Concept identification and definition

C O N C E P T A N A L Y S I S

Migration: a concept analysis from a nursing perspective

Michelle Freeman, Andrea Baumann, Jennifer Blythe, Anita Fisher & Noori Akhtar-Danesh

Accepted for publication 17 September 2011

Correspondence to M. Freeman:

e-mail: [email protected]

Michelle Freeman MSN RN

Doctoral Student

School of Nursing, McMaster University,

Hamilton, Ontario, Canada,

and Lecturer

Faculty of Nursing, University of Windsor,

Ontario, Canada

Andrea Baumann PhD RN

Associate Vice-President,

Global Health, Faculty of Health Sciences,

and Scientific Director

Nursing Health Services Research Unit

(NHSRU), McMaster Site, Hamilton,

Ontario, Canada

Jennifer Blythe PhD

Associate Professor (part-time)

School of Nursing, Research Associate

NHSRU, McMaster University, Hamilton,

Ontario, Canada

Anita Fisher PhD RN

Associate Professor

School of Nursing and Senior Researcher

NHSRU, McMaster University, Hamilton,

Ontario, Canada

Noori Akhtar-Danesh PhD

Associate Professor of Biostatistics

School of Nursing, McMaster University,

Hamilton, Ontario, Canada

F R E E M A N M . , B A U M A N N A . , B L Y T H E J . , F I S H E R A . & A K H T A R - D A N E S H N .F R E E M A N M . , B A U M A N N A . , B L Y T H E J . , F I S H E R A . & A K H T A R - D A N E S H N .

( 2 0 1 2 )( 2 0 1 2 ) Migration: a concept analysis from a nursing perspective. Journal of

Advanced Nursing 68(5), 1176–1186. doi: 10.1111/j.1365-2648.2011.05858.x

Abstract Aim. This article is a report of a concept analysis of nurse migration.

Background. International migration is increasing and nurse migrants are active

participants in this movement. Migration is a complex term and can be examined

from a range of perspectives. Analysis of nurse migration is needed to guide policy,

practice and research.

Data sources. A literature search was undertaken using electronic literature indexes,

specific journals and websites, internet search engines and hand searches. No

timeframe was placed on the search. Most literature found was published between

2001 and 2009. A sample of 80 documents met the inclusion criteria.

Method. Walker and Avant’s approach guided the analysis.

Discussion. Nurse migration can be defined by five attributes: the motivation and

decisions of individuals; external barriers and facilitators; freedom of choice to

migrate; freedom to migrate as a human right, and dynamic movement. Antecedents

of migration include the political, social, economic, legal, historical and educational

forces that comprise the push and pull framework. The consequences of migration

are positive or negative depending on the viewpoint and its affect on the individual

and other stakeholders such as the source country, destination country, healthcare

systems and the nursing profession.

Conclusion. This concept analysis clarified the complexities surrounding nurse

migration. A nursing-specific middle-range theory was proposed to guide the

understanding and study of nurse migration.

Keywords: concept analysis, human right, middle-range theory, migration, nurse

migration

Introduction

People have always migrated, either voluntarily in search of a

better life or involuntarily, because of war, famine or

persecution. International migration is a reality in our global

community with the number of migrants doubling in the last

four decades [International Organization for Migration

(IOM) 2005]. An important proportion of these migrants

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J A N JOURNAL OF ADVANCED NURSING

are professional healthcare workers, specifically Registered

Nurses (RNs) (Kingma 2007).

As one of the defining issues of the twenty-first century (IOM

2009), migration is an important area on which to focus

attention. The IOM describes migration as ‘an essential,

inevitable and potentially beneficial component of the

economic and social life of every country and region’ (IOM

2009). As the world is faced with a critical shortage of nurses,

nurse migrants are of great interest nationally and internation-

ally. These ‘on the move’ nurses, migrate each year in search of

better pay and working conditions, professional development,

personal safety, or adventure (Kingma 2006a, 2007). Although

there is a great deal of published literature on nurse migration

in the past 10–15 years (Khaliq et al. 2009), the topic has

received limited attention from the nursing community.

Migration is a complex term with many meanings that can

be examined from a range of perspectives. Definitions have

been described as vague, controversial, or contradictory and

vary by country (IOM 2004, p. 3). Although migration

theories have been evolving for many years, there are few

examples of their use in research on nurse migration.

Migration theories focus on various levels of analysis: micro

levels concentrate on individual migration decisions, macro-

levels on aggregate explanations, and the meso-level exam-

ines household and community level influences on migration

(Hagen-Zanker 2008). The theory most frequently used to

explain nurse migration is the push pull theory (Meija et al.

1979, Kline 2003, Kingma 2006a, Bach 2007). This micro-

level framework offers an explanation of why nurses migrate

but not the individual’s decision-making. It has also been

criticized for its inability to explain why people decide not to

migrate (De Jong & Fawcett 1981, Arango 2000). These

limitations affect our ability to describe, study and/or address

issues related to increasing rates of nurse migration.

This article presents a concept analysis of nurse migration.

Two aims guided this analysis: to understand how the

concept of migration is used in nursing and to propose a

middle-range theory to guide the study of nurse migration.

Background

A concept is a mental image of a phenomenon, an idea, a

person, or an object (King 1988, Walker & Avant 2005). A

concept analysis is a formal, linguistic exercise that examines

the elements of a concept, its usage and how it is similar to or

different from other related words (Walker & Avant 2005,

p. 63). It is useful in clarifying words that are vague or

overused so that everyone subsequently using the word will

be speaking about the same thing (Walker & Avant 2005,

p. 64). In addition, they give precise definitions for use in

theory and research (p. 74). Since concepts are dynamic and

change over time, a concept analysis should never be

regarded as a ‘finished product’ (p. 64) but only as one

defining its attributes at the current time.

Migration is a commonly used word with explicit meaning

and an unusual topic for a concept analysis in nursing. An

analysis is usually done on abstract concepts such as quality

of life (Haas 1999). Penrod and Hupcey (2005) state,

however, that an everyday concept with explicit meaning is

inadequate for scientific inquiry. There is also no guarantee

that everyday concepts are similarly understood. ‘Definitions-

and this is true of all terminology, not only that related to

migration- may vary according to a given perspective or

approach’ (IOM 2004, p. 3). Since the concept analysis

process includes the identification of antecedents and conse-

quences of nurse migration, it will contribute to a more

complete understanding of the concept.

Conducting a concept analysis requires similar skills and

level of rigour as other research methods (Baldwin & Rose

2009). The concept analysis method developed by Walker

and Avant (2005) was used for this analysis. This approach

involves eight sequential steps to be used iteratively: selecting

the concept; determining the aim purpose of the analysis;

identifying all uses of the concept; determining defining

attributes; developing model cases; constructing additional

cases (e.g. borderline, related, contrary, invented, and illegit-

imate cases); identifying antecedents and consequences; and

defining empirical referents. This method was chosen because

it is the most widely used in the literature (Hupcey et al.

1996), and is systematic (Brennan 1997, Xyrichis & Ream

2008). The first two steps of the process, choosing the

concept and purpose, have been described. The analysis will

continue with describing data sources and selection.

Data sources

In the past decade, there has been an explosion of interest in

international migration (Favell 2008, p. 259). This presented

a major challenge for this analysis given the constraints of

time and space and therefore required the development of

clear inclusion criteria. An extensive literature review was

conducted. All uses of the term migration were examined by

reading as many different sources as possible since ignoring

some uses could bias findings (Walker & Avant 2005).

Searches were performed on the general topic of migration

and the specific subject of nurse migration. No limit was placed

on the timeframe for the search. Electronic literature indexes

and specific journals were searched using keywords such as

‘migration’, ‘immigration’, ‘emigration’, ‘nurse migration’,

‘internationally educated nurses’ and ‘health worker migration’

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in full and truncated forms. Indexes included CINAHL,

PubMed, SCOPUS, Sociological Abstracts and PsychINFO.

Reference lists (ancestry searching) were used to locate relevant

sources and specific journals and websites focusing on migra-

tion were searched. A Google search was also performed using

the terms migration, nurse migration and human migration.

Definitions of migration were sought in dictionaries, migration

specific glossaries and in all the retrieved literature.

Data selection

The literature represented diverse disciplines including nurs-

ing, law, human resources, psychology, sociology, anthro-

pology, geography, demography, economics, statistics,

political science, and policy and professional groups. Most

publications on nurse migration were written during the last

8 years (2001–2009). Approximately 500 articles, documents

and books were initally scanned for inclusion based on the

following criteria: (a) English language; (b) contribution to

understanding of the concept of migration; (c) contribution to

the definition, attributes, antecedents and/or consequences of

nurse migration; (d) focus on out of country rather than

internal migration; and (e) reference to a professional RN in

his/or her home country. Using these criteria approximately

150 documents were identified. All documents were read in

full and excluded if they did not meet criteria.

The final sample of 80 documents included articles,

research, grey literature and books. An inductive content

analysis approach was used to organize the information (Elo

& Kyngas 2007). Each document was reviewed and infor-

mation was tracked by using sticky notes. The information

was transferred to a data tracking form and summarized in a

matrix to extract defintions and themes. Tracking is not

usually explicitly described and/or done but it was critical to

ensuring the integrity of this complex analysis.

Results

Identifying uses of the concept of migration and nurse

migration

The third step in the process was to identify all uses of the

concept. According to the Merriam-Webster dictionary

(2009) the meaning of migration is ‘to move from one

country, place, or locality to another’; ‘to pass usually

periodically from one region or climate to another for feeding

or breeding’; ‘to change position in an organism or sub-

stance’. Migration, therefore, describes the movement of

individuals, groups, organisms or objects such as humans,

birds, insects, animals, planets, cells and data.

Since the focus of this concept analysis is human migration,

definitions focusing on humans were explored. Migration,

according to the Glossary on Migration (IOM 2004, p. 41), is

‘A process of moving, either across an international border, or

within a State. It is a population movement, encompassing

any kind of movement of people whatever its length,

composition, and causes; it includes migration of refugees,

displaced persons, uprooted people, and economic migrants’.

Migrant is described in the same source as having no

universally accepted definition but ‘‘usually understood to

cover all cases where the decision to migrate is taken freely by

the individual concerned for reasons of ‘personal convenience’

and without intervention of an external compelling factor’’

(p. 40). Even these two explanations, from the same source,

present conflicting views with one including forced movement

(e.g. refugees); the second a decision to move taken freely.

Similar confusion was found in literature on nurse migration.

A specific definition of migration was ‘… the crossing of the boundary of a political or administrative unit for a certain

minimum period of time’ and includes the ‘movement of

refugees, displaced persons, uprooted people as well as

economic migrants’ [United Nations Educational, Scientific

and Cultural Organization (UNESCO) 2005]. It is interesting

that this definition does not specify the individual leaving the

home country and timeframes are vague.

Migration is also described using a variety of terms that

attempt to categorize and describe migrants (see Table 1).

These include (a) movement (e.g. external), (b) motivation

(e.g. economic), (c) freedom of choice (e.g. voluntary), (d)

length of time of migratory period (e.g. temporary), (e)

frequency of moves (e.g. circular), (f) status of migrant (e.g.

skilled) and (g) legal status.

These terms were not standardized. For example, Brettel

and Hollifield (2008, p. 21) used migration to describe

movement within borders, immigration to describe crossing

national borders but identified that some disciplines prefer

the term mobility to migration. Out-migration was an

alternative term found in the nurse migration literature for

emigration (Buchan et al. 2005).

No definition of nurse migration was found in the search.

Presumably authors assumed a common understanding of the

term. A number of different terms were used to refer to the

nurse migrant (see Table 2).

They included ‘foreign’ (Kline 2003, Brush et al. 2004),

‘foreign-educated’ (Aiken et al. 2004, Aiken 2007), ‘nurse

recruits’ (Brush et al. 2004), ‘Canadian trained’ (Pink et al.

2004), and ‘overseas qualified’ (Hawthorne 2001). The

decision of the authors about the choice of labels was not

explicit. Some of these terms, however, identified nurse

migrants as outsiders or aliens and could have important

M. Freeman et al.

1178 � 2011 Blackwell Publishing Ltd

consequences for their acceptance and treatment. Kingma

(2006a, p. 70) has identified racism and discrimination as the

most serious problem that migrant nurses encounter. She

paints a sad reality where migrants’ are bullied, their

professional skills are undermined and they are discriminated

against in promotion and continuing educational opportuni-

ties. Other terms used such as trained vs. educated commu-

nicate a different view and valuing of the nursing profession.

In summary, although there was no single definition of

nurse migration, attributes recurred in the literature and will

be described in the next section.

Defining attributes

The fourth step in the process was to describe the attributes,

the cluster of characteristics most frequently associated with

the concept in the literature (Walker & Avant 2005).

Tracking and summarizing the characteristics required multi-

ple revisions. As shown in Figure 1, five attributes were

identified: (a) the motivation and decisions of an individual,

(b) external barriers and facilitators, (c) freedom of choice,

(d) migration as a human right and (e) movement is dynamic.

A brief overview of each follows.

Migration is determined by the motivation and decisions of

an individual

Motivation to migrate is a key characteristic associated with

nurse migration. It has been described as a subjective deci-

sion-making process (Fawcett 1985) influenced by push and

pull factors (Pink et al. 2004, Brush 2008, Kingma 2008,

McGillis Hall et al. 2009). Motivation can be both intrinsic

and extrinsic. Many theories and models have been offered to

explain it including Equity Theory, Maslow’s Hierarchy of

Needs, Expectancy Theory (Winkelmann-Gleed 2006, p. 42),

behavioural models (Fawcett 1985) and economic and social

network theories (Teitelbaum 2008). Motivations driving

nurse migration are multifaceted and no theories have yet

been developed to explain them (Kingma 2006a).

Table 1 Categories and terms for migrants/migration.

Categories and terms

(a) Movement

*Internal

*External

*Emigration

*Out-migration

*Immigration

*Cross-border commuters

*Commuter migration

*Shuttle migration

*Cross-industry

*Geographical

(b) Motivation

*Economic migrant

*Quality-of-life migrant

*Career-move

*Partner

*Adventurer

*Holiday workers

Student

*Family reunification

(c) Freedom of choice

*Voluntary

Involuntary, forced, population transfer

Impelled, reluctant or imposed

Survival

(d) Length of time of migratory period

Seasonal

*Temporary

*Permanent

(e) Frequency of moves

*Carousel

*Step

*Chain

*Return

*Circular

(f) Status of migrant

*Skilled or highly skilled

(g) Legal status

*Legal

Illegal, irregular or undocumented

*Indicates terms found in nurse migration literature.

Table 2 Terms used for nurse migration/nurse migrants in literature.

Term Source

Overseas nurses Troy et al. (2007)

Overseas qualified nurses Hawthorne (2001)

Overseas trained nurses Allan et al. (2008)

Foreign-educated nurses Aiken et al. (2004),

Aiken (2007)

Foreign nurses Brush et al. (2004),

Kline (2003)

Nurse recruits Brush et al. (2004)

Internationally Educated Nurses Baumann et al. (2006)

Internationally recruited nurses Buchan et al. (2006)

International health worker Ray et al. (2006)

Global nursing migration Keatings (2006), Brush (2008),

Khaliq et al. (2009)

International Registered Nurses North (2007)

International nurses Buchan et al. (2005)

International nurse migration Kline (2003), Kingma (2008)

Non English Speaking

Background Source Countries

(NESB) and English Speaking

Background Source

Country (ESB)

Hawthorne (2001)

Canadian trained nurses Pink et al. (2004)

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Migration is influenced by external barriers and facilitators

Barriers and facilitators to nurse migration, a recurrent theme

in the literature, were classified as external when they were

not under the control of the migrant. Major barriers to

migration were language competency and inadequate

educational preparation (Kingma 2006a, 2008). Facilitators

of nurse migration assumed many forms. Nurse migrants, as

professional or highly skilled migrants, were granted prefer-

ential treatment for admission to some host countries (IOM

2004). For example, labour mobility clauses in trade agree-

ments between countries, such as the North American Free

Trade Agreement (NAFTA), were written to facilitate

migration (Blouin 2005, Aiken 2007). Countries’ immigra-

tion policies have been modified to allow additional visas for

skilled professionals, such as nurses (Aiken 2007). Improving

access to the writing of licensing exams is another strategy.

For example, the American exam (NCLEX-RN) has been

made available since 2005 in many different countries to

lessen the financial burden on qualified nurses who want to

migrate to the US (Aiken 2007).

Entrepreneurs have emerged to facilitate nurse migration,

now described as big business (Kingma 2006a). These include

international nurse recruiting agencies that link nurses with

jobs for profit (Brush et al. 2004, Perrin et al. 2007); govern-

ments, such as China, which organize groups of nurses to

work in other countries and charge handling fees (Fang 2007);

and the development of new nursing schools to train nurses for

export (Lorenzo et al. 2007). Barriers and facilitators in the

complex global environment are constantly changing and

evolving. Economic downturns and international events such

as 9/11 can quickly result in new policies that limit immigra-

tion or make it more difficult (Kingma 2006a, Buchan 2007).

Freedom of choice to migrate

Freedom of choice in nurse migration can be described as a

continuum from completely voluntary (taken freely), to

reluctant (impelled), to completely involuntary (forced). All

these forms are described in the literature on nurse migration.

Although many nurses view migration as voluntary, Kingma

(2006a, p. 5) questioned, ‘Is migration a matter of choice or is

it imposed on nurses as an obligation or [as a result of]

constraint?’ She and others stress that migration does not

occur without strong push factors from the home country.

‘‘Without both sets of [push and pull] forces operating in

unison, little migration would occur. In other words no

matter how strong the ‘pull’ forces, large scale migration will

not take place from countries where strong ‘push’ factors do

not exist’’ (Meija et al. 1979, p. 102). For example, the lack

of full time work in Canada acted as a strong push factor

resulting in Canadian nurses migrating for full time work in

the United States (McGillis Hall et al. 2009), a move that

would not be considered truly voluntary.

Freedom to migrate is a human right

Nurse migration is characterized by the human right of

freedom of movement. This right is articulated in Article 13

of the Universal Declaration of Human Rights which states

‘Everyone has the right to leave any country, including his

own, and to return to his country’ (United Nations 1948).

This right is supported by the International Council of Nurses

(2007) who state that all nurses have the right to migrate as a

function of choice, regardless of their motivation. Although

concerns were expressed in the literature about the negative

consequences of nurse migration on some countries, no one

recommended that the rights of nurses to migrate be denied

(Buchan et al. 2005, 2006, Chikanda 2005, Kingma 2006a,

2008, Thupayagale-Tshweneagae 2007).

Movement is dynamic

Nurse migration is dynamic, characterized by movement that

is unpredictable and ever changing and not, as often por-

trayed, as a ‘one-way linear brain drain’ (Buchan et al. 2005,

• Forces influencing motivation to migrate (push and pull):

• Political • Social (personal) • Economic • Legal • Historical • Educational

Antecedents

• Motivation and decisions of individuals

• External barriers and facilitators

• Freedom of choice to migrate

• Freedom to migrate as a human right

• Dynamic movement

Attributes Consequences

• Positive and/or negative dependig on view point of:

• Individual (and family)

• Stake holders (source country, destination country, health care system/organization and nursing profession)

Figure 1 Concept of nurse migration: antecedent, attributes and consequences.

M. Freeman et al.

1180 � 2011 Blackwell Publishing Ltd

p. 5, Humphries et al. 2008). Movement is influenced by

both country-specific and broader global issues and the length

of migratory periods and patterns of movement (e.g. circular;

commuter) are diverse (Bach 2004, Buchan et al. 2005). The

varieties of countries of origin, different demographic profiles

and individual motivations and career goals contribute to the

dynamic patterns of movement (Buchan 2004, Buchan et al.

2006, Perrin et al. 2007).

Model case to illustrate the concept of nurse migration

The next step in the concept analysis is to construct a model

case that illustrates all these attributes. The case can be

constructed from real life, found in the literature or invented

(Walker & Avant 2005) although it is recommended that

cases be identified rather than constructed whenever possible

(Rodgers 1989). A model case, adapted using elements from a

study by Perrin et al. (2007) and others found in the literature

is used.

Jeanette is a 24 year old who graduated from a university

in the Philippines with a bachelor’s degree in nursing. She has

just taken her licensing exams, now offered in her home

country, to work as a nurse in the US. She does not want to

leave her family but there are no jobs at home. She will make

$4000 per month in the US, compared to $69 per month in

the Philippines. This will allow her to send money home to

support her family. She knows nurses are trained for export

in her country but hoped that there would be job openings by

the time she finished school. She is recruited through an

agency that found her a job and arranged her travel. She

migrates to the US, plans to obtain a graduate degree and

work in other countries, such as Great Britain or Canada,

before returning home.

All attributes occur in this case and illustrate the complex-

ity of the concept. Jeanette demonstrated individual motiva-

tion in her decision to migrate. Her migration was facilitated

by the availability of US exams, jobs, higher income and

recruiters. She had the right to migrate but her decision was

made reluctantly, rather than freely, because of lack of work

in her home country. Her migration path will be dynamic

involving moves to other countries but it will be influenced by

her motivations.

Since the development of other cases (e.g. borderline) does

not contribute to concept clarification, Walker and Avant

(2005) support omitting them.

Antecedents and consequences

The identification of antecedents and consequences is the

next step in the process. The push and pull model is the

dominiant framework for explaining nurse migration (Bach

2007). The antecedents for nurse migration are the political,

social (personal), economic, legal, historical and educational

forces that comprise this framework (Meija et al. 1979, Kline

2003, Kingma 2006a). The pull factors are conditions in the

destination country that attract and facilitate the migration of

nurses; the push factors are conditions that encourage nurses

to leave their own country (Kingma 2006a, p. 19). These

factors usually mirror each other; for example, a nurse from a

country making a low salary will be pulled to a country

offering higher wages (Kingma 2006a, p. 19). The main pull

factor is the world-wide shortage of nurses with countries

competing for scarce resources. Common factors are the

desire for better incomes and benefits, full time work, healthy

work environments, professional development opportunities,

better resourced health systems and safe and supportive work

environments (Pink et al. 2004, Buchan et al. 2005, Interna-

tional Centre on Nurse Migration (ICNM) 2008, McGillis

Hall et al. 2009). Other pulls include a shared language,

appropriate nursing qualifications and family, historical and

trade ties to the destination country (Ross et al. 2005,

Kingma 2006a, Winkelmann-Gleed 2006). Newly emerging

pull factors include aggressive recruitment agencies who

receive large payments per nurse and encourage migration by

funding the move and linking nurses with jobs (Brush et al.

2004), the Internet which has increased awareness of oppor-

tunities around the world for nursing skills, and the growing

big business of educating nurses for export (Kingma 2006b,

Lorenzo et al. 2007).

Nurse migration can be considered both positive and

negative depending on the viewpoint and their affect on the

individual and stakeholders. Stakeholders include the source

country, destination country, healthcare systems and the

nursing profession. For example, positive consequences for

the individual (e.g. a well paying secure job) may produce

negative consequences for the home country (e.g. loss of a

scarce nursing resource). The growing mobility of nurses has

been criticized as occurring without a careful analysis of the

implications of this movement on the nurses and on health-

care delivery systems that both send and receive them (Brush

et al. 2004). One consequence for source countries is a brain

drain that diminishes nursing resources for their population

(Meleis 2003, Pink et al. 2004, Perrin et al. 2007, Kingma

2008, McGillis Hall et al. 2009).

There are social costs to the individual who migrates

(Kingma 2006a, 2006b). Adapting to a new country, a new

culture and an unfamiliar healthcare environment, with or

without a support network can be a monumental task. Often

these nurses, who may have children in their home country,

are responsible for financially supporting their families. In

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addition, they frequently experience discrimination and

exploitation by agencies and institutions in the destination

country (Hawthorne 2001, Allan et al. 2008, Kingma 2008).

There are also positive consequences. In many countries in

the world, a nursing licence is viewed as a ticket to a better

life (McCarthy 2009). Remittances sent home improve the

family life in the home country through redistribution of

global wealth (ICNM 2007, Kingma 2008). There is

improved personal and professional safety and empowerment

for some migrants (Meleis 2003, Kingma 2008) who leave

unsafe environments and countries with gender inequities

(Hawthorne 2001, Meleis 2003, Buchan et al. 2005, Buchan

2006, Thomas 2006, Allan et al. 2008, Bourgeault & Wrede

2008).

Although the Philippines has had the most success in

training nurses for export and benefited as a country from the

remittances sent home, it serves as an example of unexpected

negative consequences. The ease of nurse migration has

resulted in physicians retraining as nurses to migrate, a waste

of an already limited health human resource (Brush et al.

2004). The country also experienced a decrease in the quality

of nursing education as evidenced by high exam failure rates

as a result of schools being pressured to educate large

numbers of nurses for both foreign and domestic markets

(Perrin et al. 2007).

Nurse migration has consequences for the nursing profes-

sion, some known and others which are emerging. There

appears to be an attitude in many countries that a supply of

nurses exists somewhere in the world waiting to be enticed to

migrate to their country. As a result, many developed

countries are not educating enough nurses to meet their

needs and instead, rely on the recruitment of nurses from

other countries to address shortages (Buchan 2006). Institu-

tions have also been accused of recruitment from abroad

rather than raising salaries and improving working environ-

ments to retain nurses (Brush et al. 2004). Nurse migrants

also stress health systems resources if they require language

competency training, orientation to vastly different health-

care systems and, to autonomous professional nursing roles

(Hawthorne 2001, Buchan et al. 2005). A positive outcome is

that nurses from different cultures and countries contribute to

making the nursing profession more culturally aware (Meleis

2003, Kingma 2008). Finally, the uncontrolled growth in the

business of exporting nurses for profit presents unknown

consequences for the profession.

Defining empirical referents

The final step in the concept analysis is to determine the

empirical referents. In this step, the question is asked, ‘If we

were to measure this concept or determine its existence in the

real world, how do we do so?’ (Walker & Avant 2005, p. 73).

While nurse migration, the actual movement of nurses, can be

measured in many ways, it has been a challenge for most

researchers. Data come from a variety of sources and are

collected by different organizations for different uses (Diallo

2004). The lack of data accuracy is usually identified as a

limitation in most studies.

The attributes of nurse migration, and its antecedents and

consequences can be examined using a combination of

qualitative, quantitative and mixed methods. For example,

a survey in combination with focus groups could be used to

explore motivations for migration, perceptions of freedom of

choice and human rights and explore the facilitators, barriers

and dynamic nature of the process. The challenge for the

researcher is to understand the complex nature of these

characteristics to ensure a robust research design to capture

the many variables of interest.

One instrument was found that measures immigration-

specific distress. The Demands of Immigration Scale, devel-

oped by Aroian et al. (1998), was created for use with other

populations but tested with nurse migrants (Tsai 2002,

Beechinor & Fitzpatrick 2008). Standardized measures and

approaches would contribute greatly to the understanding of

nurse migration and allow findings to be compared to or

generalized in different contexts and countries.

Discussion

Conducting this concept analysis was a challenging exercise

which began with choosing a model. Although there were

publications on specific models, examples of applications of

models and articles criticizing the approaches and/or use of

concept analysis in nursing (Paley 1996, Hupcey & Penrod

2005, Beckwith et al. 2008) there was no guidance to assist in

the choice. To advance this scientific process, it is recom-

mended that several models be used concurrently to analyse

the same concept. This would test the strength and limita-

tions of different models and allow for examination of the

findings through the use of different approaches.

The concept analysis process was found to be a challenging

undertaking requiring the same skills and level of rigour as

any research method (Baldwin & Rose 2009). Walker and

Avant’s (2005) process, presented as simple steps, was found

to be overly simplified related to the scope of the literature

review and organizing and synthesizing the findings.

Although they state that a review of the literature helps

support and validate the attributes, they provided no direc-

tion on how to organize a review except by extensive reading

in as many different sources as possible. Therefore, the first

M. Freeman et al.

1182 � 2011 Blackwell Publishing Ltd

hurdle to clear was the huge volume of literature on the topic

of migration and determining relevant literature from irrel-

evant. The search involved not just the usual sources, but also

a large number of websites dedicated to the topic of

migration; for example the Migration Policy Institute,

Mobility of Health Professionals, Global Migration Group,

and International Centre on Nurse Migration (to name only a

few). This increased the complexity of the literature review.

Since a concept analysis involves examining all uses of the

concept, it was a challenge to conduct a comprehensive

review and not get lost in the process.

Another hurdle was organizing the findings. Defining

attributes, the heart of the concept analysis process, has been

criticized as an arbitrary process (Paley 1996). Examining

other methods and reviewing information on qualitative

content analysis were necessary to develop a method for

collecting, organizing and managing the data and distilling

defining attributes (Paley 1996, Elo & Kyngas 2007). These

insights on the challenges are meant to contribute to improv-

ing the process and offer some guidance to novice analysts.

Regardless of these challenges, this concept analysis on

nurse migration has contributed to nursing in several ways.

The first aim was to understand how the concept of migration

is used in nursing. The results can inform nurses in education,

administrative and research positions who are involved

directly and indirectly with nurse migration. It has not only

deepened the understanding of the characteristics related to

this complex concept, but it has also clarified some of the

misunderstandings related to human rights, freedom of

choice and characteristics of nurse migration. It has also

alerted nursing leadership that nurse migration is a complex

and dynamic process and that there will be no simple

solutions to the issues surrounding it (Buchan et al. 2006). An

unexpected contribution was that through this analysis of the

literature, awareness was raised that authors need to choose

the labels for nurse migrants with caution as they may be

unwittingly contributing to the alienation of and discrimina-

tion against this group. This is an important caution and

reminder about the use of language and labels in our research

and writings.

The second aim was to generate a discipline-specific theory

to guide the study of nurse migration. A middle-range theory

is a set of related ideas with suggested relationships among

the concepts depicted in a model (Smith & Liehr 2003). It is

narrower in scope than a grand theory and comprised of

concepts that are empirically measurable (Fawcett 1997). The

identification of the attributes, antecedents and consequences

represents a framework for a middle-range theory of nurse

migration. Although requiring testing and further develop-

ment, this theory is more robust than the push pull theory

which focuses only on the forces influencing the decision to

migrate (antecedents). It offers a more complete and explicit

model of this complex concept to guide policy and research.

For example, understanding that the consequences of nurse

migration should be examined through the eyes of all

stakeholders is important for policy makers. This theory

could also guide the development of a predictive model of

nurse migration to guide nursing human resource planning.

Conclusion

This article provided unique insights into conducting a

concept analysis. The analysis suggested that nurse migration

What is already known about this topic

• Nurse migration is a growing global phenomenon as a result of the RN shortage in most countries.

• Migration is a complex term with many meanings that can be examined from a range of perspectives.

• Walker and Avant’s concept analysis methodology is a standardized approach for clarifying antecedents,

attributes and consequences.

What this paper adds

• The antecedents are the political, social (personal), economic, legal, historical and educational forces that

comprise the push pull theory.

• The attributes include: the motivation and decisions of individuals; external barriers and facilitators; freedom

of choice to migrate; freedom to migrate as a human

right, and dynamic movement.

• The consequences of nurse migration can be positive or negative and depend on its affect on the individual, the

family and other stakeholders such as the source

country, destination country, healthcare systems and the

nursing profession.

Implications for policy and/or practice

• The identification of attributes, antecedents and consequences can guide the development of research

instruments to study nurse migration.

• Categories of terms used to describe nurse migration in the literature reflect its complexity.

• Terms that label nurse migrants as outsiders such as ‘foreign nurses’ should be used carefully because they

could influence the acceptance and treatment of these

nurses.

JAN: CONCEPT ANALYSIS Concept analysis nurse migration

� 2011 Blackwell Publishing Ltd 1183

is a human right, characterized by dynamic movement and a

continuum of freedom of choice, not only guided by

individual motivation and decision-making but influenced

by external barriers and facilitators. Nurse migration is on

the rise. The consequences of this movement will affect

nursing practice and health care throughout the world.

Although there has been a growing interest in nurse mobility

in the past 10 years, there is little primary research and

therefore, little evidence to guide practice, policy, or research

(Haour-Knipe & Davies 2008, McGillis Hall et al. 2009).

This concept analysis proposes a middle-range theory of

nurse migration to guide this much needed research.

Funding

This research received no specific grant from any funding

agency in the public, commercial or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

MF, AB, JB, AF and NA-D were not only responsible for the

study conception and design, but also made critical revisions

to the article for important intellectual content. They also

provided administrative, technical or material support and

approved the final version for publication. MF performed

data collection, data analysis and was responsible for the

drafting of the manuscript. AB supervised the study.

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