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Why do China-educated nurses emigrate? A qualitative exploration
International Journal of Nursing Studies 53 (2016) 163–172
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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Why do China-educated nurses emigrate? A qualitative exploration Yunxian Zhou a, Cecelia Roscigno b, Qiuhua Sun a,* a b
School of Nursing, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou 310053, Zhejiang, China School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill 27599, NC, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 December 2014 Received in revised form 18 August 2015 Accepted 18 August 2015
Background: Despite the fact that there are more and more Chinese nurses living and working in Australia, relatively little is known about the decisions to emigrate made by these nurses. Objectives: To explore factors influencing China-educated nurses to emigrate to Australia. Design: This was a secondary analysis of 46 semi-structured interviews with 28 Chinaeducated nurses working in Australia. Conventional content analysis was used, and the results are presented thematically. Results: The nurses emigrated for a wide variety of reasons: (a) personal factors (to improve English, to see more of the world and cultures, to seek novelty and adventure); (b) work-related factors (better work environment and more career choices); (c) social factors (better living environment and lifestyle); (d) cultural factors (positive perceptions in China of those who emigrate or have overseas experiences), and (e) economic factors (higher salaries and greater purchasing power). Conclusions: Confirming findings from similar studies, China-educated nurses’ decisions to migrate are complex and not based solely on economic expectations. Personal and cultural factors play vital roles in nurses’ migration decisions. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Chinese nurse Content analysis Immigrant nurses Motivation Nurse emigration Nurse migration Qualitative research Secondary analysis
What is already known about the topic? A chronic nurse shortage in developed countries has produced a growth in demand for nurses from developing countries. China is an emergent supplier of migrant nurses because of its very large supply of registered nurses. The push–pull theory is widely used to explain migration motivation.
* Corresponding author. Tel.: +86 571 86613676. E-mail address: [email protected] (Q. Sun). http://dx.doi.org/10.1016/j.ijnurstu.2015.08.008 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.
What this paper adds China-educated nurses’ decisions to emigrate are multifactorial and not based solely on economic expectations. The push–pull theory is inadequate to fully explain the factors that influence migratory moves of this group of nurses. Personal and the deeply embedded positive culture of migration in China also contribute to nurses’ decisions to migrate and work elsewhere. With developments in transportation, communication, and information technology, international migration has become much easier and the number of migrants has increased dramatically (Arends-Kuenning, 2006; Stankiewicz and O’Connor, 2014). Nurse migration is part of this
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phenomenon (Brush, 2008; Dywili et al., 2013). One key driver of international nurse migration is chronic nurse shortages in high income countries (Dall, 2007; Nelson, 2004; Stankiewicz and O’Connor, 2014). For instance, Australia is expected to have a shortage of 109,000 nurses by 2025 (Health Workforce Australia, 2012). To address this problem, both public and private health care sectors have turned to overseas recruitment of nurses (Hawthorne, 2001; Negin et al., 2013). In 2011, among 239,294 midwifery and nursing professionals in Australia, 81,383 (33.2%) were born overseas (Negin et al., 2013). Indeed, statistics indicate that around 3000 registered nurses and midwives entered the Australian workforce on 457 work visas (a subclass of visa through which employers sponsor temporary skilled workers to work in Australia) in the 2012–2013 financial years (The Sydney Morning Herald, 2015). The primary sources for nurse migration are low and middle income countries such as the Philippines and India (Brush and Sochalski, 2007; Buchan and Sochalski, 2004; Negin et al., 2013). However, with the increasing global demand for nurses, commercial and government recruiters are also interested in recruiting nurses from China (Fang, 2007; Lin, 2013; Lintern, 2013). Although nurse workloads and the nurse-population ratio indicate that China has a nurse shortage, there are also high nurse unemployment and underemployment (Fang, 2007; Hu et al., 2010; Zhu, 2012). Due to the financial incentive structure of Chinese hospitals, many hospital managers in China failed to recognize the importance of nurses to the safety and quality of patient care and to employ an adequate number of nurses (Zhu et al., 2014). Usually, less qualified carers and private hired helpers for patients are used to supplement the small nursing staff at lower cost to the hospital (Hu et al., 2010). Currently, the Chinese Nursing Association overwhelmingly supports Chinese nurses in working abroad (Fang, 2007; Zhu, 2012), in the hope that a national nurse shortage and negative impacts on patient outcomes will trigger Chinese healthcare reform and improve the welfare of Chinese nurses (Hu et al., 2010). As a result, several authors who have assessed the potential for nurse emigration from China have concluded that China will become an increasingly important supplier of nurses in the future (Hu et al., 2010; Fang, 2007; Xu, 2010; Xu and Zhang, 2005). To work in Australia as a nurse, Chinese nurses must be registered with the Nursing and Midwifery Board of Australia and meet the Board’s registration standards. They might also need to complete a skill assessment from the Australian Nursing and Midwifery Council and pass the Occupational English Test (OET) or the International English Language Testing System (IELTS) (Kingma, 2006; Stankiewicz and O’Connor, 2014). Since English is a second language in China, most Chinese nurses need a substantial period of time to improve their English and/or secure professional registration (Lynch et al., 2012). As a result, very few Chinese nurses have come to Australia as an RN. Many have come on student visas arranged by private migrant agencies (Zhou, 2010; Fang, 2007). Because these operations are ‘‘for profit’’, the nurses are usually required to pay a significant amount of money to the agency in
exchange for the visa. The agency might also give Chinese nurses unrealistically high expectations regarding work life in Australia. After meeting the registration requirement, Chinese nurses are recruited by Australian health care institutions and can apply for a work visa in Australia. Although much has been written about the experiences of migrant nurses in recipient countries, including nurses from China (Zhou, 2010, 2014; Zhou et al., 2010, 2011; Xu et al., 2008), relatively little is known about the reasons nurses choose to migrate (Dywili et al., 2013), particularly nurses from emerging source countries. Further, migrant nurses are not a homogeneous group (Alonso-Garbayo and Maben, 2009; Larsen et al., 2005); nurses from different countries have different expectations and therefore their motivations vary (Alonso-Garbayo and Maben, 2009). For example, Aboderin (2007) found that economic gain was the primary motives for Nigerian nurses to migrate, and deteriorating work and status situations at home were added incentives. The main reasons for Lebanese nurses to migrate included shift work, heavy workloads, lack of autonomy in decision-making and lack of a supportive environment (El-Jardali et al., 2008). While nurses from Canada have left for the USA in search of opportunities for full-time work and ongoing education (McGillis Hall et al., 2009), Indian and Filipino nurses have migrated in response to economic, professional, social, and cultural factors (Alonso-Garbayo and Maben, 2009; Ronquillo et al., 2011; Thomas, 2006). All together, Larsen et al. (2005) have divided the motives of migrant nurses into a ‘‘life change strategy’’ and a ‘‘working holiday strategy’’. Studies have shown that domestic colleagues and patients do not always understand migrant nurses’ motivations for choosing to work in another country (Zhou, 2010; Larsen et al., 2005). They often believe those motivations are solely economic—that is, the nurses migrate in search of higher wages (Aboderin, 2007; Zhou, 2010). Despite the fact that more and more Chinese nurses are living and working in Australia (no exact figure is available) (Zhou, 2010; Fang, 2007), the reasons why they leave to work in Australia are poorly understood and the question has received virtually no attention as a research or policy issue. Understanding the reasons that nurses leave China is important for policy makers and senior nurse managers in China, because this could help them address local factors that are motivating nurses to leave. Even those nurses who stay in China may become more satisfied if the situation is understood and problems such as inadequate work or social environments are corrected. Ignoring those motivating factors may result in a continued loss of more highly educated Chinese nurses and a loss of economic investment (time and money to train nurses) in China resulting in further deterioration of the quality of care in the Chinese health care system (Hu et al., 2010; Xu and Zhang, 2005). For the recipient countries nurse migration has been a ‘‘quick fix’’ for nurse shortages as these countries gain well educated and experienced nurses at a relatively low cost (Zhou, 2010; Kline, 2003). Given the global competition for skilled migrant nurses, it is important for nursing administrators in recipient countries to understand migrant
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nurses’ motivations and meet their expectations. Otherwise, these nurses may have low job satisfaction and possibly move elsewhere or leave nursing. It has been reported that total turnover costs range from a low of $20,561 in the US to a high of $48,790 in Australia (Duffield et al., 2014). Retaining immigrant nurses thus is essential to save the large amount of money required for recruiting and training new nurses; and it is also important for patient safety and nurse productivity (Jones, 2004). Largely due to their language skills, Chinese nurses can help provide culturally congruent care to other Chinese speaking immigrants living in those countries. Thus the purpose of this study was to explore why China-educated nurses migrate to Australia. 1. Methods This study was a secondary analysis of data from a large qualitative study which explored the experiences of Chinaeducated nurses who migrated to Australia and worked there as nurses (Zhou, 2010, 2014). The broad topic of the parent study provided the researcher with an opportunity to explore the reasons why nurses chose to migrate to Australia, which was the focus of this secondary analysis (Sandelowski, 1995, 2011; Thorne, 1993). Participants’ descriptions of their motivations for leaving China to work in Australia included novel and nuanced individual, social and cultural factors (family, friends, community, healthcare work environments, politics, economics, and cultural beliefs) in both China and Australia that influenced their decisions (Sandelowski, 1995, 2011). Before conducting the secondary analysis, the researchers reviewed the data obtained in the parent study and determined that the original grounded theory methodology, the theoretical sampling technique used to achieve social diversity in the nurses interviewed, the prolonged engagement with participants in two open-ended interviews, and the narrative transcript data describing nurses reasons for choosing to move to Australia provided sufficient data of explaining Chinese nurses’ choices and the factors important in making those choices (Thorne, 1993; Ziebland and Hunt, 2014). It was concluded that the test for completeness needed in order to answer the secondary research question was met with the original data set (Coyer and Gallo, 2005; Sandelowski, 2011). Also, the first author was the primary investigator of both the original study and this secondary analysis, which assured that the narrative transcript data were not taken out of the context of the original study in order to answer the secondary question (Thorne, 1993; Ziebland and Hunt, 2014). 1.1. Study design This secondary analysis used conventional content analysis, which focuses on analyzing textual information (Prior, 2014) and allows researchers to attend to participants’ explanations, grounded in the interview encounter and transcript data, without imposing any preconceived notions (Hsieh and Shannon, 2005; Prior, 2014). The question guiding the analytic approach was ‘‘Why do China-educated nurses choose to leave China and move to
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Australia to work as registered nurses?’’ The aim of the analysis was to generate a richly detailed, nuanced, and interpretive examination of the individual, social, and cultural factors that influenced this group of Chinese nurses to explore such opportunities. 1.2. Participants Institutional Review Board approval was obtained at the original recruitment location and at the first author’s institutions for the original study and for this analysis. Sampling for the original study was purposive with the aim of selecting Chinese-educated registered nurses who had the potential to provide rich information on the experiences of nurses now working in Australia as registered nurses (Zhou, 2010). We initially recruited participants via advertisements in local and national nursing publications. To be included in the study, participants had to be registered nurses of Chinese nationality who had migrated to Australia to work as a registered nurse for at least 6 months, in Brisbane or Adelaide. To enhance participation and vary the demographics of participants (age, education, marital status, living location in China, nursing experience and position in China or Australia), we used the snow balling technique to access participants through referrals from previous participants (Zhou, 2010). All participants provided written informed consent before being interviewed, and they were made aware that other secondary analyses might be conducted at a later date if they were in line with the original aim of study. 1.3. Data collection In order to understand the sample characteristics, social demographic data were collected from all 28 participants in the in-person interviews with the first author. Of the original 28 participants, 19 were invited to participate in second interviews; one nurse invited to participate was unable to do so due to a time conflict. Thus, 18 nurses participated in the second interviews to further develop emerging categories. The first author/sole interviewer was a Chinese nurse working on her Ph.D. in Australia at the time. Interviews were conducted in a private and quiet place of the participants’ choosing. The average length of the interviews was approximately 72 min. All interviews were conducted in Mandarin and audio-recorded. A semistructured interview guide was used for both interviews, and this was refined throughout the study based on constant comparative analysis of the interviews already conducted, which informed new questions or probes. Typical questions that support the conduction of this secondary analysis included: ‘‘Tell me your reasons for coming to work as a registered nurse in Australia?’’, ‘‘What are some of the factors that influenced your decision?’’, and ‘‘Tell me the process of your decision-making to leave China to work in Australia.’’ Probing questions were used to gain further details from each participant (e.g., ‘‘Why was that important to you?’’). The first author took field notes immediately following each interview to record details of the observations, interactions, environment, and
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body language of the participants. In addition, she made follow-up telephone and email contacts with some participants for clarification of audio or transcript data that was unclear. The data consisted of over 3000 doublespaced pages of verbatim transcription of face-to-face interviews with each of the participants. The transcribed interviews were printed out in their entirety for the two coders to read. Since the primary investigator on the original study was also one of the coders, she was able to share contextual information from field notes that helped to place the transcript data into the milieu of the individual’s life. 1.4. Data analysis In the original study, all transcribed interviews were checked for accuracy. Conventional content analysis was used for this analysis (Hsieh and Shannon, 2005; Prior, 2014). Coders (YX and QH) first read the entire transcripts of each participant’s interviews several times to gain a sense of the whole of the participant’s interview(s) and experiences. After that, the coders hand coded line-by-line any narrative data that were related to participants’ reasons for leaving China to go to Australia to work or for staying in Australia to work. In order to identify similarities and differences in participants’ reasons for leaving China and moving to Australia to work as a registered nurse, the coders carefully attended to the words used by participants to describe themselves (age, gender, years of experience, marital status, previous migration experience), the places they left, the places they went to, and the social factors that they believed influenced their decision (Sandelowski, 1995; Ziebland and Hunt, 2014). The two coders discussed their coding of individual transcripts and used an iterative process to reach agreement on codes, coding definitions and the expansion or collapsing ˜a, 2014). Chinese of any codes (Garrison et al., 2006; Saldan was used for the initial coding and codes, and they were subsequently translated into English for further comparison ˜a, by a peer reviewer (CR) and for writing the report (Saldan 2014; Squires, 2008, 2009). The primary investigator was fluent in both Chinese and English and conducted this translation. Saturation for the analysis was deemed to be met when the three coders noted repetition in participants’ responses and saw no new themes on migration decisions ˜a, 2014). were presented (Bowen, 2008; Saldan From the coded data, a matrix of themes was ˜ a, 2014). Quotaconstructed (Bradley et al., 2007; Saldan tions for each theme were selected and used to show the diverse ways in which participants expressed themes, allowing us to understand the boundaries of themes and making our findings richer and more socially relevant ˜ a, 2014). (Averill, 2002; Saldan 1.5. Credibility The rigour of the analysis was maintained using several techniques. Participants’ descriptions and field notes were the primary sources of data from which conclusions were drawn; an audit trail of the original study and the secondary analysis was maintained and reviewed. Peer
debriefing (CR) was used to maintain transparency, examine methodological issues, and consider alternative interpretations so that there was no premature analytic foreclosure (Phillips, 2014; Ryan-Nicholls and Will, 2009; Sandelowski, 1995). 2. Findings The participants came from 9 provinces and 3 municipalities in the northern and southern parts of China. All were female. Time spent working as a registered nurse in Australia ranged from 6 months to 4 years. Eight participants also had worked in countries other than China and Australia, one in Oman and seven in Singapore. Eight nurses lived with their families in Australia (Table 1). The nurses migrated to Australia for a variety of reasons, broadly categorized as personal factors (n = 25), work related factors (n = 22), social factors (n = 18), cultural factors (n = 15), and economic factors (n = 15). More than one reason was typically given by each participant. 2.1. Personal factors influencing nurse migration Personal factors were defined as individual characteristics, preferences, choices, or goals that motivated the nurse to migrate. These were the factors mentioned most often by participants. Half of the nurses (n = 14) said that they came to Australia to see more of the world, to satisfy their curiosity, or to experience a new culture and new ways of life:
Table 1 General information of the participants.
Age (years) 20–30 31–40 41–50 Education Diploma in nursing Bachelor in nursing Postgraduate qualification Marital status Single Married Divorced Separated Nursing experience in China 1–5 years 6–10 years 11–20 years Employment position in China Registered nurse Nurse manager Lecturer in nursing school Nursing experience in Australia Less than 1 year 1–2 years >2 years Employment position in Australia Level 1 year 1 to level 1 year 5 year 5 Above level 1 year 5
Number of participants
Percentage (%)
16 10 2
57.1 35.7 7.2
4 18 6
14.3 64.3 21.4
15 11 1 1
53.6 39.3 3.6 3.6
10 13 5
35.7 46.4 17.8
24 2 2
85.7 7.1 7.1
9 11 8
32.1 39.3 28.6
14
50.0
14
50.0
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You should go and see that world. . .because if you don’t go, you never know what life looks like abroad. Some nurses (n = 9) were attracted to Australia to improve their English or learn about Western nursing: I like English very much. . .and I have learned it for a long time. I hope I can improve my English further and I hope I can practice English daily in a work environment. I like being a nurse and doing nursing work. And I would like to see more and learn more about nursing in Western countries. Another participant, who was not fond of nursing, joined the profession because it provided her more opportunities to migrate than any other profession: I was not interested in nursing at that time. . .However, I was attracted by the fact that as a nurse. . .I could go to different places, travelling while working, and having different experiences. Warm weather and travel beyond the place they migrated to were also mentioned as reasons for migration (n = 6): I knew the weather in Australia was very good before I migrated. I used to catch a cold easily in China and I am afraid of cold weather. I migrated to Australia for vacation purposes. I would have both time and money for that. Two nurses chose to go abroad because they wanted to leave a place where they felt sad because of a personal situation:
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Health care organizations in China were described as strictly hierarchical. Hospitals set down rigid rules and regulations that nurses were required to adhere to. Nurse managers implemented surveillance strategies and constantly scrutinized nurses’ work. This brought extra stress for the nurses: In China, nurse managers spend all day looking at you and checking your work. . .Have you done this? Have you done that?. . .You should not sit there and chat. You should not sit there and drink, and so forth. The focus on cost containment in China was perceived by some participants (n = 4) as leading to conflicts in the nurse–patient relationship since patients and families also tended to oversee nursing activities closely. This not only undermined the personal fulfilment that nurses gained from their work but also contributed to high levels of occupational stress and consequent ‘‘burn-out’’: When you work in China, you have to consider money first. How much would it cost the patient if I did this for him?. . .Since there is money involved, patients and families [in China] pay a lot of attention to you and write down everything you do in a logbook. You feel you could easily get a lawsuit if you do anything wrong [in China]. You worry about that constantly. Australia has national health insurance and patients either have largely free health care or they have private health insurance. The nurses felt less oversight and judgement from their patients and therefore perceived Australian patients as pleasant to work with. Nursing work in Australia was described as more rewarding than in China:
I had some relationship issues at that time and I wanted to leave that environment very much and get a job.
I feel working as a nurse in Australia is a big improvement in quality for me. I can feel the essence of nursing more from my daily work.
Participants were likely to have been the only child as a result of China’s one-child family planning policy. One nurse wanted the adventure of being away from home in order to experience independence:
Poor career paths and promotion opportunities led some China-educated nurses (n = 3) to feel stuck in their jobs in China:
I am the only child in my family in China and I stayed around my parents all day long. I was very keen to be independent and be away from my family.
2.2. Work related factors influencing nurse migration Work related factors reflected working conditions in Chinese or Australian health care organizations and they were strong incentives for nurses’ migration (n = 22), sometimes even outweighing personal factors. Some nurses (n = 5) said they left China to escape unpleasant working environments such as inappropriate staffing levels and heavy workloads: The work environment [in my former hospital] somehow threatened our survival. . .We had too heavy a workload and too much stress. We were struggling even after work, worrying that we hadn’t done our job well enough and someone might sue us tomorrow.
There were more and more bachelor’s-prepared nurses after I worked in that hospital for 8–9 years. As a result, nurses like me with a secondary school education certificate didn’t have many promotion opportunities. . .At that time, I could only foresee a very gloomy future [in China], and I didn’t want to lead a life like that. A sense of lost hope was described by some of the nurses, who perceived limited freedom to choose their job sector and specialty in hospitals in China. Migration was perceived to offer new hope to the nurses (n = 3): I worked in the oncology and haematology department in China, which was very busy, stressful and tiring. It was very difficult to change to another department. . . I knew that if I had a chance to migrate, I would not have to work that hard and I would have more opportunities. One nurse migrated because she wanted to seek more equality in her work payment:
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I was a contract nurse in China. My income was less than those Dingbian1 nurses. . .I felt dissatisfied because I was not treated equally. Australia was perceived to offer better working conditions for participants in terms of workload, work environment, and benefits (n = 14): Nurses enjoy a better work environment and more flexible work schedule here and they have longer annual leaves than in China. Nursing work here is lighter compared to China, and people here respect nurses more. Patients and families regard nurses as professionals and they pay attention to their opinion and listen to them. Other work related motivations included a desire to experience professional challenges in their work environment (n = 4): I was working in a county hospital in China and the work there is easy. . .but after some time, I wanted to have some challenges. So I considered migration and experiencing the outside world. 2.3. Social factors influencing nurse migration Social factors reflected the expectations, circumstances, and lifestyles in China or Australia that were perceived to be important for quality of life. Some nurses (n = 6) were discontented with Chinese culture and the ways it influenced life in China, particularly the preoccupation with proper social relationships and their maintenance based on Confucianism (Barkema et al., 2015; Yum, 1988): Personally, I don’t like the complex human relationships in hospitals in China. Also, I felt I couldn’t find the things I wanted if I stayed there to develop my career.
You don’t have your own vacation time, you don’t have your own free time, and you get up early and go to bed late every day. I don’t like that in China. The Australian lifestyle was perceived to emphasize more of a work-life balance, which was attractive to the nurses (n = 7): The lifestyle here is very relaxed. You have no pressure to study further. As long as you finish your work, you can go home without any pressure. . . I can enjoy life more in Australia, and am not restricted by work too much. One nurse migrated because of the social constraints against having a second baby in China: One of the key reasons for my migration was that I wanted to have a second baby, as I felt it was too lonely for the only child [required by law in China].
1 In China, there are two types of employees: Dingbian and contract. Dingbian means a more stable job with a relatively satisfactory income, as compared with contract employees in the same institution.
Some nurses (n = 6) said they had moved for a better living environment for themselves and their family: I was longing for the good environment abroad, the good air. . . .The pollution in the city [in China] where I came from was very severe. . .and I was also attracted by the good quality of life here. Migration was believed by some (n = 6) to be particularly beneficial to their children since it offered the children the option of being raised in a less competitive educational environment: The education here for the kids is better and they don’t have much stress. 2.4. Cultural factors influencing nurse migration Cultural factors referred to the values, beliefs and perceptions of Chinese society about migration or working overseas. Historically, the Chinese people have perceived emigration to the West as a desirable goal since it is believed that Western countries are more advanced and thus better places to live and work than China. Also, the Western image of ‘‘the good life’’ relayed through global media makes it trendy to migrate. Some participants (n = 8) said they had been longing for the outside world and dreaming of migration for a long time: Ever since I started my nursing study, I was thinking of migration. . . I wanted to go abroad and I studied hard for that. Even though my classmates thought that was something impossible, I believe nothing is impossible. . .and I did not give up my migration dream. The perception that overseas education or work experience was especially valued in Chinese society was emphasized by some nurses (n = 4), and this partially contributed to the migration decision: I like being a nurse and doing nursing work. And I would like to see more and learn more about nursing in Western countries. Even if I go back to China one day, I will have overseas working experience, which is valuable. These nurses perceived that they gained not only social position, but also social respect from peers back in China because of their networking with peers in other countries. Their economic, social, and personal gains influenced others who also wanted to migrate to attain these benefits to their overall career: I had a friend working in Australia at that time. . .She felt she experienced great changes after migration. She suggested that I do the same if I had this idea myself.
Everyone is emigrating and I want to go abroad to open my eyes as well. Migration to high income countries is generally perceived as a sign of career success for migrants, as well as for their family. International migration of a family member is about pride, and is linked to the desire to be modern and successful. In contrast, not emigrating may be
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perceived as being incapable of taking advantage of an opportunity:
Australia but it is 10 RMB [one Australian dollar is about 6 RMB at that time] in China.
People around me are emigrating and if I don’t do the same, it may indicate that I don’t have such ability.
One nurse felt a need to make more money to relieve the family’s financial distress in China. After working in Singapore for a few years, she had planned to stay in China for some time. However, the need for money was a strong incentive for her to migrate again:
Indeed, this positive perception of migration is so deeply engrained in Chinese society that not doing so when one is qualified would be strongly questioned by others, as pointed out by some participants (n = 7): My family would like me to stay in Australia. They don’t want me to go back to China. It was not easy for me to come to Australia to study. Many people would like to migrate [but they can’t]. If I return to China, many people would feel it is a disappointment. Because of the positive perceptions of migration in Chinese culture, 11 of the 28 participants said that they had not given much thought to the decision to migrate: I didn’t think much about my migration decision because at that time the impulse to migrate outweighed anything. That is to say, I was willing to take any risk. I wanted to migrate; all I wanted was to migrate. Many of the nurses (n = 18) also pointed out that a lack of information on nursing in Australia contributed to the fact that they did not give much thought to their migration decision because there was not much they could draw on to make the decision: I had totally no idea about what nursing in Australia would be like before I migrated. I only thought of Australia as a Western country that might have a more advanced medical system, and also Australians speak English. That is all I knew before I came. This is a lack of knowledge from which to make migration decisions has been overlooked as an important factor influencing some nurses migration decisions in other published reports. 2.5. Economic factors influencing nurse migration Economic factors reflected the financial incentives in Australia and the barriers in China which influenced the migration decision. Economic factors were never the only factors, yet there is no doubt that they played some role in the decision-making processes of these nurses. Thirteen participants mentioned the wage differential between China and Western countries as one of their key motives: Nurses in Australia, the UK and the USA earn much more than in China; that is why I wanted to go abroad to work. Although the average income in China has been increasing in recent years, the inflation rate has increased more. As a result, it is not just the absolute amount of salary that matters, but also the relative purchasing power of one’s salary: If one does not calculate the exchange rate, the salary I earn here is similar to the amount I can earn in China. . . However, things are expensive in China. Take a bottle of milk as an example: it only costs one dollar or so in
There were some conflicts in my family. It was mainly about financial issues. That is to say, I needed a certain amount of money to solve my domestic problems. That is why I came to Australia to work. Interestingly, one-fourth of the participants pointed out that they were not motivated or not primarily motivated by the fact that they could earn more in Australia. One nurse recalled: I could earn over 10,000 RMB each month, sometimes even more. . .I own two apartments and two cars there. . .My life in China was not too bad already. The fact that they could afford to go abroad also meant that these nurses were financially well situated, at least to some degree. As one nurse remarked: All those emigrant nurses, their economic situation in China was good enough. Otherwise, they would not able to afford the cost of migration.
3. Discussion In recent decades, globalisation and the increasing integration of labour markets worldwide have increased the number of people with the desire and capacity to move to other places. Further, the rapid expansion of communication and information technology has made information transmission faster and cheaper, and development of transportation has made long-distance travel much cheaper (Zhou, 2010; Martin, 2005). As a result, migrants are able to recoup their financial outlay in a shorter timeframe. Some employers offer incentives such as paid airfare/travel on condition that a working contract for a given period of time will be fulfilled. All these factors facilitate the movement of people from one country to another. Kingma (2007) has suggested that most nurses are reluctant to leave their home countries and would be willing to stay if offered a good living wage. Thus, overseas nurses are often described as motivated primarily by economic reasons (Alonso-Garbayo and Maben, 2009; Larsen et al., 2005; Negin et al., 2013; Ross et al., 2005). However, while the income gap between China and Australia was a factor in the migration of nurses in this study based on the neoclassical economics view (Arango, 2000; King, 2012; Massey et al., 1993), this did not entirely explain their decision to move. For some participants, the need for money was important; but for others, this was not the case since they already had a stable economic position in China. Indeed, most participants did not belong to the poor ‘‘masses’’ in China but to a relatively privileged group with a stable job, income, and benefits (housing stipend,
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paid annual leave, health care insurance, bonuses, holiday allowances). They were emigrating not to survive, but to thrive. Nurse training overseas is expensive (Zhou, 2010; Kingma, 2006), and most of the nurses in this study had paid a fee to an agent for help with obtaining a visa. Immigration agencies usually select those who are healthier, better educated, and more affluent (Anson, 2004; Chiswick, 2000; Wallace and Kulu, 2014). These privileges (as well as their choice of a profession) made migration possible for these nurses. This study offers some new insights on why nurses migrate (Table 2). Most studies to date have described migration as a subjective decision-making process influenced by social, work related and economic push and pull factors (Bach, 2007; Kingma, 2001; Kline, 2003). Push factors are conditions in the source country that compel individuals to migrate (Kline, 2003). Pull factors are conditions in the receiving country that attract migrants to come (Kline, 2003). This study suggests that the push– pull theory is useful in explaining the emigration of Chinaeducated nurses. Nurses in China carry a heavy workload and work under great stress. Because of lack of recognition of the importance of nursing and minimal investment in nurses, a nurse may care for 15–20 patients on average during a day shift, and this number increases on public holidays (Hu et al., 2010; Ma, 2005). In addition, there is also a lack of mobility in the Chinese nursing workforce market. Migration is regarded as one way for Chinese nurses to escape from the perceived high risk and low quality of the health care work environment, other than leaving nursing (Zhu, 2012). The work environment in Australia is perceived to be better, the workload lighter, and paid annual leave is longer. Also, social constraints and a preoccupation with social relationships in China make some nurses long for a better living environment, both for themselves and for their children. Thus these push and pull factors acted as strong incentives for China-educated nurses to emigrate. However, push–pull theory did not explain all aspects of the migratory move by participants in this study. Arango (2000) has noted that push–pull theory fails to explain why people living in the same conditions in source countries do not move. Also, the theory assumes that pull factors are known ahead time by those deciding to migrate, but we
found that this was not the case. As our findings indicate, knowledge of the receiving country is not always readily available or accurate. Indeed some of the advantages and disadvantages of moving to an area are only known after living there. Thus, there are always some elements of ignorance, mystery, or uncertainty about the receiving country, which makes rational calculation difficult or impossible (Zhou, 2010). In addition to common motivations such as work related factors, economic factors, and social factors, personal factors such as a longing to see the outside world and a desire to open their eyes, experience new things, experience a change of environment, and learn new skills (such as English or nursing skills) were also important. Further, the positive perceptions of migration in Chinese society were influential in the decision making process. We found that cultural and personal factors were not so much about local and foreign conditions, as suggested by push– pull theory, but about the attitudes and beliefs of Chinese society or of these individual China-educated nurses. Historically, only a few privileged Chinese have had the opportunity and means to migrate. Those who have migrated do not consciously manipulate the perceptions of those who never left, but they do communicate certain signs of success to others when they return. Also, they are unlikely to share the less attractive aspects of life abroad. This explains why people in Chinese society generally perceive migration positively. The positive perceptions have been reflected in the mass media for more than a decade with terms such as the going abroad wave (Xiao, 1989); the going abroad heat (Li, 1998); the going abroad fever (Wang, 1987); and the going abroad frenzy (Li, 2004). Migration has been described as ‘‘becoming gold-plated’’, and people often refer to those who go abroad as rich and successful (Wang and Lethbridge, 1995). Thus a culture of migration (Massey et al., 1993; Xu, 2010) in Chinese society makes additional migration much more likely. The new economics of migration theory views migration as a household decision instead of an individual one, taken to maximize expected incomes and minimize risks (King, 2012; Massey et al., 1993; Stark and Bloom, 1985). Our study findings suggest that while some Chinese nurses migrated to reduce environmental risks for the family, others left for personal reasons. Thus nurse migration is
Table 2 A comparison of current study with previous literature on motivation of nurse migration. Studies
This study Ronquillo et al. (2011) Alonso-Garbayo and Maben (2009) McGillis Hall et al. (2009) El-Jardali et al. (2008) Aboderin (2007) Thomas (2006) Larsen et al. (2005)
Topic
Why China-educated nurses migrate to Australia? Why Filipino nurses migrate to Canada? Why India and the Philippines nurses migrate to the UK? Why nurses from Canada leave for the USA? Why Lebanese nurses emigrate? Why Nigerian nurses migrate to the UK? Why Indian nurses emigrate? Why overseas nurses migrate to the UK?
Theme/concept in findings Work related factors
Economic factors
Social factors
Cultural factors
Personal factors
U
U
U
U
U
U U
U U
U U
U U
U U U U
U U U U
U U U U U
U
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not solely driven by new economics of migration theory. The establishment of family and personal migration networks (links between communities at home and in destination countries) helps potential migrants learn about opportunities abroad and provides financial assistance as well as facilitating employment and accommodations for new arrivals (Fawcett, 1989; King, 2012; Martin, 2005; Stark and Bloom, 1985). In so doing, they reduce the costs and uncertainty of migration and therefore facilitate it (Massey et al., 1998). Networks can also induce migration through demonstration effects (Zhou, 2010). Our study findings suggest that networking with others who have migrated influences Chinese nurse migration flows. Most participants in this study said that they were emigrating for several reasons, not just one. It is possible that nurses in China need a strong motivation to migrate. Unlike other low and middle income countries, such as the Philippines or India (Alonso-Garbayo and Maben, 2009), in China there is no institutionalized system in place to facilitate nurse migration. Also, since English is a second language in China, nurses need to invest a lot in improving their English in order to be qualified for migration. Because of these difficulties, nurses may need stronger motivations to leave. As this study shows, China-educated nurses’ motivations to migrate to Australia are complex and they include both individual and broader societal factors. While some reasons for migrating are beyond the control of healthcare organizations (such as personal factors), our findings suggest that a reasonable staffing level and workload, less surveillance and scrutinizing of nurses’ work from nurse managers, more career choices and development opportunities for nurses are strategies that could be employed in China to prevent or minimize nurse migration. In addition, our findings indicate that the social and cultural environments where nurses live have a great influence in the decision to migrate. Chinese nurses looking for migration are generally attracted by more leisure and better living environments in Australia. Thus, migration of Chinese nurses is likely to persist and even increase if the underlying social cultural factors are not adequately resolved. Knowledge of the reasons China-educated nurses choose to migrate can be used by nurse administrators in Australia to provision pre-departure information about what nurses can expect after migration. This could prevent or minimize unmet expectations, and improve the early migration experience. Economic incentives may be just part of the solution, and improving work environment and offering professional development opportunities may be just as important for increasing satisfaction and retention of migrant nurses from China. While this study provides useful insights into nurses’ reason for emigration from China to Australia, it also had several limitations. It was a secondary analysis and although we achieved saturation of themes (repetition across participants and no new themes), there was no formal member check to confirm our interpretations. The findings should therefore be regarded as tentative, providing an initial understanding of reasons for Chinese-educated
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nurses to migrate. Further, this is the first study of its kind focusing on nurses from China; additional research is needed to identify what motivates Chinese nurses to migrate to other high income countries, and determine what incentives need to be in place to retain Chinese nurses in China. Conflict of interest. None declared. Funding. The work was sponsored by Zhejiang Provincial Program for the Cultivation of High-level Innovative Health Talents (http://www.zjwst.gov.cn/) and the Education Bureau of Zhejiang Province (grant number: pd2013213, http://www.zjedu.gov.cn/gb/index1.html). Ethical approval. This study was approved by the following ethical review boards: (1) Human Research Ethics Committee of the Queensland University of Technology. Reference number: 0700000707. (2) Office of Human Research Ethics, The University of North Carolina at Chapel Hill. Reference number: 14-2499. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j. ijnurstu.2015.08.008.
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Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Why do China-educated nurses emigrate? A qualitative exploration Yunxian Zhou a, Cecelia Roscigno b, Qiuhua Sun a,* a b
School of Nursing, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou 310053, Zhejiang, China School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill 27599, NC, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 December 2014 Received in revised form 18 August 2015 Accepted 18 August 2015
Background: Despite the fact that there are more and more Chinese nurses living and working in Australia, relatively little is known about the decisions to emigrate made by these nurses. Objectives: To explore factors influencing China-educated nurses to emigrate to Australia. Design: This was a secondary analysis of 46 semi-structured interviews with 28 Chinaeducated nurses working in Australia. Conventional content analysis was used, and the results are presented thematically. Results: The nurses emigrated for a wide variety of reasons: (a) personal factors (to improve English, to see more of the world and cultures, to seek novelty and adventure); (b) work-related factors (better work environment and more career choices); (c) social factors (better living environment and lifestyle); (d) cultural factors (positive perceptions in China of those who emigrate or have overseas experiences), and (e) economic factors (higher salaries and greater purchasing power). Conclusions: Confirming findings from similar studies, China-educated nurses’ decisions to migrate are complex and not based solely on economic expectations. Personal and cultural factors play vital roles in nurses’ migration decisions. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Chinese nurse Content analysis Immigrant nurses Motivation Nurse emigration Nurse migration Qualitative research Secondary analysis
What is already known about the topic? A chronic nurse shortage in developed countries has produced a growth in demand for nurses from developing countries. China is an emergent supplier of migrant nurses because of its very large supply of registered nurses. The push–pull theory is widely used to explain migration motivation.
* Corresponding author. Tel.: +86 571 86613676. E-mail address: [email protected] (Q. Sun). http://dx.doi.org/10.1016/j.ijnurstu.2015.08.008 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.
What this paper adds China-educated nurses’ decisions to emigrate are multifactorial and not based solely on economic expectations. The push–pull theory is inadequate to fully explain the factors that influence migratory moves of this group of nurses. Personal and the deeply embedded positive culture of migration in China also contribute to nurses’ decisions to migrate and work elsewhere. With developments in transportation, communication, and information technology, international migration has become much easier and the number of migrants has increased dramatically (Arends-Kuenning, 2006; Stankiewicz and O’Connor, 2014). Nurse migration is part of this
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phenomenon (Brush, 2008; Dywili et al., 2013). One key driver of international nurse migration is chronic nurse shortages in high income countries (Dall, 2007; Nelson, 2004; Stankiewicz and O’Connor, 2014). For instance, Australia is expected to have a shortage of 109,000 nurses by 2025 (Health Workforce Australia, 2012). To address this problem, both public and private health care sectors have turned to overseas recruitment of nurses (Hawthorne, 2001; Negin et al., 2013). In 2011, among 239,294 midwifery and nursing professionals in Australia, 81,383 (33.2%) were born overseas (Negin et al., 2013). Indeed, statistics indicate that around 3000 registered nurses and midwives entered the Australian workforce on 457 work visas (a subclass of visa through which employers sponsor temporary skilled workers to work in Australia) in the 2012–2013 financial years (The Sydney Morning Herald, 2015). The primary sources for nurse migration are low and middle income countries such as the Philippines and India (Brush and Sochalski, 2007; Buchan and Sochalski, 2004; Negin et al., 2013). However, with the increasing global demand for nurses, commercial and government recruiters are also interested in recruiting nurses from China (Fang, 2007; Lin, 2013; Lintern, 2013). Although nurse workloads and the nurse-population ratio indicate that China has a nurse shortage, there are also high nurse unemployment and underemployment (Fang, 2007; Hu et al., 2010; Zhu, 2012). Due to the financial incentive structure of Chinese hospitals, many hospital managers in China failed to recognize the importance of nurses to the safety and quality of patient care and to employ an adequate number of nurses (Zhu et al., 2014). Usually, less qualified carers and private hired helpers for patients are used to supplement the small nursing staff at lower cost to the hospital (Hu et al., 2010). Currently, the Chinese Nursing Association overwhelmingly supports Chinese nurses in working abroad (Fang, 2007; Zhu, 2012), in the hope that a national nurse shortage and negative impacts on patient outcomes will trigger Chinese healthcare reform and improve the welfare of Chinese nurses (Hu et al., 2010). As a result, several authors who have assessed the potential for nurse emigration from China have concluded that China will become an increasingly important supplier of nurses in the future (Hu et al., 2010; Fang, 2007; Xu, 2010; Xu and Zhang, 2005). To work in Australia as a nurse, Chinese nurses must be registered with the Nursing and Midwifery Board of Australia and meet the Board’s registration standards. They might also need to complete a skill assessment from the Australian Nursing and Midwifery Council and pass the Occupational English Test (OET) or the International English Language Testing System (IELTS) (Kingma, 2006; Stankiewicz and O’Connor, 2014). Since English is a second language in China, most Chinese nurses need a substantial period of time to improve their English and/or secure professional registration (Lynch et al., 2012). As a result, very few Chinese nurses have come to Australia as an RN. Many have come on student visas arranged by private migrant agencies (Zhou, 2010; Fang, 2007). Because these operations are ‘‘for profit’’, the nurses are usually required to pay a significant amount of money to the agency in
exchange for the visa. The agency might also give Chinese nurses unrealistically high expectations regarding work life in Australia. After meeting the registration requirement, Chinese nurses are recruited by Australian health care institutions and can apply for a work visa in Australia. Although much has been written about the experiences of migrant nurses in recipient countries, including nurses from China (Zhou, 2010, 2014; Zhou et al., 2010, 2011; Xu et al., 2008), relatively little is known about the reasons nurses choose to migrate (Dywili et al., 2013), particularly nurses from emerging source countries. Further, migrant nurses are not a homogeneous group (Alonso-Garbayo and Maben, 2009; Larsen et al., 2005); nurses from different countries have different expectations and therefore their motivations vary (Alonso-Garbayo and Maben, 2009). For example, Aboderin (2007) found that economic gain was the primary motives for Nigerian nurses to migrate, and deteriorating work and status situations at home were added incentives. The main reasons for Lebanese nurses to migrate included shift work, heavy workloads, lack of autonomy in decision-making and lack of a supportive environment (El-Jardali et al., 2008). While nurses from Canada have left for the USA in search of opportunities for full-time work and ongoing education (McGillis Hall et al., 2009), Indian and Filipino nurses have migrated in response to economic, professional, social, and cultural factors (Alonso-Garbayo and Maben, 2009; Ronquillo et al., 2011; Thomas, 2006). All together, Larsen et al. (2005) have divided the motives of migrant nurses into a ‘‘life change strategy’’ and a ‘‘working holiday strategy’’. Studies have shown that domestic colleagues and patients do not always understand migrant nurses’ motivations for choosing to work in another country (Zhou, 2010; Larsen et al., 2005). They often believe those motivations are solely economic—that is, the nurses migrate in search of higher wages (Aboderin, 2007; Zhou, 2010). Despite the fact that more and more Chinese nurses are living and working in Australia (no exact figure is available) (Zhou, 2010; Fang, 2007), the reasons why they leave to work in Australia are poorly understood and the question has received virtually no attention as a research or policy issue. Understanding the reasons that nurses leave China is important for policy makers and senior nurse managers in China, because this could help them address local factors that are motivating nurses to leave. Even those nurses who stay in China may become more satisfied if the situation is understood and problems such as inadequate work or social environments are corrected. Ignoring those motivating factors may result in a continued loss of more highly educated Chinese nurses and a loss of economic investment (time and money to train nurses) in China resulting in further deterioration of the quality of care in the Chinese health care system (Hu et al., 2010; Xu and Zhang, 2005). For the recipient countries nurse migration has been a ‘‘quick fix’’ for nurse shortages as these countries gain well educated and experienced nurses at a relatively low cost (Zhou, 2010; Kline, 2003). Given the global competition for skilled migrant nurses, it is important for nursing administrators in recipient countries to understand migrant
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nurses’ motivations and meet their expectations. Otherwise, these nurses may have low job satisfaction and possibly move elsewhere or leave nursing. It has been reported that total turnover costs range from a low of $20,561 in the US to a high of $48,790 in Australia (Duffield et al., 2014). Retaining immigrant nurses thus is essential to save the large amount of money required for recruiting and training new nurses; and it is also important for patient safety and nurse productivity (Jones, 2004). Largely due to their language skills, Chinese nurses can help provide culturally congruent care to other Chinese speaking immigrants living in those countries. Thus the purpose of this study was to explore why China-educated nurses migrate to Australia. 1. Methods This study was a secondary analysis of data from a large qualitative study which explored the experiences of Chinaeducated nurses who migrated to Australia and worked there as nurses (Zhou, 2010, 2014). The broad topic of the parent study provided the researcher with an opportunity to explore the reasons why nurses chose to migrate to Australia, which was the focus of this secondary analysis (Sandelowski, 1995, 2011; Thorne, 1993). Participants’ descriptions of their motivations for leaving China to work in Australia included novel and nuanced individual, social and cultural factors (family, friends, community, healthcare work environments, politics, economics, and cultural beliefs) in both China and Australia that influenced their decisions (Sandelowski, 1995, 2011). Before conducting the secondary analysis, the researchers reviewed the data obtained in the parent study and determined that the original grounded theory methodology, the theoretical sampling technique used to achieve social diversity in the nurses interviewed, the prolonged engagement with participants in two open-ended interviews, and the narrative transcript data describing nurses reasons for choosing to move to Australia provided sufficient data of explaining Chinese nurses’ choices and the factors important in making those choices (Thorne, 1993; Ziebland and Hunt, 2014). It was concluded that the test for completeness needed in order to answer the secondary research question was met with the original data set (Coyer and Gallo, 2005; Sandelowski, 2011). Also, the first author was the primary investigator of both the original study and this secondary analysis, which assured that the narrative transcript data were not taken out of the context of the original study in order to answer the secondary question (Thorne, 1993; Ziebland and Hunt, 2014). 1.1. Study design This secondary analysis used conventional content analysis, which focuses on analyzing textual information (Prior, 2014) and allows researchers to attend to participants’ explanations, grounded in the interview encounter and transcript data, without imposing any preconceived notions (Hsieh and Shannon, 2005; Prior, 2014). The question guiding the analytic approach was ‘‘Why do China-educated nurses choose to leave China and move to
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Australia to work as registered nurses?’’ The aim of the analysis was to generate a richly detailed, nuanced, and interpretive examination of the individual, social, and cultural factors that influenced this group of Chinese nurses to explore such opportunities. 1.2. Participants Institutional Review Board approval was obtained at the original recruitment location and at the first author’s institutions for the original study and for this analysis. Sampling for the original study was purposive with the aim of selecting Chinese-educated registered nurses who had the potential to provide rich information on the experiences of nurses now working in Australia as registered nurses (Zhou, 2010). We initially recruited participants via advertisements in local and national nursing publications. To be included in the study, participants had to be registered nurses of Chinese nationality who had migrated to Australia to work as a registered nurse for at least 6 months, in Brisbane or Adelaide. To enhance participation and vary the demographics of participants (age, education, marital status, living location in China, nursing experience and position in China or Australia), we used the snow balling technique to access participants through referrals from previous participants (Zhou, 2010). All participants provided written informed consent before being interviewed, and they were made aware that other secondary analyses might be conducted at a later date if they were in line with the original aim of study. 1.3. Data collection In order to understand the sample characteristics, social demographic data were collected from all 28 participants in the in-person interviews with the first author. Of the original 28 participants, 19 were invited to participate in second interviews; one nurse invited to participate was unable to do so due to a time conflict. Thus, 18 nurses participated in the second interviews to further develop emerging categories. The first author/sole interviewer was a Chinese nurse working on her Ph.D. in Australia at the time. Interviews were conducted in a private and quiet place of the participants’ choosing. The average length of the interviews was approximately 72 min. All interviews were conducted in Mandarin and audio-recorded. A semistructured interview guide was used for both interviews, and this was refined throughout the study based on constant comparative analysis of the interviews already conducted, which informed new questions or probes. Typical questions that support the conduction of this secondary analysis included: ‘‘Tell me your reasons for coming to work as a registered nurse in Australia?’’, ‘‘What are some of the factors that influenced your decision?’’, and ‘‘Tell me the process of your decision-making to leave China to work in Australia.’’ Probing questions were used to gain further details from each participant (e.g., ‘‘Why was that important to you?’’). The first author took field notes immediately following each interview to record details of the observations, interactions, environment, and
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body language of the participants. In addition, she made follow-up telephone and email contacts with some participants for clarification of audio or transcript data that was unclear. The data consisted of over 3000 doublespaced pages of verbatim transcription of face-to-face interviews with each of the participants. The transcribed interviews were printed out in their entirety for the two coders to read. Since the primary investigator on the original study was also one of the coders, she was able to share contextual information from field notes that helped to place the transcript data into the milieu of the individual’s life. 1.4. Data analysis In the original study, all transcribed interviews were checked for accuracy. Conventional content analysis was used for this analysis (Hsieh and Shannon, 2005; Prior, 2014). Coders (YX and QH) first read the entire transcripts of each participant’s interviews several times to gain a sense of the whole of the participant’s interview(s) and experiences. After that, the coders hand coded line-by-line any narrative data that were related to participants’ reasons for leaving China to go to Australia to work or for staying in Australia to work. In order to identify similarities and differences in participants’ reasons for leaving China and moving to Australia to work as a registered nurse, the coders carefully attended to the words used by participants to describe themselves (age, gender, years of experience, marital status, previous migration experience), the places they left, the places they went to, and the social factors that they believed influenced their decision (Sandelowski, 1995; Ziebland and Hunt, 2014). The two coders discussed their coding of individual transcripts and used an iterative process to reach agreement on codes, coding definitions and the expansion or collapsing ˜a, 2014). Chinese of any codes (Garrison et al., 2006; Saldan was used for the initial coding and codes, and they were subsequently translated into English for further comparison ˜a, by a peer reviewer (CR) and for writing the report (Saldan 2014; Squires, 2008, 2009). The primary investigator was fluent in both Chinese and English and conducted this translation. Saturation for the analysis was deemed to be met when the three coders noted repetition in participants’ responses and saw no new themes on migration decisions ˜a, 2014). were presented (Bowen, 2008; Saldan From the coded data, a matrix of themes was ˜ a, 2014). Quotaconstructed (Bradley et al., 2007; Saldan tions for each theme were selected and used to show the diverse ways in which participants expressed themes, allowing us to understand the boundaries of themes and making our findings richer and more socially relevant ˜ a, 2014). (Averill, 2002; Saldan 1.5. Credibility The rigour of the analysis was maintained using several techniques. Participants’ descriptions and field notes were the primary sources of data from which conclusions were drawn; an audit trail of the original study and the secondary analysis was maintained and reviewed. Peer
debriefing (CR) was used to maintain transparency, examine methodological issues, and consider alternative interpretations so that there was no premature analytic foreclosure (Phillips, 2014; Ryan-Nicholls and Will, 2009; Sandelowski, 1995). 2. Findings The participants came from 9 provinces and 3 municipalities in the northern and southern parts of China. All were female. Time spent working as a registered nurse in Australia ranged from 6 months to 4 years. Eight participants also had worked in countries other than China and Australia, one in Oman and seven in Singapore. Eight nurses lived with their families in Australia (Table 1). The nurses migrated to Australia for a variety of reasons, broadly categorized as personal factors (n = 25), work related factors (n = 22), social factors (n = 18), cultural factors (n = 15), and economic factors (n = 15). More than one reason was typically given by each participant. 2.1. Personal factors influencing nurse migration Personal factors were defined as individual characteristics, preferences, choices, or goals that motivated the nurse to migrate. These were the factors mentioned most often by participants. Half of the nurses (n = 14) said that they came to Australia to see more of the world, to satisfy their curiosity, or to experience a new culture and new ways of life:
Table 1 General information of the participants.
Age (years) 20–30 31–40 41–50 Education Diploma in nursing Bachelor in nursing Postgraduate qualification Marital status Single Married Divorced Separated Nursing experience in China 1–5 years 6–10 years 11–20 years Employment position in China Registered nurse Nurse manager Lecturer in nursing school Nursing experience in Australia Less than 1 year 1–2 years >2 years Employment position in Australia Level 1 year 1 to level 1 year 5 year 5 Above level 1 year 5
Number of participants
Percentage (%)
16 10 2
57.1 35.7 7.2
4 18 6
14.3 64.3 21.4
15 11 1 1
53.6 39.3 3.6 3.6
10 13 5
35.7 46.4 17.8
24 2 2
85.7 7.1 7.1
9 11 8
32.1 39.3 28.6
14
50.0
14
50.0
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You should go and see that world. . .because if you don’t go, you never know what life looks like abroad. Some nurses (n = 9) were attracted to Australia to improve their English or learn about Western nursing: I like English very much. . .and I have learned it for a long time. I hope I can improve my English further and I hope I can practice English daily in a work environment. I like being a nurse and doing nursing work. And I would like to see more and learn more about nursing in Western countries. Another participant, who was not fond of nursing, joined the profession because it provided her more opportunities to migrate than any other profession: I was not interested in nursing at that time. . .However, I was attracted by the fact that as a nurse. . .I could go to different places, travelling while working, and having different experiences. Warm weather and travel beyond the place they migrated to were also mentioned as reasons for migration (n = 6): I knew the weather in Australia was very good before I migrated. I used to catch a cold easily in China and I am afraid of cold weather. I migrated to Australia for vacation purposes. I would have both time and money for that. Two nurses chose to go abroad because they wanted to leave a place where they felt sad because of a personal situation:
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Health care organizations in China were described as strictly hierarchical. Hospitals set down rigid rules and regulations that nurses were required to adhere to. Nurse managers implemented surveillance strategies and constantly scrutinized nurses’ work. This brought extra stress for the nurses: In China, nurse managers spend all day looking at you and checking your work. . .Have you done this? Have you done that?. . .You should not sit there and chat. You should not sit there and drink, and so forth. The focus on cost containment in China was perceived by some participants (n = 4) as leading to conflicts in the nurse–patient relationship since patients and families also tended to oversee nursing activities closely. This not only undermined the personal fulfilment that nurses gained from their work but also contributed to high levels of occupational stress and consequent ‘‘burn-out’’: When you work in China, you have to consider money first. How much would it cost the patient if I did this for him?. . .Since there is money involved, patients and families [in China] pay a lot of attention to you and write down everything you do in a logbook. You feel you could easily get a lawsuit if you do anything wrong [in China]. You worry about that constantly. Australia has national health insurance and patients either have largely free health care or they have private health insurance. The nurses felt less oversight and judgement from their patients and therefore perceived Australian patients as pleasant to work with. Nursing work in Australia was described as more rewarding than in China:
I had some relationship issues at that time and I wanted to leave that environment very much and get a job.
I feel working as a nurse in Australia is a big improvement in quality for me. I can feel the essence of nursing more from my daily work.
Participants were likely to have been the only child as a result of China’s one-child family planning policy. One nurse wanted the adventure of being away from home in order to experience independence:
Poor career paths and promotion opportunities led some China-educated nurses (n = 3) to feel stuck in their jobs in China:
I am the only child in my family in China and I stayed around my parents all day long. I was very keen to be independent and be away from my family.
2.2. Work related factors influencing nurse migration Work related factors reflected working conditions in Chinese or Australian health care organizations and they were strong incentives for nurses’ migration (n = 22), sometimes even outweighing personal factors. Some nurses (n = 5) said they left China to escape unpleasant working environments such as inappropriate staffing levels and heavy workloads: The work environment [in my former hospital] somehow threatened our survival. . .We had too heavy a workload and too much stress. We were struggling even after work, worrying that we hadn’t done our job well enough and someone might sue us tomorrow.
There were more and more bachelor’s-prepared nurses after I worked in that hospital for 8–9 years. As a result, nurses like me with a secondary school education certificate didn’t have many promotion opportunities. . .At that time, I could only foresee a very gloomy future [in China], and I didn’t want to lead a life like that. A sense of lost hope was described by some of the nurses, who perceived limited freedom to choose their job sector and specialty in hospitals in China. Migration was perceived to offer new hope to the nurses (n = 3): I worked in the oncology and haematology department in China, which was very busy, stressful and tiring. It was very difficult to change to another department. . . I knew that if I had a chance to migrate, I would not have to work that hard and I would have more opportunities. One nurse migrated because she wanted to seek more equality in her work payment:
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I was a contract nurse in China. My income was less than those Dingbian1 nurses. . .I felt dissatisfied because I was not treated equally. Australia was perceived to offer better working conditions for participants in terms of workload, work environment, and benefits (n = 14): Nurses enjoy a better work environment and more flexible work schedule here and they have longer annual leaves than in China. Nursing work here is lighter compared to China, and people here respect nurses more. Patients and families regard nurses as professionals and they pay attention to their opinion and listen to them. Other work related motivations included a desire to experience professional challenges in their work environment (n = 4): I was working in a county hospital in China and the work there is easy. . .but after some time, I wanted to have some challenges. So I considered migration and experiencing the outside world. 2.3. Social factors influencing nurse migration Social factors reflected the expectations, circumstances, and lifestyles in China or Australia that were perceived to be important for quality of life. Some nurses (n = 6) were discontented with Chinese culture and the ways it influenced life in China, particularly the preoccupation with proper social relationships and their maintenance based on Confucianism (Barkema et al., 2015; Yum, 1988): Personally, I don’t like the complex human relationships in hospitals in China. Also, I felt I couldn’t find the things I wanted if I stayed there to develop my career.
You don’t have your own vacation time, you don’t have your own free time, and you get up early and go to bed late every day. I don’t like that in China. The Australian lifestyle was perceived to emphasize more of a work-life balance, which was attractive to the nurses (n = 7): The lifestyle here is very relaxed. You have no pressure to study further. As long as you finish your work, you can go home without any pressure. . . I can enjoy life more in Australia, and am not restricted by work too much. One nurse migrated because of the social constraints against having a second baby in China: One of the key reasons for my migration was that I wanted to have a second baby, as I felt it was too lonely for the only child [required by law in China].
1 In China, there are two types of employees: Dingbian and contract. Dingbian means a more stable job with a relatively satisfactory income, as compared with contract employees in the same institution.
Some nurses (n = 6) said they had moved for a better living environment for themselves and their family: I was longing for the good environment abroad, the good air. . . .The pollution in the city [in China] where I came from was very severe. . .and I was also attracted by the good quality of life here. Migration was believed by some (n = 6) to be particularly beneficial to their children since it offered the children the option of being raised in a less competitive educational environment: The education here for the kids is better and they don’t have much stress. 2.4. Cultural factors influencing nurse migration Cultural factors referred to the values, beliefs and perceptions of Chinese society about migration or working overseas. Historically, the Chinese people have perceived emigration to the West as a desirable goal since it is believed that Western countries are more advanced and thus better places to live and work than China. Also, the Western image of ‘‘the good life’’ relayed through global media makes it trendy to migrate. Some participants (n = 8) said they had been longing for the outside world and dreaming of migration for a long time: Ever since I started my nursing study, I was thinking of migration. . . I wanted to go abroad and I studied hard for that. Even though my classmates thought that was something impossible, I believe nothing is impossible. . .and I did not give up my migration dream. The perception that overseas education or work experience was especially valued in Chinese society was emphasized by some nurses (n = 4), and this partially contributed to the migration decision: I like being a nurse and doing nursing work. And I would like to see more and learn more about nursing in Western countries. Even if I go back to China one day, I will have overseas working experience, which is valuable. These nurses perceived that they gained not only social position, but also social respect from peers back in China because of their networking with peers in other countries. Their economic, social, and personal gains influenced others who also wanted to migrate to attain these benefits to their overall career: I had a friend working in Australia at that time. . .She felt she experienced great changes after migration. She suggested that I do the same if I had this idea myself.
Everyone is emigrating and I want to go abroad to open my eyes as well. Migration to high income countries is generally perceived as a sign of career success for migrants, as well as for their family. International migration of a family member is about pride, and is linked to the desire to be modern and successful. In contrast, not emigrating may be
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perceived as being incapable of taking advantage of an opportunity:
Australia but it is 10 RMB [one Australian dollar is about 6 RMB at that time] in China.
People around me are emigrating and if I don’t do the same, it may indicate that I don’t have such ability.
One nurse felt a need to make more money to relieve the family’s financial distress in China. After working in Singapore for a few years, she had planned to stay in China for some time. However, the need for money was a strong incentive for her to migrate again:
Indeed, this positive perception of migration is so deeply engrained in Chinese society that not doing so when one is qualified would be strongly questioned by others, as pointed out by some participants (n = 7): My family would like me to stay in Australia. They don’t want me to go back to China. It was not easy for me to come to Australia to study. Many people would like to migrate [but they can’t]. If I return to China, many people would feel it is a disappointment. Because of the positive perceptions of migration in Chinese culture, 11 of the 28 participants said that they had not given much thought to the decision to migrate: I didn’t think much about my migration decision because at that time the impulse to migrate outweighed anything. That is to say, I was willing to take any risk. I wanted to migrate; all I wanted was to migrate. Many of the nurses (n = 18) also pointed out that a lack of information on nursing in Australia contributed to the fact that they did not give much thought to their migration decision because there was not much they could draw on to make the decision: I had totally no idea about what nursing in Australia would be like before I migrated. I only thought of Australia as a Western country that might have a more advanced medical system, and also Australians speak English. That is all I knew before I came. This is a lack of knowledge from which to make migration decisions has been overlooked as an important factor influencing some nurses migration decisions in other published reports. 2.5. Economic factors influencing nurse migration Economic factors reflected the financial incentives in Australia and the barriers in China which influenced the migration decision. Economic factors were never the only factors, yet there is no doubt that they played some role in the decision-making processes of these nurses. Thirteen participants mentioned the wage differential between China and Western countries as one of their key motives: Nurses in Australia, the UK and the USA earn much more than in China; that is why I wanted to go abroad to work. Although the average income in China has been increasing in recent years, the inflation rate has increased more. As a result, it is not just the absolute amount of salary that matters, but also the relative purchasing power of one’s salary: If one does not calculate the exchange rate, the salary I earn here is similar to the amount I can earn in China. . . However, things are expensive in China. Take a bottle of milk as an example: it only costs one dollar or so in
There were some conflicts in my family. It was mainly about financial issues. That is to say, I needed a certain amount of money to solve my domestic problems. That is why I came to Australia to work. Interestingly, one-fourth of the participants pointed out that they were not motivated or not primarily motivated by the fact that they could earn more in Australia. One nurse recalled: I could earn over 10,000 RMB each month, sometimes even more. . .I own two apartments and two cars there. . .My life in China was not too bad already. The fact that they could afford to go abroad also meant that these nurses were financially well situated, at least to some degree. As one nurse remarked: All those emigrant nurses, their economic situation in China was good enough. Otherwise, they would not able to afford the cost of migration.
3. Discussion In recent decades, globalisation and the increasing integration of labour markets worldwide have increased the number of people with the desire and capacity to move to other places. Further, the rapid expansion of communication and information technology has made information transmission faster and cheaper, and development of transportation has made long-distance travel much cheaper (Zhou, 2010; Martin, 2005). As a result, migrants are able to recoup their financial outlay in a shorter timeframe. Some employers offer incentives such as paid airfare/travel on condition that a working contract for a given period of time will be fulfilled. All these factors facilitate the movement of people from one country to another. Kingma (2007) has suggested that most nurses are reluctant to leave their home countries and would be willing to stay if offered a good living wage. Thus, overseas nurses are often described as motivated primarily by economic reasons (Alonso-Garbayo and Maben, 2009; Larsen et al., 2005; Negin et al., 2013; Ross et al., 2005). However, while the income gap between China and Australia was a factor in the migration of nurses in this study based on the neoclassical economics view (Arango, 2000; King, 2012; Massey et al., 1993), this did not entirely explain their decision to move. For some participants, the need for money was important; but for others, this was not the case since they already had a stable economic position in China. Indeed, most participants did not belong to the poor ‘‘masses’’ in China but to a relatively privileged group with a stable job, income, and benefits (housing stipend,
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paid annual leave, health care insurance, bonuses, holiday allowances). They were emigrating not to survive, but to thrive. Nurse training overseas is expensive (Zhou, 2010; Kingma, 2006), and most of the nurses in this study had paid a fee to an agent for help with obtaining a visa. Immigration agencies usually select those who are healthier, better educated, and more affluent (Anson, 2004; Chiswick, 2000; Wallace and Kulu, 2014). These privileges (as well as their choice of a profession) made migration possible for these nurses. This study offers some new insights on why nurses migrate (Table 2). Most studies to date have described migration as a subjective decision-making process influenced by social, work related and economic push and pull factors (Bach, 2007; Kingma, 2001; Kline, 2003). Push factors are conditions in the source country that compel individuals to migrate (Kline, 2003). Pull factors are conditions in the receiving country that attract migrants to come (Kline, 2003). This study suggests that the push– pull theory is useful in explaining the emigration of Chinaeducated nurses. Nurses in China carry a heavy workload and work under great stress. Because of lack of recognition of the importance of nursing and minimal investment in nurses, a nurse may care for 15–20 patients on average during a day shift, and this number increases on public holidays (Hu et al., 2010; Ma, 2005). In addition, there is also a lack of mobility in the Chinese nursing workforce market. Migration is regarded as one way for Chinese nurses to escape from the perceived high risk and low quality of the health care work environment, other than leaving nursing (Zhu, 2012). The work environment in Australia is perceived to be better, the workload lighter, and paid annual leave is longer. Also, social constraints and a preoccupation with social relationships in China make some nurses long for a better living environment, both for themselves and for their children. Thus these push and pull factors acted as strong incentives for China-educated nurses to emigrate. However, push–pull theory did not explain all aspects of the migratory move by participants in this study. Arango (2000) has noted that push–pull theory fails to explain why people living in the same conditions in source countries do not move. Also, the theory assumes that pull factors are known ahead time by those deciding to migrate, but we
found that this was not the case. As our findings indicate, knowledge of the receiving country is not always readily available or accurate. Indeed some of the advantages and disadvantages of moving to an area are only known after living there. Thus, there are always some elements of ignorance, mystery, or uncertainty about the receiving country, which makes rational calculation difficult or impossible (Zhou, 2010). In addition to common motivations such as work related factors, economic factors, and social factors, personal factors such as a longing to see the outside world and a desire to open their eyes, experience new things, experience a change of environment, and learn new skills (such as English or nursing skills) were also important. Further, the positive perceptions of migration in Chinese society were influential in the decision making process. We found that cultural and personal factors were not so much about local and foreign conditions, as suggested by push– pull theory, but about the attitudes and beliefs of Chinese society or of these individual China-educated nurses. Historically, only a few privileged Chinese have had the opportunity and means to migrate. Those who have migrated do not consciously manipulate the perceptions of those who never left, but they do communicate certain signs of success to others when they return. Also, they are unlikely to share the less attractive aspects of life abroad. This explains why people in Chinese society generally perceive migration positively. The positive perceptions have been reflected in the mass media for more than a decade with terms such as the going abroad wave (Xiao, 1989); the going abroad heat (Li, 1998); the going abroad fever (Wang, 1987); and the going abroad frenzy (Li, 2004). Migration has been described as ‘‘becoming gold-plated’’, and people often refer to those who go abroad as rich and successful (Wang and Lethbridge, 1995). Thus a culture of migration (Massey et al., 1993; Xu, 2010) in Chinese society makes additional migration much more likely. The new economics of migration theory views migration as a household decision instead of an individual one, taken to maximize expected incomes and minimize risks (King, 2012; Massey et al., 1993; Stark and Bloom, 1985). Our study findings suggest that while some Chinese nurses migrated to reduce environmental risks for the family, others left for personal reasons. Thus nurse migration is
Table 2 A comparison of current study with previous literature on motivation of nurse migration. Studies
This study Ronquillo et al. (2011) Alonso-Garbayo and Maben (2009) McGillis Hall et al. (2009) El-Jardali et al. (2008) Aboderin (2007) Thomas (2006) Larsen et al. (2005)
Topic
Why China-educated nurses migrate to Australia? Why Filipino nurses migrate to Canada? Why India and the Philippines nurses migrate to the UK? Why nurses from Canada leave for the USA? Why Lebanese nurses emigrate? Why Nigerian nurses migrate to the UK? Why Indian nurses emigrate? Why overseas nurses migrate to the UK?
Theme/concept in findings Work related factors
Economic factors
Social factors
Cultural factors
Personal factors
U
U
U
U
U
U U
U U
U U
U U
U U U U
U U U U
U U U U U
U
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not solely driven by new economics of migration theory. The establishment of family and personal migration networks (links between communities at home and in destination countries) helps potential migrants learn about opportunities abroad and provides financial assistance as well as facilitating employment and accommodations for new arrivals (Fawcett, 1989; King, 2012; Martin, 2005; Stark and Bloom, 1985). In so doing, they reduce the costs and uncertainty of migration and therefore facilitate it (Massey et al., 1998). Networks can also induce migration through demonstration effects (Zhou, 2010). Our study findings suggest that networking with others who have migrated influences Chinese nurse migration flows. Most participants in this study said that they were emigrating for several reasons, not just one. It is possible that nurses in China need a strong motivation to migrate. Unlike other low and middle income countries, such as the Philippines or India (Alonso-Garbayo and Maben, 2009), in China there is no institutionalized system in place to facilitate nurse migration. Also, since English is a second language in China, nurses need to invest a lot in improving their English in order to be qualified for migration. Because of these difficulties, nurses may need stronger motivations to leave. As this study shows, China-educated nurses’ motivations to migrate to Australia are complex and they include both individual and broader societal factors. While some reasons for migrating are beyond the control of healthcare organizations (such as personal factors), our findings suggest that a reasonable staffing level and workload, less surveillance and scrutinizing of nurses’ work from nurse managers, more career choices and development opportunities for nurses are strategies that could be employed in China to prevent or minimize nurse migration. In addition, our findings indicate that the social and cultural environments where nurses live have a great influence in the decision to migrate. Chinese nurses looking for migration are generally attracted by more leisure and better living environments in Australia. Thus, migration of Chinese nurses is likely to persist and even increase if the underlying social cultural factors are not adequately resolved. Knowledge of the reasons China-educated nurses choose to migrate can be used by nurse administrators in Australia to provision pre-departure information about what nurses can expect after migration. This could prevent or minimize unmet expectations, and improve the early migration experience. Economic incentives may be just part of the solution, and improving work environment and offering professional development opportunities may be just as important for increasing satisfaction and retention of migrant nurses from China. While this study provides useful insights into nurses’ reason for emigration from China to Australia, it also had several limitations. It was a secondary analysis and although we achieved saturation of themes (repetition across participants and no new themes), there was no formal member check to confirm our interpretations. The findings should therefore be regarded as tentative, providing an initial understanding of reasons for Chinese-educated
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nurses to migrate. Further, this is the first study of its kind focusing on nurses from China; additional research is needed to identify what motivates Chinese nurses to migrate to other high income countries, and determine what incentives need to be in place to retain Chinese nurses in China. Conflict of interest. None declared. Funding. The work was sponsored by Zhejiang Provincial Program for the Cultivation of High-level Innovative Health Talents (http://www.zjwst.gov.cn/) and the Education Bureau of Zhejiang Province (grant number: pd2013213, http://www.zjedu.gov.cn/gb/index1.html). Ethical approval. This study was approved by the following ethical review boards: (1) Human Research Ethics Committee of the Queensland University of Technology. Reference number: 0700000707. (2) Office of Human Research Ethics, The University of North Carolina at Chapel Hill. Reference number: 14-2499. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j. ijnurstu.2015.08.008.
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