supervision or support

Language competencies:

• Required minimum level of German language competencies on the European Reference
level of A2-B12.

Working experiences in Germany:

• RHPs must have had contact with the German healthcare system with a minimum duration
of one month – be it a steady job, an internship or job shadowing

• Supervisors had to work in jobs with close contact with refugee health professionals regard-
less of their hierarchical status. They must have had supervised RHPs at their ward or as an
external supervisor

Context:

• RHPs and supervisors in all healthcare institutions comprising primary, secondary and ter-
tiary care were included

Providers were informed about the inclusion criteria and selected fitting participants. All inter-
views were conducted in German. In one case the inclusion criteria did not match as the participant
was a student of the educational organization without sufficient working experience. Participants
that matched the inclusion criteria were approached via phone followed by an invitation to live
interviews. Participants received two consent forms: one for their participation in the study and one
for their consent to audio recording. The consent form and the study information were orally
explained prior to the interview.

Data collection

The interview guide was developed based on literature focused on the daily work experiences of
refugee health professionals using the SPSS3. approach by Helfferich (2009). The interview guide
was sent to experts in the field of migration research to be critically reviewed. Based on this
review, the authors discussed and adapted the interview guide. Finally, the interview guide was

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

piloted with two migrant nurses that resulted in the specification of some questions. The interview
guide was structured into six main themes:

(1) General experiences while working in a hospital
(2) Experiences with team members and supervisors
(3) Experiences with patients
(4) Experiences with the working culture
(5) Experiences with the healthcare system
(6) Suggestions for improvement

In each interview, the same semi-structured guide was used. After the interview was finished and
the audio recorder was switched off, demographic data were retrieved. The interviews lasted from
00:18 to 00:55 min with a median range of 00:40. Some (n = 4) interviews were transcribed by a
student researcher but the majority (n = 20) of the interviews were transcribed verbatim by a pro-
fessional agency. All transcripts were proofread by the first author.

Data analysis

The interviews were analysed using content analysis (Mayring, 2015). The first author coded all
interviews by means of a computer-based coding programme (MAXQDA, version 10). Deductive
codes were derived from the interview guide but as an explorative approach was preferred more
inductive categories were derived from the material. Code memos were created for all codes includ-
ing a description of the code and typical quotes. For the purpose of quality assurance, a research
assistant coded a random selection of one-quarter of all interviews. Differences in coding were dis-
cussed until a consensus was reached that led to the creation of some new sub codes and a revision
of the category system. Results were presented and discussed with other experts in an interdisci-
plinary research colloquium to ensure comprehensibility and intersubjective reproducibility. The
revised system was then crosschecked by the main author in a second round of coding taking all
interviews into consideration.

Description of sample

Sixteen RHPs and 8 supervisors participated in the study. Two interviews were conducted via tele-
phone due to reduced mobility of the participants. The sample is described in Table 1.

RESULTS

In general, nine major challenges could be identified which either RHPs or supervisors described as
relevant: (1) the recognition of professional qualifications, (2) language competencies, (3) different
healthcare systems, (4) working culture, (5) challenges with patients, (6) challenges with team
members, (7) emotional challenges, (8) discrimination, (9) exploitation. Table 2 provides an over-
view of the identified fields and their specifications.

Recognition4. of professional qualifications

Both supervisors and RHPs pointed out the challenges they faced with regard to the recognition
process of their professional qualifications. Supervisors especially emphasized the difficulties
regarding the recognition process. They criticized the long waiting times for the recognition process

Labour market: Refugee health professionals 5

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

TABLE 1

SAMPLE DESCRIPTION (REFUGEE HEALTH PROFESSIONALS AND SUPERVISORS)

Refugee health professionals (RHPs)

Participant Sex Age
Country
of birth Occupation

Working
experience
in Germany

Working experience
in birth country

A1 m 26 Iran Nurse 1 month 6 years as a nurse
A2 m 23 Iraq Physician 3 months 2 years as a general

physician and
3 years as a
surgeon

A3 m 28 Syria Physiotherapist 2 years 4 years as a physio-
therapist

A4 m 28 Syria Physician
(specialized
in Anaesthesia)

8 months 2,5 years as a medi-
cal assistant in sur-
gery

A6 m 33 Syria Physician 5 months 5 years as a physi-
cian

A7 m 38 Afghanistan Physician one year 1 year as a medical
assistant, 3 years in
public health depart-
ment

A8 w 29 Syria Physician 1,5 years 1 year as a physician
A9 m 30 Afghanistan Physician 3 months 1 year as a medical

assistant
A10 m 44 Syria Physician

(specialized
in anaesthesia)

3, 5 years 4 years as a medical
assistant, two years
as a senior physi-
cian, 9 years as a
chief physician

A11 w 52 Afghanistan Physician (specialized
in gynaecology)

6 months 23 years as a gynae-
cologist (also as a
chief gynaecologist)

A12 m 39 Yemen Physician 4 months 10 years as a physi-
cian

A13 m 45 Afghanistan Physician 2 years 2,5 years as a physi-
cian

A14 m 51 Syria Dentist 3 months 21 years as a dentist
A15 m 39 Afghanistan Physician

(specialized
in
otorhinolaryngology)

6 weeks 3 years as an ear-
nose-throat (ENT)
specialist

A16 w 33 Senegal Midwife and Nurse 3 months eleven months as a
midwife, 15 years
as a nurse

A17 w 36 Azerbaijan Nurse 3 months 2 years as a nurse

Supervisors

Participant Sex Age
Country
of birth Education Current job Experience

B1 m 34 Germany Physiotherapist Part time
physiothera-
pist, part
time supervi-
sor for RHPs
and migrants

5 years as a
physiotherapist,
1 year as a
supervisor

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

(B2-B4, B8) and noted that the bureaucratic procedures for recognition in Germany were not clear
and prolonged the recognition process (B4, B7, B8). RHPs also criticized the length and complex-
ity of the recognition process (A4, A7, A8, A11, A12). Two supervisors (B4, B8) criticized that
former positions such as leadership titles of RHPs were not recognized in Germany. They also criti-
cized that RHP’s specialist medical training or their internships in Germany were not considered
for recognition as working experiences. Furthermore, in one case there was confusion about the
legal foundations of the responsible authorities’ bodies:

One colleague receives a temporary work permit [from the recognition authority] but federal medi-
cal council law and health insurance company’s law contradict each other which inhibits him from
working as a physician unless he has a full licence to practise medicine. But he can only acquire
the full license after taking an exam. Taking that exam is on hold because the [recognition] authori-
ties are understaffed. (B3)5.

RHPs (A1, A11, A13, A15) also indicated their anxiety regarding the licensing examinations as
they feared the examination would be too difficult.

Language competencies

Supervisors and RHPs considered acquiring German language proficiency and German technical
and medical language as a major topic. Supervisors emphasized especially the need to learn the

TABLE 1

(CONTINUED)

Supervisors
Participant Sex Age
Country
of birth Education Current job Experience

B2 m 64 Germany Librarian and editor Commissioner
for refugees
at the medi-
cal associa-
tion in lower
Saxony

2,5 years as
a commissioner

B3 m 64 Germany Physician Physician and
Supervisor
for RHPs

34 years as a
physician,
one year as
a supervisor

B4 m 73 Germany Physician Supervisor for
RHPs/
retired

47 years as
a physician,
2 years as
a supervisor

B5 w 50 Germany Nurse and
professional
advisor

Professional
advisor

15 years as
an advisor

B6 w 54 Germany Nurse Nurse and
supervisor

37 years as nurse
and supervisor

B7 w 38 Germany Nurse and
Psychologist

Psychologist seven years as a
psychologist

B8 m 52 Germany Physician,
Medical
journalist

Managing
director of
refugee and
migrant edu-
cation centre

2 years as
managing director

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

technical language. They (B1, B5, B8) described that RHPs were afraid to admit there were
parts they did not understand and continued to say “yes” in order to maintain the conversation
flow. This has often led to misunderstandings. RHPs described difficulties in speaking everyday
language and technical language. They (A1, A2, A4) found it difficult to understand handover
reports from physicians or keep up in meetings and written documentation. They (A1, A3, A7,
A12) were also afraid of not being able to understand the language which influenced their
behaviour:

I am afraid if [a patient] someone rings the bell. [. . .] Because my language is not [well] enough
and I am afraid of understanding something wrong or not being able to answer [the patient’s ques-
tion]. That’s why I remain seated and others [colleagues] keep asking me “why are you always sit-
ting?” (A1)

One of them also expressed their fear of being deemed to be incompetent due to their language
competencies: “They think I have learned it wrong in Iran. But in fact I couldn’t understand what
they were asking me” (A1). Moreover, RHPs (A1, A3, A12) felt their language competencies held
them back as they were reluctant to share their opinion: “If we discuss a patient’s case and some-
one has a contradicting opinion on that patient’s case I am afraid to discuss our opinions as I fear
they will say ‘I can’t express myself’” (A3).

Different healthcare systems

Supervisors and RHPs described challenges that derived from differing standards in the home
and host countries’ healthcare system. All supervisors described that RHPs would have to
familiarize themselves and catch up with the healthcare system in Germany. Eleven RHPs (A1,
A2, A8, A9, A11-17) emphasized the difference in the medical equipment, the names of

TABLE 2

CHALLENGES EXPERIENCED BY REFUGEE HEALTH PROFESSIONALS

Recognition of professional
qualifications

Difficulties in the context of the recognition process
Non-recognition of former experiences
Examinations for recognition

Language competencies Knowledge of everyday language
Knowledge of technical language
Feelings and consequences of lacking language competencies

Different healthcare systems Unfamiliarity with and differences between the healthcare systems
Unfamiliarity with bureaucratic procedures within the healthcare system
Consequences of differences and unfamiliarity

Working culture Adaption to formal aspects of work
Adaption to cultural aspects of work
Intercultural and interpersonal differences

Difficulties with patients Language difficulties
Difficulties in delivering bad news
Distrust from patients

Difficulties with team members Difficulties during internships
Interpersonal and interprofessional difficulties

General Emotional Difficulties Discouragement
Negative feelings of RHPs in the context of labour market integration.

Discrimination Discrimination by patients
Discrimination by team members

Exploitation Financial exploitation of RHPs in the context of work.
Professional exploitation of RHPs in the context of work

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

medication and working habits and the feeling to need to familiarize themselves with these dif-
ferences. In this context, supervisors referred especially to the differing professional role of
nurses in Germany:

They mostly come from countries where nursing care is much higher regarded as a profession, it
gets a very high recognition. And here they have to understand this in such a way that the job
description or the professional role is not so highly regarded. (B6)

RHPs (A1-4, A7, A9-A10, A12-A15) criticized bureaucratic procedures in hospitals in Germany
as it was challenging to keep up with all the procedures of them. They (A4, A17, A16) did not
know about occupational law and were also insecure about their rights and obligations in their pro-
fessional duties. During internships or work, they (A2, A3, A8, A9, A10, A13-17) felt held back
as some of them were not allowed to work either because of their status as interns or because they
did not have their license yet:

Yes, the situation was unpleasant that I could not do anything alone. And if I wanted to do some-
thing, someone had to stay with me, a senior physician or chief physician. That was a bit uncom-
fortable for me because I already graduated from university and I also worked as an assistant
physician in my home country for a year. But I didn’t have a solution. I had to come to Germany
and here, the rule is if someone doesn’t have a license he has to cooperate with a chief physician
or with a senior physician. (A9)

Working culture

Supervisors described two facets of working culture that they found important in the context of
their experiences with RHPs: formal and cultural aspects of work and RHPs adaption to these
aspects. They emphasized formal aspects such as being punctual, submitting holiday applications
correctly, calling in sick, being polite and committed to work. Some of the supervisors (B1, B2,
B3, B6, B7, B8) criticized some of these aspects in the context of RHPs as deficits. With regard to
cultural aspects, supervisors mentioned that RHPs had different values that sometimes inhibited
their integration such as examining other-sex patients (B1, B6-B8), taking off headscarves for sev-
eral reasons (B1, B8), dealing with homosexuality (B1) or accepting female superiors (B1-B4, B7).
These values were often attributed to cultural differences although they may result from context-
specific causes, as one supervisor who had a mediatory role describes:

The [female] colleague shouted at him [the RHP] in front of the patients [. . .] Luckily, we heard
about it and picked it up [. . .] she said he was a macho and suggested women were worth less than
men. The trigger was a basic nursing situation which is difficult for our participants as they haven’t
learned it in their home countries. And she gave instructions that were too brief, for example
“wash” and he didn’t know what to do with that instruction. […] And that caused the escalation
spiral. (B7)

RHPs were also asked about their experiences in the context of working culture. They pointed
out that formal aspects of work, such as being punctual and committed, were universal. However,
they (A1, A3, A8, A13, A16) experienced differences on the intercultural and interpersonal level,
such as the value of families and treating other sex patients, and developed several strategies to get
adapted to it:

I was born in an Islamic country. I am not Muslim but born there and I grew up there. And some-
times I think, maybe the [female] patient is embarrassed. Or I ask may I look, may I do. Because

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

maybe the other colleague does not say anything at all but for me it is a bit ok – maybe she has
problem with men and so on, so I ask. (A1)

Challenges with patients

RHPs experienced difficulties with patients especially if patients did not speak clearly due to their
illness, their age or their way of speaking:

The problem was that I couldn’t understand. For example, the patient said “bring me this and that”.
And the problem was that they spoke very unclearly and for German people it [is] also difficult to
understand and for me of course [it is] especially difficult. (A1)

Some described that talking to patients’ relatives was a new challenging experience especially if
they were furious (A8) or if they had to pass bad news to them (A7). Another challenge was asso-
ciated with distrust from patients: “Maybe they don’t trust the foreign physicians as much but that’s
general [generally the case]. All patients are like that, almost all of them. […] You can tell, they’re
a little scared or something” (A4).

Challenges with team members

Almost all supervisors (B2, B4-8) mentioned the important role of internships in the context of
team integration. However, one supervisor reported that finding internship placements became more
and more difficult due to lower capacities of the hospitals (B4). During some internships, partici-
pants were not given appropriate tasks or were not supervised (B2, B5, B7, B8) as “it is associated
with effort to take along someone” (B7). Sometimes local trained team members were not aware of
what RHPs were allowed or permitted to do which often led to misunderstandings (B5, B7, B8).
Almost all of the RHPs mentioned several other challenges in the context of teamwork, such as a
distanced relationship towards local trained team members (A8, A11, A15, A16), their expectation
that RHPs could do and know everything and wrong ideas of them and their education (A1, A9,
A10).

General Emotional challenges

Some of the RHPs (A3, A8, A16) experienced discouragement on their path to reintegration. They
were told by their employment agency consultants that they could not succeed as health profession-
als in Germany and were advised to pursue other career options:

I wanted to go to the hospital and see how this works. And I wasn’t sure if I could do that again. I
thought it is not possible. Because everywhere where I had asked [they said]: “No, you can’t do
that. Do another one. Do a retraining and so on. Do some care. But you can’t do midwife.” And I
came to my ward. I saw it, it is the same thing. (A16)

Additionally to being discouraged, supervisors thought RHPs felt impeded (B4), afraid (B5, B7,
B8), frustrated (B1, B6), under pressure and isolated (B1) as a consequence of the experienced bar-
riers. Moreover, they acknowledged RHPs’ loss of their professional status and mentioned that
RHPs were reduced to their language deficits (B1, B6, B7) which influenced their self-perception
and made them question themselves (B7).

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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

Discrimination

RHPs experienced several forms of discrimination. One supervisor reported that RHPs were some-
times rejected and ignored in decision-making. He describes a situation between a refugee physi-
cian and a locally trained nurse:

I can give you an example: my [refugee] physician is treating a patient. Another [locally trained]
nurse has a question about that patient. He [the nurse] is standing in front of my [refugee] physi-
cian and tells him: “I don’t want to clarify this with you. I will talk to your colleague who under-
stands me.” And that is a nice form of rejection. There are even more blatant cases. (B1)

Five supervisors (B1, B5, B6, B7, B8) and six RHPs (A1, A2, A3, A7, A10, A15) also reported
discrimination from patients towards foreign health professionals: “I was in the room, I had to take
[a] blood [sample] and the patient and also her husband said: ‘No, you may not come here. We do
not want a foreign physician here’” (A15). However, supervisors differentiated between open dis-
crimination and subtle racism from patients. They also differentiated between patients who did not
fully trust RHPs and patients who treated them in a racist manner from the beginning. In the con-
text of foreign-trained health professionals, one supervisor described intersectional discrimination as
some patients racially and sexually harassed female nurses from Thailand:

There was a situation where an older “fascist grandfather” in quotation marks somehow said he
didn’t want that or the Thai ladies – how shall I say, perhaps sexualised? So, with Thai participants
or Asian looking participants, the gentlemen often become a little bit, how can you say, more
cheeky. (B1)

Although this quote does not explicitly refer to refugee health professionals, it is likely that
RHPs also experience intersectional discrimination.
Additionally, RHPs (A3, A4, A8, A10-A13, A15) experienced discrimination from senior team

members as one female physicians describes:

I was at that interview with the chief physician and at the end he said: “Your German is well, […]
but there is something negative. [. . .] You have this headscarf. You are Muslim and there are a lot
of (tourist? terrorists? [incomprehensible]). How can the patients be sure that you are not a (tourist?
terrorist?)?” That moment was horrible for me. (A8)

The physician described that she refused the position afterwards due to this experience and
started working in a catholic hospital as her headscarf is not a problem there “because nuns also
wear a headscarf” (A8).

Exploitation

In addition to the discrimination faced by patients and team members, two supervisors (B2, B8)
described experiences of exploitation:

There are hospitals who misuse the situation of RHPs. There are hospitals that pay below the pay
scale (Tarifvertrag), very far below the scale. I will give you an example. There are hospitals in the
[anonymized] region who employ physicians from Afghanistan, Syria, Iraq. They hire them for-
mally as assistants, pay them 800 to 1200 Euros for a full time job, but they work as normal physi-
cians and are involved in normal hospital routine. No plaintiff, no judge6.. For the RHP it is at
least something. He can work as a physician after a long time and familiarize with procedures,
improve his language and do what he is qualified to do. But, by our standards, that is exploitation.

(B8)

Labour market: Refugee health professionals 11

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

This would also affect RHPs’ claims for benefits after terminating the employment (B8). Addi-
tionally to financial exploitation, one supervisor also mentioned that RHPs were sometimes hired as
gap fillers not correspondingly to their qualifications and did not have a long-term perspective
(B8). RHPs did not explicitly mention being exploited. However, many of them were not yet per-
manently working and one reported doing unpaid overtime, as he did not know about working
rights in Germany (A4).

Resources and strategies

RHPS and supervisors described several strategies they had developed in order to address the experi-
enced barriers. These strategies refer to individual strategies of RHPs, strategies in the context of edu-
cation and support, strategies on the team level and strategies on the organizational and societal level.

Individual strategies

All RHPs described several individual strategies to cope with challenges they had faced such as being
patient (A1, A2, A6, A9), trusting and believing in their own power resources (A3, A13, A16) or pre-/
post-processing relevant professional content (A1, A7, A12, A16). They also actively engaged with
their colleagues, asked them questions, demanded feedback (A9, A16) in order to cope with language
deficits. Furthermore, RHPs developed several strategies to cope with patients’ discrimination. They
either tried to reassure patients (A10, A12), accepted patients’ wishes and called a team member (A4),
ignored (A7) or avoided patients that rejected them (A16). In dealing with discrimination from team
members, some RHPs would focus on their goal instead of focusing on conflicts and try not to think
too much about these experiences (A12, A15). Others would use humour in order to unburden a
tensed situations with jokes (A10). Staying silent was described as a strategy as well:

I didn’t do anything and I didn’t say anything because I knew that if I said something, the situation
would get worse and I didn’t want that to happen. Yes, I was very calm and I wanted this nurse to
go home and think for herself, then she would understand. […] Yes, later she was a little better. All
beginnings are difficult. (A9)

Supervisors pointed out individual competencies of RHPs in dealing with the barriers. They
emphasized RHPs’ great commitment and their positive working attitudes. They also highlighted
the competencies of RHPs such as their intercultural competence (B4, B8), their openness to new
experiences (B1, B6, B7), a high motivation to work (BB7, B4, B3, B2), their cooperation capabil-
ity (B3), their gratefulness (B5) and their fighting spirit (B7).

Strategies in the context of education and support

In the field of education, supervisors demanded: mandatory, well organized, on the job programmes for
all RHPs that are funded (B8), career advice services (B6, B7), follow-up support (B7), more resources
and equipment for the training of RHPs (B4, B6, B7), material and support for language training.

Strategies on the team level

Generally speaking, positive contact towards patients and team members was perceived as very
helpful. One supervisor described RHPs’ and patients’ relationships as “a mutual connection as
they are stronger dependent on each other” (B7) than in other cases. Likewise, team members were
described by all RHPS to be open, interested and supportive: “They were all friendly and every

12 Khan-G€okkaya and M€osko

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

morning when I came to work they smiled at me and said ‘good morning’. And that I find really
important for a newly arrived” (A12). Almost all of them (A1-A4, A7-A9, A11-A14, A16-A17)
emphasized that colleagues were forthcoming if they had questions and that they benefitted from
their induction and their feedback. Two of them (A8, A11) pointed out the role of other (locally
trained) interns and students who helped them in their free time. Supervisors focused more on
structural resources for teams. They suggested training for local team members and mediators (B1,
B7), more personnel and more time to induct RHPs (B3, B6, B7), clear contact persons that RHPs
can talk to (B1, B4) and clear instructions of team members (B3). They also mentioned time to
familiarize for RHPs (B1, B2, B6, B7), less patients to care for at the beginning (B7) and sensitiza-
tion and reflexivity of locally trained team members (B1, B3, B7).

Strategies on an organizational and societal level

On an organizational and societal level, supervisors suggested enhancing an overall integration
approach so that RHPs can have a quick arrival in the system (B1), build up networks (B1, B6)
and earn their own money (B1). They also mentioned an opening welcoming culture (B1), public
sensitivity actions and support from the management boards (B7):

But we also need the attitude from above [the management board] that says: “We want that [the
labour market integration of RHPs], and we also provide time and resources, and teams also get a
benefit for getting involved”. (B7)

One supervisor referred to the commitment of supervisors and the healthcare providers when
observing racism and sexism: “If the hospital positions itself clearly and says ‘take your documents
and go home because we are not going to treat you’. Great, because that is a clear line. But if they
talk around the issue the patient will continue to show racist behaviour” (B8).

DISCUSSION

This paper aimed to explore the barriers and resources RHPs faced at their workplaces. The broad
range of identified barriers and difficulties indicates that their experiences depend very much on their
employers and their working environment. Moreover, as understaffing is a common problem in
health care (Angerer et al., 2011; Deutscher Gewerkschaftsbund (DGB), 2018), it is questionable to
what extent only RHPs are affected by these experiences or if they are a consequence of the precari-
ous staffing situations. Moreover, it remains open to what degree the migration status influences the
experienced challenges. Since no questions were asked about their flight, their psychological well-
being or their residency permit and none of the participants mentioned it in the context of their
workplace experiences, it is not possible to state whether only refugees experience these barriers.
Instead, our results indicate that when focusing at their workplaces, RHPs face similar barriers as
internationally recruited professionals and voluntary migrants (Humphries et al., 2013; Jirovsky
et al., 2015; Klingler and Marckmann, 2016; P€utz et al., 2019). Nine major challenges were identi-
fied: 1) recognition of qualifications, (2) language competencies, (3) different healthcare systems, (4)
working culture, (5) challenges with patients, (6) challenges with team members, (7) emotional chal-
lenges, (8) discrimination and (9) exploitation. These challenges illustrate that hiring RHPs should
not be a quick response to filling shortages. Instead, the integration process should be carefully pre-
pared in order to prevent some of these challenges. Labour market integration is a two-sided process
that requires not only a welcoming culture but also welcoming structures (Knuth, 2019). Educational
providers, employers as well as authorities need to address these barriers and implement structural
changes in order to contribute to a sustainable labour market integration of RHPs.

Labour market: Refugee health professionals 13

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

Both RHPs and supervisors emphasized the challenges with the recognition process. This is con-
sistent with previous findings that many legal and formal barriers inhibit a successful labour market
integration and prevent organizations to invest in RHPs integration (Schmidt, 2019).
RHPs and supervisors both stressed the role of acquiring the language and the consequences of

lacking language competencies. RHPs suffered from not speaking German fluently, and it affected
their self-esteem. Likewise, the knowledge and familiarization with the local healthcare system is
an important prerequisite in order to deliver a good working performance. Both barriers are
reported to be common challenges in the context of labour market integration of refugees as well
as other migrant groups (Cohn et al., 2006; Bloch, 2008; Leblanc et al., 2013; Klingler and Marck-
mann, 2016). This indicates a stronger need for occupational specific language courses and infor-
mation on the healthcare system of the host country. This would not only concern educational
providers but also employers. In order to maintain a good quality of care and prevent misunder-
standings or mistreatment due to language barriers (Klingler and Marckmann, 2016), employers
can invest in further education of their RHP employees. Although this would mean additional
financial investment from the employer, a corporate study indicates that those investments would
pay off within a year (Baic et al., 2017).
In the context of working culture, a fast adaptation to local standards was expected by supervi-

sors and team members. Deviations from these local standards were seen as problematic and
obstructive. This coincided with results from other studies (Klingler et al., 2018; P€utz et al., 2019)
However, it remains problematic due to several reasons. Firstly, the term “local standards” pre-
sumes shared standards (Klingler et al., 2018). However, it remains unclear if these standards refer
to professional standards, legal regulations, norms, cultural aspects or hospital routines. Secondly,
the knowledge about certain established standards may be tacit and implicit (Sakamoto et al., 2010)
thus unspoken. As RHPs are unaware of these unspoken standards, deviations in behaviour can
lead to frustration, conflicts and exclusion (Lai et al., 2017). Thirdly, most of the perceived differ-
ences in the context of working culture from the supervisors were culturalized. Supervisors saw the
causes of conflicts in cultural distinctions, although they could as well be interpreted situation and
person specifically or result from differing concepts of work. This is consistent with previous find-
ings (P€utz et al., 2019) that in the process of labour market integration differing concepts attributed
to work clash. These concepts may be influenced by stereotypes and prejudices. As a result, on the
one hand immigrated employees identify themselves as the “outsiders” contrary to local employees.
On the other hand, an enhancement of the existing working culture that could have been adaptable
to a new environment is excluded (Steinberg et al., 2019). Fourthly, the performance of RHPs is
measured according to their adaption and stabilization to the system. But the potential that RHPs
bring along is wasted if adaption and stabilization are the only possible and acceptable outcomes
since they bring along important working experiences and attitudes that may enrich local standards.
Thus, it is important to verbalize standards and address them before or ideally concomitant to
RHPs labour market integration (Sakamoto et al., 2010). At the same time, it is important to offer
local team members opportunities to reflect on their own standards of work and their expectations.
This could also contribute to an overall improvement of the working atmosphere and reduce the
challenges experienced with team members. However, difficulties with team members were also
attributed to a lack of supervision during internships. Results indicate that most of the time, indi-
vidual team members were intrinsically motivated to support RHPs and engaged in their induction.
But the responsibility of integrating RHPs should not only be outsourced to committed employees
or in the worst case, as described in the results, to unwilling employees. The support of RHPs
should be implemented on a structural level. It is estimated that a one and a half additional hours
of individual support per month are sufficient to generate good integration prospects (Baic et al.,
2017). However, it remains open to question if team members who provide individual support
should be further trained and/or remunerated for their effort. In order to expand the support possi-
bilities, mentoring programmes could also be helpful in supporting RHPs. These findings are

14 Khan-G€okkaya and M€osko

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

consistent with recommendations given by the German Employer Association stating that mentor-
ing programmes are a classical approach towards integrating foreign workers (Robra and B€ohne,
2013).
In general, more acknowledgement and empowerment for RHPs is needed. This is consistent

with previous findings describing the loss of RHPs’ professional status (Leblanc et al., 2013) result-
ing in deskilling (Stewart, 2003), the loss of self-confidence (Jirovsky et al., 2015), feelings of frus-
tration (Mozetic, 2018) and negative psychological impacts (Cohn et al., 2006). Results in this
study further indicate that RHPs experience several forms of discouragement, discrimination as well
as disparagement, although they are fully educated and bring along valuable human capital (A9).
Although RHPs have already developed several strategies in dealing with negative feelings and the
barriers they face, organizations and educational institutions could further engage in strengthening
RHPs’ professional identity, acknowledge their strategies and/or make the potential of RHPs visible
in order to empower them.
In the light of the discrimination that RHPs faced by team members and patients, healthcare pro-

viders need to promote measures of diversity management as discrimination may be one result of
poor diversity management (Dickie and Soldan, 2008). Discrimination influences the motivation
and job satisfaction of RHPs and in the long term, it can also have negative psychological impact
and lead to leaves of RHPs (Bouncken et al., 2015). On the contrary, a diversity climate within the
organization can enrich the psychological capital of refugee employees and contribute to their com-
mitment (Newman et al., 2018). Nevertheless, several forms of discrimination from patients and
colleagues were commonly mentioned topics consistent with previous findings on RHPs’ experi-
ences (Cohn et al., 2006; Bloch, 2008; Jirovsky et al., 2015). According to the federal German law
“General Act on equal Treatment,” employers are legally obliged to protect their employees from
discrimination (Allgemeines Gleichbehandlungsgesetz, 2006). But especially experiences of racism
are often denied in health care as “the illusion of non-racism” exists and impedes progressive poli-
cies (Johnstone and Kanitsaki, 2008). Progressive policies may refer to promoting equal opportu-
nity policies (Wrench, 1999) and prevent any form of discrimination (B8). Condemning racist
comments (B8), establishing anti-discrimination commissioners, setting up transparent complaint
systems and offering anti-discrimination and empowerment workshops could be first steps (Wrench,
1999) towards an inclusive and healthier working environment for both staff and patients.
Similarly, the exploitation of RHPs needs to be addressed and employers as well as policymakers

should take responsibility for it. Due to their uncertain legal status, foreign workers are at high risk
of being exploited (Rights, 2010). Labour unions have recognized that and demanded that refugees
must be given access not only to the labour market but also to career advice services (Deutscher
Gewerkschaftsbund (DGB), 2015) in order to increase awareness of their working rights. Another
way for employers to prevent exploitation could be to appoint an integration commissioner for their
organizations. These commissioners could monitor the integration process and ensure compliance
with working rights. Educational providers working with clinics could inform RHPs as well as clin-
ics on the legal rights and duties of RHPs. In any case, this finding points to a severe grievance
that has not been reported in previous studies in this context. Further research is necessary to find
out if these are selective experiences or structural problems in the health care sector.
In general, results indicate the need to reflect on the term integration itself. Several migration

scholars criticize the term for numerous reasons. Firstly, in Germany the term “integration” mostly
refers to regulatory policies which focus on integrating migrants into the existing social orders
(Karakayali and Bodjadzijev, 2010). However, social orders are predefined and shaped by members
of the majority group (Essed, 2000). Secondly, the term is based on negative narratives about the
unwillingness or failed integration of migrants which contributes to the fact that new demands are
constantly being claimed on migrants (Mecheril, 2011). Hence, the term puts migrants into the
focus while structural and institutional deficits as well as power asymmetries within the host coun-
tries are ignored. Subsequently, the experiences of racism and exploitation that RHPs describe in

Labour market: Refugee health professionals 15

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

this study point to the need to focus research on structural and institutional inequalities, power
asymmetries and intersectional discrimination. For further research in this context, it would be help-
ful to consider the Critical Race Theory (CRT) as it is based on principles of race equity and social
justice and provides tools in order “to elucidate contemporary racial phenomena, expand the vocab-
ulary with which to discuss complex racial concepts and challenge racial hierarchies” (Ford and
Airhihenbuwa, 2010). Furthermore, activists and scholars who contributed to the CRT study and
transform the relationship between race, racism and power (Delgado and Stefancic, 2017). How-
ever, for the purpose of this study it can be concluded that equal participation in the labour market
and society requires equal treatment, equal opportunities and protection against discrimination
(Uslucan, 2017).

Policy recommendations

Refugee health professionals face personal, structural and institutional barriers at their workplaces.
Although they have developed strategies to overcome these barriers, structural and institutional
changes are needed in order to improve the working environment. In the following, the most impor-
tant conclusions from this study are pointed out as recommendations in order to contribute to a bet-
ter labour market and workplace integration of refugee health professionals. First, there is a need to
offer job-specific language courses and courses addressing formal and cultural aspects of work (as it
is done for example in Sweden (Ministry of Employment and Sweden, 2016)). Similarly, local team
members need to be sensitized for cooperation with refugee health professionals in order to decrease
the potential for conflict. Second, structural changes within teams need to be implemented in order
to supervise refugee health professionals and ensure a proper induction at the beginning. Third, in
light of the experienced barriers, the discrimination and the exploitation, there is a need to empower
refugee health professionals and make their qualifications and their potential visible. Fourth, mea-
sures of diversity management and anti-discrimination need to be implemented and supported by the
management board. Fifth, compliance with working rights must be ensured and team members as
well as refugee health professionals need to be informed about their working rights.

Strengths and limitations

This study identified major challenges in the context of the working experiences of RHPs. By
choosing an explorative approach, a broad range of topics could be identified which provide a basis
for further research and in-depth analysis of the difficulties in the identified fields. The perspective
of RHPs and their supervisors were integrated in order to get an insight into the field of health pro-
fessions and the labour market integration into health professions. For further research, it could also
be helpful to interview colleagues of RHPs and focus on specific healthcare settings. Participants in
this study were selected from rural as well as urban areas and comprised several health professions.
Another strength of this study lies in the methodology. Discussing data with an interdisciplinary
group ensures comprehensibility and critical reflection. Nevertheless, as participants were not
recruited representative and most participants worked only for a short time in Germany, there might
be a selection bias and results are questionable in terms of generalizability. Another limitation is
the compilation of the sample as more physicians and more men in urban areas were interviewed.
Intersectional barriers, language competencies, training experience and other demographic-specific
aspects were neglected. Hence, no conclusions could be drawn for subgroups. Furthermore,
although a certain language competency was required, language barriers and socially desirable
answers may have influenced the interview process. However, due to the researchers’ background
and the reflection of her characteristics, a trustful interview situation could be created and reflected
afterwards.

16 Khan-G€okkaya and M€osko

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

ACKNOWLEDGEMENT

We are grateful to the participants and to the organizations who have made this study possible
through their support. Open access funding enabled and organized by Projekt DEAL.

FUNDER INFORMATION

The study was funded by the European Social Fund. SKG and MM received the funding. The fun-
ders did not play any role in the study design, data collection, decision to publish or preparation of
the manuscript.

DECLARATION OF INTERESTS

We have no conflicts of interest to disclose.

Peer Review

The peer review history for this article is available at https://publons.com/publon/10.1111/imig.
12752.

NOTES

1. The terms “refugee health professionals” and “supervisors” were selected as they describe a shared experi-
ence. However, it should be noted that both terms reduce these persons to only one aspect of identity. The
terms do not reflect the multiple aspects of identity and the social and ethical dimensions of the workplace
identity that all interviewed person and health care professionals have.

2. The Common European Framework of Reference for Languages: Learning, Teaching, Assessment (CEFR)
is a reference system to describe six levels (A1, A2, B1, B2, C1, and C2) of language proficiency from
beginners (A1) to experts (C2).

3. SPSS is an abbreviation for Sammeln, Pr€ufen, Sortieren and Subsumieren (Collect, Check, Sort, Subsume).
4. Health professions are registered professions in Germany which is why foreign health professionals need

to have a full or temporary license before they can practise. In order to obtain a license, they have to
go through a recognition process. The first step of the recognition process is an equivalence assessment.
Based on this assessment, recognition bodies grant full recognition, no recognition or partial recognition.
If qualifications are only partly recognised, foreign health professionals can participate (professional
groups like nurses must participate) in adaption training programmes or internships and prove their
required knowledge through language and proficiency tests. The proficiency tests covers internal medi-
cine and surgery. However, based on the equivalence assessment authorities may also evaluate other
subjects.

5. As the interviews were conducted in German, citations in this section were translated one-on-one from Ger-
man to English. If terms were not equivalent in English, then those terms were translated one-on-one and
supplemented with further explanations in the reference mark (Koller, 2011 Einf€uhrung in die €Uberset-
zungswissenschaft [Introduction to translation science], Francke, T€ubingen; Basel.).

6. “No plaintiff, No judge” (German translation: Wo kein Kl€ager, da kein Richter) is a common phrase in
German. It describes that certain irregularities or grievances remain uncovered as no one complains about
them.

Labour market: Refugee health professionals 17

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

https://publons.com/publon/10.1111/imig.12752

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22 Khan-G€okkaya and M€osko

© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration

GLOBALIZATION AND THE HEALTHCARE
WORKFORCE

Leah E. Masselink

CHAPTER

Learning Objectiv

After completing this chapter, the reader should be able to

• describe the history and current trends in international migration of
physicians and nurses;

• enumerate the factors that motivate physicians and nurses to migrate to
other countries;

• discuss the implications of physician and nurse migration for sending an

receiving countries;

• understand the policy context and policy interventions that attempt to
manage physician and nurse migration; and

• explain the issues of ethical recruitment, visa regulation, credentialing,
and adaptation for managers of foreign-born and -trained physicians and
nurses.

Introductio

In an increasingly interconnected world, the movement of people and infor-
mation across international borders has become a phenomenon that is often
taken for granted. As skilled healthcare providers, physicians and nurses hav

had opportunities to seek employment internationally for several decades, and
foreign-trained professionals are important parts of the healthcare systems in
many countries. In the United States alone, about 25 percent of physicians are
foreign born and educated and about 4 percent of nurses were educated over-
seas (Cooper and Aiken 2006; Aiken et al. 2004).

The implications of international migration of physicians and nurses
are complex, becoming a source of increasing debate in recent years. While
physicians and nurses who migrate to other countries can benefit from better
working conditions or salaries in their destinations, their movement can exacer-
bate inequalities in the worldwide distribution of healthcare workers. Migration

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EBSCO Publishing : eBook Academic Collection (EBSCOhost) – printed on 2/1/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY
AN: 237620 ; Fottler, Myron D., Fried, Bruce.; Human Resources in Healthcare : Managing for Success
Account: s8993066.main.ehost

of healthcare workers from developing countries has particularly far-reaching
implications. These developing countries not only lose their investments in ed-
ucation and training, income tax revenue, and potential for national growth,
buy they also see adverse health effects on their populations. In nations where
healthcare workforce shortages are already severe, the need to replace healthcare
professionals who have left for other countries only further depletes the health
system’s resources—funds that normally go toward fighting diseases and pro-
moting public health. In addition, the lack of highly skilled care providers pre-
vents these countries from meeting their own needs for healthcare innovation
and problem solving. These factors exacerbate the existing inequalities in health-
care between developed and developing countries.

Given that foreign-trained physicians and nurses play an important role
in many healthcare organizations in the United States, healthcare managers in
this country must understand several issues related to the globalization of the
healthcare workforce:

• In what areas do international migration of physicians and nurses occur?
What can explain these patterns?

• What factors motivate the international migration of physicians and
nurses?

• What are the ethical and logistical implications of physician and nurse
migration for sending and receiving countries?

International migration of physicians and nurses is inherently difficult
to manage because policies designed to direct and oversee it must balance two
often competing objectives: (1) to protect the inherent right of people to mi-
grate and (2) to ensure that quality healthcare services are available to all. This
chapter describes past and current migration trends, causes, policy context,
and responses. It also explores several international migration issues, such

ethical recruitment, visa regulation, credentialing, and adaptation. All of these
topics are essential knowledge for U.S. healthcare managers.

History and Current Trends

Anecdotal accounts of international migration of physicians and nurses began
to circulate in the 1960s. Initial reports mostly documented migration be-
tween developed countries, such as from Canada to the United States (BMJ
1968). In the 1970s, the World Health Organization (WHO) commissioned
The Multinational Study of the International Migration of Physicians. This no-
table study found that, at the time, significant numbers of international med-
ical graduates (IMGs) were practicing in the United States (about one in
every five physicians), the United Kingdom (more than one in every four
physicians), and Canada (one in every three physicians). Germany also had

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substantial numbers of migrant physicians, including many from Iran and the
Middle East (Mejía 1978). In addition, the study reported that significant
numbers of international nursing graduates (INGs) worked in the United
States, European countries, and other developed nations. Sending countries
(the countries from which healthcare professionals migrate) with particularly
high proportions of nurses who go abroad to work include Haiti, Suriname,
Hong Kong, Jordan, and the Philippines. In absolute numbers, more Filipino
nurses were registered in the United States and Canada than in the Philippines
in 1970 (Mejía 1978).

The characteristics of healthcare workforce migration have shifted since
the WHO study was conducted in the 1970s. New sending countries have be-
come significant sources of migrant physicians, including Egypt, Cuba, and
nations in the Caribbean; sub-Saharan Africa; and the former Soviet Union.
New receiving countries (the destinations of migrant healthcare professionals),
such as the Persian Gulf states, have begun to draw physicians and nurses from
all over the world, including Europe and India. Migration between the Euro-
pean Union and African countries has also increased (Martineau, Decker, and
Bundred 2004). Some countries—particularly South Africa—have emerged as
“holding grounds” for migrant workers who stay temporarily on their way to
their final destination country (Vujicic et al. 2004).

According to Mullan (2005), the countries that send the largest num-
bers of physicians abroad are India, the Philippines, and Pakistan, while the
countries that receive the greatest numbers of IMGs are the United States, the
United Kingdom, Canada, and Australia. IMGs compose approximately
25 percent of the physician workforce in the United States, 28 percent in the
United Kingdom, 23 percent in Canada, and 27 percent in Australia (Mullan
2005). In the United States, the three largest sending countries or regions for
INGs are the Philippines, Canada, and Africa (especially South Africa and Nige-
ria). Between 1997 and 2000, 33 percent of foreign-born nursing-licensure ap-
plicants were Filipino, 22 percent were Canadian, and 7 percent were African
(Buchan, Parkin, and Sochalski 2003).

Migration streams, particularly between English-speaking countries,
appear to be well established: While IMGs make up more than 20 percent of
the total physician workforces in the United States, the United Kingdom,
Australia, and Canada, they represent only a tiny proportion of the physician
workforces in France (3 percent) and Japan (1 percent) (Mullan 2005). In
sub-Saharan Africa, rates of nurse migration are also markedly higher in An-
glophone countries than in French- and Portuguese-speaking countries
(Dovlo 2007). Many sending countries tend to have historical relationships
with English-speaking receiving countries. For example, physicians from India
and Pakistan make up the largest and third-largest groups, respectively, of IMGs
in the United Kingdom, and doctors from the Philippines are the second-
largest group of noncitizen IMGs in the United States (Mullan 2005).1

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Many policymakers in both sending and receiving countries have ex-
pressed concern about the fact that the largest receiving countries draw sig-
nificant proportions of their IMG workforces from lower-income countries.
More than 75 percent of the IMGs in the United Kingdom come from lower-
income countries, and other receiving countries have substantial proportions
as well: Sixty percent of IMGs in the United States and about 40 percent of
those in Canada and Australia are from developing nations (Mullan 2005).

Causes of International Migration

Determinants of physician and nurse migration are often discussed in terms of
“push” and “pull” factors. Push factors motivate physicians and nurses to leave
their home countries, while pull factors cause them to choose particular receiv-
ing countries. The reasons are chiefly discussed within an economic framework,
considering a variety of factors as potential determinants. These include per
capita gross domestic product, physician coverage, manpower production rates,
rural/urban distribution of physicians and nurses, and workforce imbalances.

Push factors cited by the majority of studies include low pay, poor
working conditions, political instability and insecurity, inadequate housing
and social services, and lack of educational opportunities and professional de-
velopment. Job dissatisfaction, lack of motivation, and weak professional lead-
ership are also mentioned as contributing factors (Saravia and Miranda 2004).
Pull factors, on the other hand, include opportunities for professional train-
ing, better job opportunities, and higher wages (Forcier, Simoens, and Giuf-
frida 2004). Other pull factors relate to workforce-supply issues that have cre-
ated an imbalance between the demand for services and the supply of workers
in receiving countries, such as aging of both the general population and the
nursing workforce and the slowdowns in enrollment in training programs
(Buchan and Sochalski 2004). The nursing workforces in receiving countries
are vulnerable to such shortages, particularly with the opening of male-dom-
inated careers to women (Marchal and Kegels 2003). IMGs and INGs are par-
ticularly needed in some receiving countries where domestically trained
providers are reluctant to serve in certain capacities, such as in remote areas or
in nursing homes.

Sending Country/Region Trends

Physician and nurse migration can be managed to varying degrees by sending
countries. Some regions (such as sub-Saharan Africa and the Caribbean) con-
tinue to lose workers in the face of severe shortages, while other nations (such
as Cuba, India, and the Philippines) purposely train surplus physicians and

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nurses for overseas employment. Still other countries (particularly China) are
currently looking to shift into a training-for-export mode. This section sheds
light on the diverse situations faced by sending countries and describes in de-
tail the factors that contribute to each situation.

Brain Drain: Sub-Saharan Africa and the Caribbean

The situation in sub-Saharan Africa and the Caribbean is often referred to as
brain drain—the widespread, uncontrolled departure of physicians and
nurses from countries that already suffer healthcare worker shortages.

In sub-Saharan Africa, the largest sending countries are South Africa and
Nigeria. In 2005, nearly 7,000 South African physicians and more than 4,000
Nigerian physicians were practicing in the United States, the United Kingdom,
Canada, and Australia (Mullan 2005). Ghana has also experienced high rates
of physician and nurse emigration: In 2000, that country lost more practicing
nurses than the number of nursing graduates it produced (Dovlo 2007). As a
relatively wealthy sub-Saharan African state, South Africa is unique in that it
acts as both a sending and a receiving country for migrant physicians and
nurses, many of whom come from other countries in the region.

In Africa, among the factors that influence health professionals’ deci-
sions to leave are low quality of life, high crime rates, conflict, political repres-
sion, and lack of educational opportunities for children. The HIV/AIDS epi-
demic has seriously depleted the healthcare workforce through death and
attrition, and caring for growing numbers of patients with HIV/AIDS has
overburdened the remaining providers. Nurses in this region are poorly paid,
and this lack of adequate compensation also contributes to the workforce
shortage. Sub-Saharan Africa suffers from a serious maldistribution of healthcare
workers, with uneven supply between the public and private sectors, urban and
rural areas, and tertiary and primary levels of care (Padarath et al. 2004).

A lack of higher education and career-development opportunities is an-
other major push factor in this region. This dearth reflects a pattern of under-
investment in higher education by governments and outside donors. Health-
professional education and training not only subsist on very limited material
resources but are also plagued by a shortage of qualified teachers.

Similarly, countries in the Caribbean are overwhelmed by extremely
high rates of HIV infection that are second only to the epidemic in sub-Saharan
Africa. This region has also experienced crippling losses of nurses in recent
years: 42 percent of all nursing positions across the Caribbean are vacant, and
the lack of nursing educational capacity serves only to perpetuate the massive
losses of nursing educators and experienced nurses. Jamaica is particularly af-
fected, with a 58 percent average nursing vacancy rate in 2003. Many Ja-
maican nurses left to work in the United States, the United Kingdom, and
Canada, and Jamaican healthcare leaders have begun to recruit from other
countries in the Caribbean to make up for losses (Salmon et al. 2007).

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Strategic Deployment: Cuba, the Philippines, and India

Some developing countries train surplus physicians and nurses for overseas
employment, and both state and business interests promote and manage
this practice. Cuba has a long-standing program of physician deployment,
and the Philippine government has worked to manage nurse migration for
many years. Recently, strategic deployment programs have also arisen in
India.

For several decades now, Cuba has made the provision of healthcare
workers to developing countries a part of its foreign policy, sending physicians
to developing countries as participants in a Peace Corps–style international
medical-aid program (Feinsilver 1989). These efforts are part of a larger ef-
fort by the Cuban government to promote its political agenda and to position
itself as a “world medical power.” Dozens of countries have received Cuban
physicians over the years, including Algeria, South Africa (Lee 1996), and
more recently Venezuela (Muntaner et al. 2006). Cuban physicians who par-
ticipate in the program often provide services in isolated rural areas and are
often involved in training their host countries’ indigenous healthcare workers
(Feinsilver 1989).

The Philippine government has been particularly active in establishing
policies that aim to make the country the niche producer of nurses in the
global economy (Ball 1996). The Philippines produces about 20,000 new
nurses every year (Lorenzo et al. 2007), and the vast majority of these grad-
uates eventually find work overseas: In 2004, 85 percent of all Filipino nurses
practiced abroad (Aiken et al. 2004). A government agency regulates recruit-
ment of Filipino overseas workers and processes documents for those bound
to work in other countries. The emergence of nursing as a pathway to migra-
tion has led to unprecedented demand for nursing education in the Philip-
pines. The number of nursing schools has grown exponentially in the past few
decades, from 40 schools in the 1970s to 460 schools in 2006 (Lorenzo et al.
2007). This growth has led to concerns about the quality of nursing educa-
tion, as schools compete with each other for faculty and hospital training space
(Lorenzo et al. 2007).

Historically, India has been one of the largest sending countries of
physicians to developed nations, including the United States and the United
Kingdom (Mullan 2006). In recent years, it has also become a popular source
country for nurses. Since the 1990s, it has moved from sixth to second posi-
tion (after the Philippines) among countries that send nurses to the United
States. Like the Philippines, India has a huge overall labor surplus, although
it also has a very low nurse-to-population ratio. It has also become the site of
increasing commercial activity around nursing education and migration. In-
dian hospitals have become involved in recruiting and training nurses for over-
seas markets, and local recruitment agencies that partner with U.S.-based re-
cruiters have appeared in many urban areas. In recent years, some state

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governments have also begun to engage in international deployment of nurses
(Khadria 2007).

The most frequently cited reason for the strategic deployment of physi-
cians and nurses is the remittance income that migrant workers send to their
home countries. Remittances can be a substantial source of revenue for send-
ing countries. For example, Filipino migrant workers remitted $10.7 billion
in 2005 (Lorenzo et al. 2007). Remittance income is often considered a po-
tentially positive outcome of emigration. However, while such income m

offset sending countries’ financial losses, it may not make up for the staffing
issues and poor outcomes associated with workforce migration.

Up-and-Coming Player: China

China is a relative newcomer to the global nursing market. It has sent nurses
abroad for about 15 years, when the government began deploying groups of
English-speaking nurses to Singapore and Saudi Arabia under temporary gov-
ernment-arranged contracts (Fang 2007). Since the early 2000s, this migra-
tion has shifted to countries such as Australia and the United Kingdom, where
it is usually arranged by private agencies. U.S. healthcare organizations have
begun to express interest in recruiting nurses from China.

For some Chinese nurses, the desire to seek employment abroad is in-
fluenced by several domestic factors. First, China has not invested enough in
healthcare to employ all of its trained and educated nurses. Like the Philip-
pines, China has a surplus of nurses based on the number of budgeted posi-
tions. Many nurses are unable to find work, or they are forced to retire early
to make room for new graduates who are entering the workforce. Also, China
has more physicians than nurses, contrary to recommendations by the WHO.
In this context, overseas markets are becoming a desirable alternative for some
Chinese nurses.

Consequences for Receiving Countries

The presence of IMGs and INGs has several important consequences for re-
ceiving countries. Some of the consequences of physician and nurse migration
relate to larger issues of recruitment and retention. International recruitment
is suggested to be a quick fix for recruitment and retention problems in re-
ceiving countries, allowing domestic supply lines to avoid developing their
own solutions to unmet health-system needs. International migration may
help receiving countries to fill positions in areas that are not as attractive to
domestic workers. This leads to concerns that foreign-trained professionals
may be subject to exploitation or may be forced to work in positions that are
below their expertise—a phenomenon referred to as “brain waste” (Marchal
and Kegels 2003).

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The effects of having immigrant physicians and nurses on accessibility
and quality of care are unclear: Some suggest that the quality and safety of care
provided by internationally trained providers may be cause for concern, while
others argue that the presence of these professionals may improve access to
care, lower prices, and induce competition and higher quality (Forcier,
Simoens, and Giuffrida 2004). The “safety net” use of immigrant healthcare
workers has been demonstrated to be a real phenomenon (Forcier, Simoens,
and Giuffrida 2004). The presence of immigrant health workers may prevent
receiving healthcare systems from solving their own training and staffing
problems. For example, while U.S. hospitals hire thousands of IMGs each
year, thousands of domestic medical-school applicants are turned away (Mar-
tineau, Decker, and Bundred 2004).

The Policy Context

International migration occurs in the context of several important trade
agreements. One such agreement that could affect future migration dynam-
ics is the General Agreement on Trade in Services (GATS), which was imple-
mented in 1995. GATS is an international treaty that governs the trade of
services, including health services, among member countries of the World
Trade Organization. GATS has three main objectives: (1) to liberalize trade
in services, (2) to encourage economic growth through liberalizing trade in
services, and (3) to increase the participation of developing countries in the
world trade in services. The four modes of trade governed by GATS are (1

)

cross-border supply (services provided by workers in one country for organ-
izations in another country), (2) consumption abroad (including medical
tourism and education of foreign students), (3) commercial presence (invest-
ment of capital from one country into another), and (4) movement of natu-
ral persons (temporary cross-border migration of workers to provide services
in another country [Kingma 2006]). While the GATS provision for tempo-
rary migration has caused concern that it would encourage further migration
of health workers from developing countries to developed countries, this el-
ement is still being negotiated, and its final effects remain unclear (Kingma
2007).

Another agreement that particularly affects migration patterns in the
United States is the North American Free Trade Agreement (NAFTA), which
was implemented in 1994. NAFTA provides for the movement of workers be-
tween Canada, the United States, and Mexico, including special visa cate-
gories and mutual recognition of nurse licensure in the United States and
Canada. This agreement has raised Canada’s profile as a sending country of
nurses in the United States, but movement between the two countries has
been mostly unidirectional: About 15,000 Canadian nurses have moved to the
United States under NAFTA, but relatively few U.S.-trained nurses have
moved to Canada (Kingma 2006; Mautino 2003).

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Policy Responses

A broad variety of policy initiatives have been proposed and implemented by
sending and receiving countries to manage international migration of physi-
cians and nurses. These include programs instituted by worldwide bodies such
as the WHO and the International Council of Nurses (ICN), domestic policy
changes in sending and receiving countries, government-to-government bi-
lateral agreements, and proposed compensation schemes. Some countries or
regions have adopted unique policies to manage the effects of physician and
nurse migration: The Caribbean, as a sending region, has adopted a program
called Managed Migration, and the United Kingdom, as a receiving country,
has established the “Code of Practice on International Recruitment.”

The WHO (2007) has developed a variety of initiatives to manage the migra-
tion of healthcare workers. It is working with the Global Health Workforce
Alliance Task Force to support efforts to scale up health-worker education,
particularly in countries faced by workforce crises. It also provides technical
support to countries and assists regional human resources for health observa-
tories. Additionally, the WHO supports the Treat, Train, Retain (TTR) initia-
tive, begun in 2006 to curb the effects of HIV/AIDS on the healthcare work-
force and health systems in low- and middle-income countries. The goals of
TTR are threefold: (1) to provide treatment, prevention, and support to
health workers affected by HIV/AIDS; (2) to train providers (including com-
munity health workers) to maximize existing capacity to treat HIV/AIDS;
and (3) to retain health workers in rural areas and the public sector in un-
derresourced countries. The WHO will provide assistance to participating
countries in developing TTR plans and budgeting for proposed changes,
but TTR’s implementation and financing will be managed by individual
countries.

The ICN—the federation of national nurses associations (e.g., American
Nurses Association, Philippine Nurses Association)—has developed a position
statement on ethical recruitment of nurses to guide the recruitment efforts
between its member countries. While acknowledging nurses’ inherent right to
migrate, the statement also calls for receiving countries to work toward build-
ing self-sustainable, domestically trained nursing workforces. The statement
also aims to protect migrant nurses, calling for several measures such as good-
faith contracting, freedom of employment and association, and fair pay and
working conditions (ICN 2007).

Some sending countries have implemented domestic policy changes to reduce
the effects of push factors that motivate physicians and nurses to seek overseas
employment. These changes include improvement in pay, career opportunities,
and working conditions; provision of incentives to induce overseas workers to

55C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e

WHO Activities

ICN Statement

Domestic
Policies in
Sending
Countries

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return home; and the development of private-sector opportunities. Other meas-
ures focus more specifically on medical education, including pre-education
screening of candidates likely to stay in-country, shortening of domestic train-
ing programs, and adaptations of curriculum to local conditions.

Still other policies aim to use financial disincentives to keep workers in-
country, requiring emigrants to pay fees upon departure. For example, Eritrea
has a bond program in which departing physicians are required to make up-
front payments that guarantee their return from studies in South Africa (Mar-
chal and Kegels 2003). This type of system could be particularly useful if rev-
enues generated were used to fund human resources development in sending
countries (Saravia and Miranda 2004).

Some receiving countries have adopted domestic policy changes to address
the underlying human resources imbalances that contribute to the demand
for foreign-trained workers. In many developed countries, nursing short-
ages are exacerbated by difficulties in retaining domestically trained
nurses—difficulties that are often related to poor working conditions and
low salaries (Janiszewski Goodin 2003). Turnover rates for nurses in U.S.
hospitals were estimated at between 10 percent and 30 percent in 2000
(HSM Group 2002). To improve domestic retention, receiving countries,
such as the United Kingdom and Australia, have implemented programs to
recruit and retain domestic healthcare workers (Martineau, Decker, and
Bundred 2004). Other countries have begun recruiting nonconventional
workers, such as firefighters, to the healthcare field (Marchal and Kegels
2003).

In 2002, the U.S. Congress passed the Nurse Reinvestment Act, a
piece of legislation that uses a combination of expanded eligibility for loan re-
payment, education vouchers, and other measures to improve retention of
nurses (Andrews 2004). While this legislation represents a positive step in im-
proving retention of domestically trained nurses, its funding stream has been
subject to frequent cuts in the past few years, so its overall impact is unclear
(Janiszewski Goodin 2003).

Some sending and receiving countries have attempted to regulate the migration
of healthcare workers between them by signing government-to-government
bilateral agreements. Under this agreement, a receiving country pledges to
underwrite the costs of training additional staff; to recruit staff for a fixed pe-
riod (often providing training before staff return to the sending country); or
to recruit surplus staff from a sending country (Buchan 2007). For example,
the United Kingdom has bilateral agreements with the Philippines and Spain
that allows the United Kingdom to recruit nurses from these two countries
for temporary work in the National Health Service (Kline 2003). Bilateral
agreements can help to manage the flow of physicians or nurses between

56 H u m a n R e s o u r c e s i n H e a l t h c a r e

Domestic
Policies in
Receiving
Countries

Government-to-
Government

Bilateral
Agreements

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sending and receiving countries by mandating short-term rather than perma-
nent migration.

Another policy intervention that has been proposed requires receiving coun-
tries to compensate sending countries for the financial losses associated with
worker migration. Various versions of this plan call for remuneration of the
costs of educating migrant workers, for assistance with human resources de-
velopment in sending countries, and for additional compensation for sending
countries’ lost tax revenue. Although well intended, these measures are diffi-
cult to implement because administrative costs would likely be high and be-
cause determining payment amounts, procedures, and enforcement would
present further challenges to sending and receiving countries (Marchal and
Kegels 2003).

The Managed Migration program in the Caribbean is one of the most sophis-
ticated policy responses to the issue of nurse migration in a sending country
or region. Managed Migration aims to promote regional cooperation and
strategic planning in six critical areas:

1. Terms and conditions of work
2. Recruitment, retention, and training
3. Value of nursing
4. Utilization and deployment
5. Management practices
6. Policy development

This program was developed by a partnership among national, re-
gional, bilateral, and international stakeholders. Initiatives developed under
the program include efforts to promote temporary or part-time migration of
Caribbean-trained nurses to developed countries, agreements requiring re-
ceiving countries to invest in sending countries’ health-professions education
systems, and promotion of health tourism in Caribbean countries (Salmon et
al. 2007).

The United Kingdom is one of the few major receiving countries to develop
a specific policy to guide the recruitment of internationally trained physicians
and nurses. Its National Health Service (NHS) has created the Code of Prac-
tice on International Recruitment, which includes the following provisions
(Buchan 2007):

• Developing countries should not be targeted for active recruitment by
the NHS unless the government of that country formally agrees.

• NHS employers should only use recruitment agencies that have agreed
to comply with the Code.

57C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e

Compensation
Schemes

Managed
Migration in
the Caribbean

Code of
Practice on
International
Recruitment in
the United
Kingdom

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• NHS employers should consider regional collaboration in international
recruitment activities.

• Staff recruited from abroad have the same legal protection as other
employees.

• Staff recruited from abroad should have the same access to further
training as other employees.

While the Code has been touted as an example for other countries to
follow, its effectiveness is somewhat limited by the fact that it only applies to
the public sector (not to independent or private employers or recruitment
agencies), and employers and migrant healthcare workers have found many
ways to work around it. Nonetheless, the Code represents a deliberate effort
by a receiving country to reduce the negative effects of healthcare worker re-
cruitment from developing countries.

Issues for Managers

The movement of IMGs and INGs into the U.S. healthcare system raises sev-
eral important issues for managers and leaders. In particular, managers must
be aware of issues of ethical recruitment, regulation (visas), credentialing,
and adaptation for internationally trained physicians and nurses. (For a sum-
mary of the elements in these issues, see Table 3.1.) Careful consideration of
all of these areas is necessary to facilitate the successful recruitment and in-
corporation of internationally trained healthcare professionals into the U.S.
healthcare system and to minimize the migration’s negative effects on send-
ing countries.

Recruitment

Healthcare organizations can recruit workers from overseas through several
mechanisms. These include, but are not limited to, the following (Buchan and
Perfilieva 2006):

• Twinning. Hospitals in sending and receiving countries develop links,
based on staff exchanges, staff support, and flow of resources.

• Staff exchange. Healthcare workers temporarily move between
organizations in sending and receiving countries for career and personal
development opportunities or for organizational growth.

• Educational support. Educators and/or educational/funding resources
temporarily move from receiving to sending organizations.

• Bilateral agreement. Employers in the receiving country develop an
agreement with employers or educators in the sending country to help
pay the costs of training additional staff or to recruit staff for training
and development before returning staff to the sending country.

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59C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e

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60 H u m a n R e s o u r c e s i n H e a l t h c a r e

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Additionally, IMGs and INGs also find jobs through informal mecha-
nisms, such as personal and professional contacts (Bagchi 2001). In all of these
models, the recruitment process can be conducted directly by the employer or
mediated by either domestic or overseas recruitment agencies. A recruitment
agency typically charges a hiring organization between $5,000 and $10,000
per nurse. In return, nurses agree to work for the hiring organization for a
fixed period of time—usually two to three years. For-profit recruitment agen-
cies represent an important and growing presence in overseas hiring of nurses
in particular; many of them set up both domestic and sending-country offices
to facilitate the process (Brush, Sochalski, and Berger 2004).

Employers in receiving countries must consider the implications of
their recruiting practices for the countries and organizations from which they
are recruiting. They must also be aware of the rights of the workers them-
selves. The United States has no overarching code of practice for international
recruitment of healthcare workers, so the decisions about how to balance eth-
ical concerns with domestic staffing needs are the responsibility of individual
employers and the recruitment agencies with which they work. Recruitment
agencies’ behavior has improved since a rash of abuses was documented in the
1980s. Today, efforts toward better practice are fueled by market competition
between agencies (Kingma 2006). Employers and recruiters must take re-
sponsibility for not recruiting from countries with severe shortages and for
providing a safe and transparent recruitment process for migrant workers.

Regulation (Visas)

Because most IMGs enter the United States as residents, the first type of visa
that they commonly obtain is the J-1 visa, a category for trainees. The Edu-
cational Commission for Foreign Medical Graduates (ECFMG 2007) is au-
thorized by the U.S. Department of State to sponsor J-1 visas for IMGs. Af-
ter completing their training, some physicians obtain permanent residency
status, while others remain in the country on H-1B or O temporary visas.

H-1B visas apply to immigrants in “specialty occupations,” which usu-
ally require at least a bachelor’s degree. These visas allow for a three-year
length of stay, which can then be extended for three additional years. O visas
can be obtained by physicians who have “outstanding” abilities in their field;
these are usually researchers or specialists. O visas are more loosely tied to em-
ployers than H-1B visas and allow their holders to stay in the United States
indefinitely (Mautino 2002).

IMGs who wish to work permanently in the United States can pursue
permanent residency through one of two main avenues: going through a la-
bor certification process or obtaining a national interest waiver. The labor cer-
tification process requires that an IMG’s employer demonstrate a shortage of
qualified workers to fill the position in the geographic area; if approved, the
physician is obligated to remain with his or her employer for 18 months to

61C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e

Physicians

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5 years after the application is approved. The national interest waiver requires
the IMG to demonstrate that he or she has exceptional abilities in a field, such
that his or her admission to the workforce is in the national interest of the
United States. Physicians who seek a national interest waiver need not be
linked to a specific employer, but they must demonstrate unique abilities that
contribute to the country’s quality of life, which may include service in a med-
ically underserved area for five years or more (Mautino 2002).

From 1990 to 1995, many INGs entered the United States under H-1A visas,
which were aimed at encouraging the migration of overseas-educated nurses.
This visa category was withdrawn after many U.S. healthcare organizations
downsized in the mid-1990s. Since 1995, nurses have entered the country un-
der one of four visa categories:

1. H-1B: See the provisions described in the physicians visa section earlier.
2. H-1C: Established under the Nursing Relief for Disadvantaged Areas Act

of 1999, this visa allows INGs to work in underserved areas. It has a
yearly cap of 500 nurses and permits a three-year length of stay (Bieski
2007).

3. TN: Linked to NAFTA, this visa applies to nurses from Mexico and
Canada. It is good for a one-year stay in the United States and is
renewable.

4. EB-3: A permanent employment-based visa, this was made available in
2005 to nurses and other healthcare workers from sending countries
such as India, the Philippines, and China. Although the EB-3 visa quotas
had been reached, the visa was extended to 50,000 more workers,
enabling U.S. healthcare organizations to hire many overseas-trained
nurses (Kingma 2006). Employers that hire nurses are not subject to the
usual provision that requires them to prove that no U.S. workers are
available to take jobs to be filled by visa recipients (Arends-Kuenning
2006).

Many of these visa categories either have very specific requirements or are
difficult to obtain. Thus, many INGs apply for permanent residency permits
(green cards) when coming to the United States (Kingma 2006). INGs can pur-
sue permanent residency through the employer-dependent labor certification
process, which is described earlier in the IMG visa section (Mautino 2003).

Credentialing

IMGs who desire to work as physicians in the United States must complete
their residency training in a U.S. healthcare organization before they can prac-
tice. Their entry into these training programs must be certified by the
ECFMG, which has been managing the entry of IMGs into the U.S. work-
force since 1958 (Whelan et al. 2002). Applicants must submit a verifiable

62 H u m a n R e s o u r c e s i n H e a l t h c a r e

Nurses

Physicians

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diploma from a medical school listed in the International Medical Education
Directory published by the Foundation for Advancement of International
Medical Education and Research. They must also show a passing score on
Step 1 and Step 2 (clinical knowledge and clinical skills) of the U.S. Medical
Licensing Examination (USMLE), along with acceptable scores on the Test
of English as a Foreign Language (TOEFL). The USMLE Step 1 and Step 2
examination and the TOEFL are given at test centers worldwide, while the
USMLE Step 2 examination is given at regional test centers in the United
States (ECFMG 2007).

IMGs must obtain a USMLE/ECFMG identification number to take
the required examinations. They are certified by the ECFMG after comple-
tion of (and acceptable scores in) all examinations and meeting all other re-
quirements, including school/diploma verification. Candidates may apply to
residency programs before their certification is completed, but they must be
fully certified before their programs begin. IMGs follow the same residency
application and matching process as followed by U.S. medical graduates, al-
though IMGs are also eligible to sign residency contracts outside of the
matching system (ECFMG 2007).

Credentialing of INGs in the United States is managed by the Commission
on Graduates of Foreign Nursing Schools (CGFNS), which was established in
1977 to standardize the examination process for internationally trained
nurses. The CGFNS conducts mandatory reviews of incoming nurses’ educa-
tional backgrounds and credentials, documentation of English proficiency,
and successful completion of the National Council Licensure Examination for
Registered Nurses (NCLEX-RN) (Bieski 2007). The CGFNS credential re-
view ensures that nurses have at least the minimum credentials required for li-
censure within the United States, although precise licensing requirements are
still managed by state boards of nursing and may vary. The English-language
proficiency requirement can be fulfilled through the submission of test scores
on the TOEFL or another test of English proficiency.

The CGFNS offers a pre-immigration examination in more than 30
countries around the world. While the examination is not a substitute for the
NCLEX-RN, it is an important predictor of success on the NCLEX-RN,
which is required for employment in the United States. The NCLEX-RN is
given at testing locations nationwide and in testing centers throughout Eu-
rope, Asia, and South America.

Adaptation

IMGs in the United States face a variety of barriers that may inhibit their
successful adaptation to working in the healthcare system. These barriers in-
clude the culture of medicine in this country—for example, patient-centered
care and more accepting views of mental illness—that is most likely different

63C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e

Nurses
Physicians

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from that in the IMG’s homeland. The IMG will also need to adjust to var-
ious models of the American family—for example, single-parent and step
families—that can influence physician–patient/family interactions (Whelan
2006). Also, some IMGs may encounter language difficulties when commu-
nicating with patients, some of whom may be suspicious of being treated by
“foreign” physicians, and when working with nursing and support staff.
IMGs’ professional experiences, attitudes, and practices in their home coun-
tries may also cause misunderstanding or conflict with American staff mem-
bers (Kuczkowski 2004).

Managers must take into account these and other potential adaptation
issues when designing orientation and ongoing support programs to help for-
eign-trained physicians to adapt to their new roles within the U.S. healthcare
system.

Once INGs, who have a broad variety of job experiences and expectations, ar-
rive at their jobs in the United States, their organizations must provide ade-
quate information and training to ensure that they can successfully perform
their new roles within the American healthcare system. Managers who hire
INGs have found the following areas in which training is especially useful:

• Culture (e.g., relative independence of nurses, work with professional
care staff rather than with patients’ family members) and communication

• Supervision and delegation of care
• Hospital systems, technology, and documentation
• Clinical skills and drug administration

Many healthcare organizations have found that INGs require addi-
tional orientation relative to U.S.-trained nurses, and to this end, organiza-
tions have initiated longer orientation programs that include elements such as
those listed above. Nurse managers who supervise INGs will also benefit from
educational programs that address many of the same areas. Such training will
enable managers to facilitate the quick adaptation of their nurses and head off
potential problems (Sherman 2007).

The Future of International Health Workforce Migration

The international migration of physicians and nurses is a long-standing phe-
nomenon that is likely to continue for many years in the future. Healthcare
organizations in many developed countries rely on these physicians and nurses
to offset domestic staffing shortages. In some cases, this migration can exac-
erbate healthcare workforce shortages in sending countries. In other cases,
however, this migration is anticipated, moving sending countries to educate
and train surplus physicians and nurses for export.

64 H u m a n R e s o u r c e s i n H e a l t h c a r e

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While some receiving countries, such as the United Kingdom, have
taken steps to minimize the negative effects of international recruitment on
sending countries, the United States has not enacted similar policies. American
healthcare workforce planners have made little effort to ensure that the supply
of U.S.-trained physicians and nurses is self-sufficient. As a result, at least for
the moment, this country will likely continue to need foreign-trained health-
care professionals to meet the demand. Although this reliance on international
migration is unlikely to be a sustainable long-term strategy, it is and will be an
essential part of the U.S. healthcare system for many years to come. Because
the federal government has yet to develop a coherent workforce policy on this
issue, the responsibility for managing the effects of international recruitment
lies with leaders of individual healthcare organizations.

Issues of ethical recruitment will also continue to be important for
healthcare workforce planners and organizational managers. These leaders
must carefully consider how domestic needs place burdens on other countries’
healthcare systems, healthcare professions’ educational needs, and healthcare
workforce supplies. They must also provide adequate support to IMGs and
INGs once they arrive to work and train in the United States.

Summary

This chapter discusses several aspects of a critical issue to U.S. healthcare man-
agers: the globalization of the physician and nursing workforces. Given the es-
sential role that foreign-trained physicians and nurses play in many U.S.
healthcare organizations, an understanding of the history, current patterns,
and factors that motivate physician and nurse migration is vital for managers.
Physicians and nurses have sought work across international borders for sev-
eral decades, and their movement is likely to continue long into the future,
particularly in light of current healthcare workforce shortages in many receiv-
ing countries.

Many internationally trained physicians and nurses who work in the
United States and other developed countries are trained in developing coun-
tries. Some of these sending countries—particularly those in sub-Saharan
Africa and the Caribbean—face an uncontrolled “brain drain” of skilled health
workers, while other countries such as India, Cuba, the Philippines, and pos-
sibly China purposely train physicians and nurses to work overseas. While
these workers play a vital role in the health systems of many developed coun-
tries, their departure can have serious implications for the healthcare system
in their home countries. Several international bodies and individual countries
have adopted policies that attempt to manage the movement of physicians and
nurses from developing to developed nations, but thus far no universal prac-
tices have been adopted.

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In this context, U.S. healthcare organizations can recruit internation-
ally trained physicians and nurses through a variety of mechanisms. Because
the United States has not yet established a specific code of practice that gov-
erns international recruitment, employers themselves are responsible for pro-
viding a safe and transparent recruitment process for migrant workers. Addi-
tionally, managers must understand visa and credentialing regulations that
apply to internationally trained healthcare workers as well as the challenges
that these newly hired workers face as they adapt to working in the United
States. Careful consideration of all these issues will help to ensure the fair hir-
ing and successful incorporation of internationally trained physicians and
nurses into the U.S. healthcare workforce.

66 H u m a n R e s o u r c e s i n H e a l t h c a r e

Discussion Questions

1. Why is it important for healthcare
managers to be aware of the trends in
international migration of physicians
and nurses?

2. What impact do these trends have on
the U.S. healthcare system?

3. Sending countries experience two
distinct situations as a result of
international migration—brain drain and
strategic deployment. What are the
differences between the two? What are
the advantages (if any) and
disadvantages of each situation?

4. Suppose that U.S. policymakers are
developing ethical international
recruitment guidelines based on the
National Health Service’s Code of

Practice on International Recruitment.
What elements of the Code can be
included in the guidelines, and what can
be implemented in the context of the
U.S. healthcare system?

5. What are the ethical issues that
healthcare leaders and managers must
consider when recruiting IMGs and
INGs? What steps can be taken to deal
with these issues?

6. Discuss the importance of orienting
IMGs and INGs to their roles in the
U.S. healthcare system. What obstacles
(cultural, organizational, and
professional) do they face, and what are
the implications if these barriers are not
addressed?

Experiential

Exercise

For the Philippines, ex-
porting nurses has been a

long-standing government strategy, part of a
broad and concerted program of labor migra-
tion introduced in the 1970s during the ad-

ministration of President Ferdinand Marcos
(Tyner 2004). Although intended initially as
a short-term solution to domestic unemploy-
ment and high foreign debt, this program has
become a permanent strategy for generating

Case

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income for the country through regular re-
mittances from migrant workers.

The Philippines has a net surplus of
nurses because of high production and rela-
tively low demand, mainly because of under-
funding of the country’s health system. Be-
cause of nurse migration, the country has lost
many of its most skilled nurses. For the last
several years, the Philippines has been expe-
riencing two trends that are causing concern
among nursing leaders:

1. An explosive growth in the number of
nursing programs. In the 1980s, only 40
nursing schools were in existence
throughout the country; in 2007, the
number was much higher: 460
programs in total. Some schools have
sought rapid, drastic expansions to their
enrollment, contributing to the vast and
steady increase in the number of nursing
students. The Philippines currently
produces about 20,000 nurses per year
(Lorenzo et al. 2007).

2. A movement of physicians into “second
course” nursing education. Physicians are
leaving their posts in public hospitals and
rural areas to work abroad as nurses.
Demand for medical education has
declined, and some nursing schools have
created special programs that allow
physicians to pursue nursing education
while continuing to practice as physicians.

67C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e

Policymakers in the Philippines are
concerned that the growth in the number of
nursing programs has been accompanied by a
decline in quality of education: In recent
years, fewer than half of the nursing graduates
passed the nursing licensure examination.
This means that many nursing graduates can-
not even work as nurses in the Philippines,
much less in the United States and other
overseas markets. Nonetheless, thousands of
students enter nursing programs every year.

In this context, nursing leaders in the
Philippines are struggling to maintain quality
education and a sense of public service in a
profession that is increasingly governed by
business interests and influenced by individual
aspirations for overseas employment. The
country’s Department of Health (DOH) has
developed the Master Plan for Health Human
Resources to address domestic healthcare hu-
man resources distribution, motivation (com-
pensation—provision of living wages for gov-
ernment workers), and production. The DOH
has attempted to be directly involved in im-
proving the quality of nursing education and
the process of nurse migration, but the de-
partment’s efforts have been rebuffed by the
president, who wants these issues to be han-
dled by the Philippine Overseas Employment
Administration, the division of the Depart-
ment of Labor and Employment that manages
overseas deployment of Filipino workers.

You are a consultant to a
task force charged with

overhauling nursing education and migra-
tion practices in the Philippines. You have
been asked to recommend short-term and
long-term strategies to achieve sustainable
improvements in nursing education and to

harmonize the nursing-deployment policy
with domestic health system needs.

1. Who are your stakeholders, and from
whom will you seek perspectives? What
questions will you ask each of them?

Exercise

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2. Which issue—explosive growth of
programs, declining quality, training of
physicians to be nurses—will you
address first? How will you engage the
labor and health departments to

68 H u m a n R e s o u r c e s i n H e a l t h c a r e

implement your recommendations
successfully?

3. What obstacles do you expect to face in
this process? What strategies will you use
to overcome them?

Note

1. IMGs who are U.S. citizens make up approximately 3 percent of the physician work-
force in the United States (Mullan 2005). Many of these physicians are trained in “off-
shore” medical schools in the Caribbean or Central America. This phenomenon is not
discussed in this chapter.

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