Importing health

March 4, 2006 -- Today the Taiwan News ran a short piece by Jenny W. Hsu headlined "Nurses groups warn of mass exodus to U.S." It says that the Taiwan National Nurses Association (NNA) is concerned that poor working conditions for local health workers and aggressive recruiting by the United States are driving a surge in nurse migration. This reportedly poses a grave threat to Taiwan's ability to care for its own rapidly aging population.

The piece leads with the NNA's warning that if working conditions do not "improve soon," many Taiwanese health workers will go to the U.S. and "leave many vulnerable groups, such as the elderly, in a disadvantageous situation." The piece cites NNA Secretary-general Liu Yue-rong, who notes that Taiwanese nurses average about US$1,200 per month in salary, compared to about $4,000 in the U.S.--which is more than Taiwanese physicians earn. Liu also states that the workload in Taiwan is "20 to 30 percent heavier," by which she seems to mean that Taiwan nurses average 7-13 patients during days, a number that can rise to 30 on "graveyard" shifts. The term "graveyard" is well-chosen, since a hospital patient whose nurse has 29 other patients stands a much increased chance of ending up in one. As for the comparative workloads, it would seem that there is a natural limit to the number of patients any nurse can handle, and the amount of work he can do. So there may be little difference between the actual amount of work done by a severely understaffed nurse with 10 patients and one with 30 patients. Both are likely working as hard as humanly possibly every minute of their shifts. Of course, for the nurse with 30 patients, the threat to each patient's outcome would be even greater, as would the psychological burden on the nurse. At the same time, Liu states, Taiwan hospitals are trying to cut costs by hiring more "short-term contract nurses" whom they apparently pay less than regular staff nurses. Liu rightly notes that nursing is "a very physically and emotionally demanding profession," so if Taiwan's nurses remain "underpaid," the "dropout rate" will keep rising.

Meanwhile, the United States is making "tempting offers" of high wages and "free green cards" to lure Taiwan's health workers, especially nursing home workers, leading to a "sharp upward trend" in migration. The piece quotes the director of "an organization for overseas Taiwanese health workers" as saying that figures suggest that in 10 years, seniors will constitute 40% of the U.S. population. The article reports that this has led to the U.S. "offering lucrative deals" to attract nurses from "countries such as Taiwan, Japan, Hong Kong, and South Korea." But Liu points out that Taiwan has the second fastest aging population in the world, and that if the health worker migration continues, many of the nation's elderly will soon lack adequate care.

The piece might have gone into these issues a little more deeply. The populations in both Taiwan and the U.S. are aging rapidly, and so far neither nation seems especially interested in paying for the nursing it needs, but the U.S. does have more money and a higher overall salary structure. The piece might have noted that such nurse migration is hardly a new trend in Asia, as nations like the Philippines and India have long lost nurses to the U.S. And the loss of African nurses to the U.K. and other nations has become a major issue, with the U.K. actually imposing some limits on aggressive recruitment. The East Asian nations listed in this article are more developed than the Asian nations that have traditionally sent nurses to the U.S., but global nursing migration has always included flows among more developed nations. Some have pointed to the remittances the foreign workers send back to their home nations as a benefit to the nation that has lost them. Of course, it's not clear that those remittances provide the local populations with the health care they need, nor that they can compensate for the resources the local nations have spent in training the departed nurses. Moreover, while this piece suggests that the main reform needed to stem the flow from Taiwan is an increase in local salaries, it might also have explored the apparent need for improved working conditions. No nurse can safely care for 30 patients, and this may also contribute to nurses leaving such a care setting, or leaving nursing entirely.

In any case, the Taiwan News piece does highlight some important issues in global nursing migration, and we thank those responsible.

We believe that developed nations should carefully examine the practice of nurse recruitment from other nations. Large-scale nursing migration can threaten the already overwhelmed health care systems of the nurses' home nations, and also weaken efforts to address the root causes of shortages in the recruiting nations, including poor workplace conditions and a lack of real respect. Of course the issue is complex, but it seems to us that in the end each nation must invest in its own nursing education, clinical practice and research.

Click here to see the article "Nurses groups warn of mass exodus to U.S." in the March 4, 2006 of Taiwan News.