Impact of the emigration of nurses on health care delivery system in selected hospitals, Benin‑City, Edo State, Nigeria

Olaolorunpo OLORUNFEMI, David Idenyi AGBO,Omotayo Mercy OLORUNFEMI, Esther Odogho OKUPAPAT

1Department of Medical Surgical Nursing, School of Nursing,University of Benin Teaching Hospital; 2Department of Measurement and Evaluation, University of Benin Teaching Hospital Staff School; 3Department of Perioperative Nursing,School of Postbasic Nursing Studies, University of Benin Teaching Hospital, Benin‑city, Edo State, Nigeria

ABSTRACT

Background: Globally, there is a high demand for nurses, resulting in migration from low‑to high‑income countries.The emigration of nurses is the act of leaving one's own country to settle permanently in another country, leading to a shortage in the number of nurses in their home countries.Consequently, this study aims to assess the impact of the emigration of nurses on the health‑care delivery system in Nigeria.

Materials and Methods: A descriptive cross‑sectional survey was conducted with a stratified sampling technique to select 270 nurses from three selected hospitals in Benin‑city Edo state.A self‑structured questionnaire with open and Likert scale questions were used as an instrument to assess the Impact of the Emigration of nurses on the Health Care Delivery System.Data collected were analyzed using tables,percentages, means, standard deviation and t‑test.

Results: The result showed a mean score of 1.59 ± 0.92 impacts of the emigration of nurses on health‑care delivery system and identified how to reduce it.The study also showed that there is no significant difference between gender and reason for emigration among nurses (t = 3.84, P ≤ 0.001).

Conclusion: The emigration of nurses is severely affecting the health care delivery system in the country.Recently, the Nursing and Midwifery Council of Nigeria gave the directive for training schools to increase their training capacity and number of students’ intake to cushion the effect,and this study shows that this palliative can only be a short time measure, and however will encourage more nurses traveling abroad on the long run.Therefore, the hospital managers and government should provide a conducive working environment, better remuneration, attractive retirement benefit, and other incentives as a push in factor for nurses to stay back in their home countries.

Keywords: Emigration, health-care system, migration, Nigeria, nurses

INTRODUCTION

One of the paramount hurdles to Africa’s development is the emigration of African skilled workers to developed countries.The trained people from underdeveloped and developing nations to developed or industrialized countries are not a new occurrence; however, the enormousness of the problem in Africa soil is on the increase and calls for immediate action, as the result of emigration pose a major challenge to the overall development of Africa.[1,2]The emigration of nurses is the act of leaving one's own country to settle permanently in another country in search of a better standard of living and life quality,higher salaries, access to advanced technology, and more stable political conditions in different places worldwide.[1]Migration in most cases, refers to cross‑border or international migration and often from the developing countries to the developed ones.[2]International migration of highly skilled professionals first emerged as a major public health issue in the 1940s, when many European health professionals emigrated to the United Kingdom and the United States and by the mid‑60s, the losses were enough to cause concern.[3]In 1979, World Health Organization published a detailed 40‑country study on the importance and flow of health professionals, which findings suggested that close to 90% of all migrating nurses were moving to just five countries: Australia,Canada, the Federal Republic of Germany, the United Kingdom,and the United States.[4]The global high demand for nurses,resulting into migration from low‑to high‑income countries,has received considerable attention from policymakers in both sending and receiving countries.[5]For a country like Nigeria,which is highly reliant on international aid and has a weak health‑care infrastructure, the consequences of significant emigration of health‑care professionals were striking.[6,7]Like most other African countries, Nigeria is facing a human resource crisis in the public health sector: many of its health professionals, such as doctors and nurses, are migrating to developed countries to seek better employment prospects.[8]Although the government’s economic survey of 2007 shows greatly increased spending on public health, the sector remains severely under‑funded and migration to urban areas in Nigeria and overseas continues unabated.[9]In Africa, the public health sector is seriously affected by the migration of health professionals because the majority of the continent’s population relies on its countries’ health‑care services.[10]HIV/AIDS, malaria, coronavirus, and other major diseases also create a huge burden on systems and require the skills of these same professionals.[11,12]The phenomenon popularly called the brain drain, more specifically the “medical brain drain.”Contemporary literature refers to the term “brain drain” as a situation in which a country experiences an outflow of its educated individuals on such a large scale that it threatens the country’s long‑term needs for national development.[13]The researchers discovered that on a weekly basis most nurses in the university of Benin teaching hospital and other hospitals in Nigeria travel abroad in search for greener pasture,causing a severe shortage of nurses in the country.Based on this noticed problem, the researcher aimed at looking at the impact of the emigration of nurses on health‑care delivery system in three selected hospitals in Benin‑city Edo state,Nigeria.

MATERIALS AND METHODS

Research design

A descriptive cross‑sectional survey was conducted with a stratified probability sampling method through different wards of the hospitals.The population of interest in this study comprises all trained nurses in the selected hospitals who are currently working in the clinical areas.

Sample size and sampling procedure

The sample size was determined using Taro Yamane method of sample size calculation according to the formula,n= sample size, e = margin of error = 0.05, with a confidence level of 95%.A sample size of 270 nurses was selected, and the setting was 155 nurses from University of Benin Teaching hospital,80 nurses from Edo State Central Hospital, and 35 nurses from Faith Mediplex Hospital.The inclusion criteria were nurses who were willing to participate in the study and who consented after carefully going through the detailed procedure of bioethical principles in conducting research studies on human participants.The exclusion criterion was nurses who were on leave.

Data collection tools and procedures

Data collection instrument was a structured questionnaire consisting of questions made up of four parts; Section A: sociodemographic data of respondents with 4 items,Section B: causes of migration of nurses in Nigeria.The mean score of 1.5 and above rated as a major cause of migration, 1–1.4 mean score rated as a moderate cause of migration, and a mean score below 1.0 is rated as a possible cause of migration of nurses.Section C: Perceived impact of emigration of nurses from the country.It contains 7 items and the mean score is rated as follows: (0–1) = Moderately affected, (1–1.5) = Majorly affected, and (1.5–2) = Severely affected.

Section D: how to reduce the emigration of nurses in Nigeria.This section contained 7 items and rated as follows:the mean score of 1.5 and above, 1–1.5 represents most and major ways of preventing the emigration of nurses,respectively, while means scores below 1.0 is possible ways of reducing emigration rate among nurses.To ensure reliability of the questionnaire, a pilot study was carried out among nurses from Igbinedion Teaching Hospital, Okada,using test‑retest method of reliability.Ten percent of the population questionnaire was administered and analyzed through Cronbach Alpha, and a correlational score (s) of 0.80 was obtained, showing a high level of reliability of the instrument..

Ethical considerations

Consent form was given to the participants to seek written consent, and verbal consent was also taken before data collection.Participants were not exploited financially and physically.

Statistical analysis

Data obtained were coded and analyzed using the Statistical Package for the Social Science (SPSS) version 21.00 statistical software (IBM Corp.released 2012.IBM SPSS statistics for windows, version 21.0 Armonk, NY, USA: IBM Corp).Variables and research questions were analyzed using frequencies,percentage, mean, standard deviation, andt‑test for inferential statistics.

RESULTS

Characteristics of research participants

The sociodemographic characteristics of the participants are reported in Table 1: the participants were characterized by 180 females, accounting for 66.67%, and 90 males, accounting for 33.33%; they were majorly at age 20–25 years.The participants were selected from the different ward with a slightly higher percentage from medical and surgical ward with a total number of 100, accounting for 37.04%; moreover,about two‑thirds of the participants were married and no one divorced.

Table 1: Sociodemographic data of nurses from the three selected hospitals benin‑city, Edo state (n=270)

Causes of migration of nurses

The causes of migration of nurses are reported in Table 2: It shows that there are four major reasons why nurses travel to developed countries which are: better career prospect or advancement, improved working condition, availability of better training opportunities, attractive retirement benefits and also identified seven moderate causes such as: higher income or attractive salaries, better employment contract, great health safety, availability of job opportunities,recognition of professional expertise, professional working environment, and stable sociopolitical environment.The table also reported three major reasons that discouraged nurses from working in their home countries as: low wages, limited career, and educational opportunities, it also identified five moderate reasons why they do not stay in their countries as: lack of resources, unstable economy, unstable retirement benefits, unstable political environment, and poorly funded health‑care system is shown in Table 2.

Table 2: The causes of migration of nurses in Nigeria among three selected hospitals, Benin‑city, Edo State

Impact of emigration of nurses

The perceived impact of emigration of nurses on Nigeria health‑care services was reported in Table 3: It identified four severe impact of emigration as: increase work load, severe shortage of nurses, reduced quality of care, and increase in mortality and morbidity rate.It also identified three major impact of emigration of nurses from the country as: brain drainage, source of distraction to others, and reduced job satisfaction are shown in Table 3.

Table 3: The perceived impact of the emigration of nurses in Nigeria on Health Care Delivery system among three selected hospitals,Benin‑City, Edo State

Ways to reduce emigration in the country

How to reduce emigration rate among nurses in Nigeria is reported in Table 4: it shows five most reliable ways of reducing emigration as: creating a conducive‑working environment, upward review of salaries and allowances,access to further education, establishment of attractive retirement packages and other incentives is shown in Table 4.Finally, thet‑test analysis for differences between the gender of nurses and reasons for emigration is reported in Table 5:it shows that there is a significance different between the gender of nurses and reasons for emigration (t= 3.84,P≤ 0.001) is shown in Table 5.

Table 4: How to reduce emigration rate among nurses in Nigeria

Table 5: t‑test analysis for difference between gender of nurses and reason for emigration

DISCUSSION

The push in and push out factors responsible for migration of nurses in Nigeria

The results of this study showed that the major push (s) in factor for nurses into developed countries are better career prospect or advancement, improved working condition,availability of better training opportunities, attractive retirement benefit and major push out of Nigeria’s nurses are low wages, limited career, lack of educational opportunities,unstable economy, unstable retirement benefit, unstable political environment, and poorly funded health‑care system.This is in agreement with a study in 2018, examined the pull factors of Filipina immigrants working as nurses in the NHS in the UK, through an online survey questionnaire completed by 75 respondents is used to gather the results and found that primarily negative, economic push factors,such as the lack of jobs, lack of professional development and low salaries for nurses are the most prevalent reasons behind nurse migration.[14]Moreover, it is also found that the positive pull factors, including career growth or progression and higher wages, economic factors, individual social issues,for example, a chance of a better life, better opportunities,and greener pastures in the UK, are the most common reasons.[14]This is further supported by a study[15]carried out in South Africa in 2015 on Health worker migration from South Africa: causes consequences and policy responses and found that increased wages for health workers, is critical in retaining nurses in their home country.This is also in line with a study[16]conducted in Nigeria in 2017 on the health workforce crises in the Nigerian health sector and found that the Nigerian health system is relatively weak, and there is yet a coordinated response across the country, and opined that a number of health workforce crises have been reported in recent times due to several months’ salaries owed, poor welfare, lack of appropriate health facilities.These crises have consequently promoted the emigration of health workers in Nigeria.During the military regime in Nigeria, the economy was bastardized, and selection of people base on merit was sacrificed on the altar of mediocrity, and appointments were dispensed to trusted companions or friends of the dictator government in power.The situation compelled many Nigerian professionals, including nurses to “flee” to a more conducive clime in their effort to increase their standard of living.[3]

Perceived impact of the emigration of nurses on Nigeria health‑care delivery system

Knowing the impact of the emigration of nurses in the country will help the policymakers to adopt the recommended solution to the concern or threat to health‑care system.This study identified increase workload, severe shortage of nurses, reduced quality of care and an increase in mortality and morbidity rate as a severe impact, and also identified three major impact as: brain drainage, source of distraction to others, and reduced job satisfaction.This findings is in agreement with a study[15]carried out in South Africa in 2015 on Health worker migration from South Africa: causes,consequences and policy responses and found that emigration of South Africa’s health worker resulted into severe shortages of health workers which is significant and harmful to the health care system of the country.This is further supported by a study carried out in 2016 on the medical “Brain drain”and health‑care worker shortages: How should international training programs respond and found that the movement of health‑care workers from countries such as Nigeria with resource scarcity and immense need to areas of resource abundance and greater personal opportunity contribute to“brain drain of the home country”.[17]

On the contrary, a study conducted in 2016 on the views of migrant health workers living in Austria and Belgium on return migration to sub‑Saharan Africa and opined that if migrated health workers eventually return to their home countries, this will lead to beneficial effects following the transfer of their acquired skills and knowledge to the home country (brain gain) (brain gain).[18]

Ways of reducing emigration rate in the country

The results of this study showed that excessive emigration of nurses could mostly be reduced if the hospital manager and government can create a conducive‑working environment,upward review of salaries and allowances, access to further education, establishment of attractive retirement packages and provision of other incentives.This disagrees with a study conducted in 2017 on deterring emigration with foreign aid: an overview of evidence from low‑income countries,and found that aid can only encourage economic growth,employment, and security to a limited degree.Beyond this, successful development in almost all formerly‑poor countries has produced an increase in emigration.[19]This view is further supported by Clemens 2014, who said in his book that though, most basic economic theory suggests that rising incomes in developing countries will deter emigration from those countries, an idea that captivates policymakers in international aid and trade diplomacy.After reviewed of literature, he found something quite different:that over the course of a “mobility transition,” emigration generally raises with economic development until countries reach upper middle income, and only thereafter there will be a reduction in emigration.[20]We found out that these studies’ findings are different from the findings of this present study because they focused on the broad economic development while this present study only focused on nurses.Therefore, a conducive‑working environment, an upward review of salaries and allowances, access to further education, the establishment of attractive retirement packages, and provision of other incentives will encourage them to stay in their home country.[21,22]A study in Ghana 2014 on the effects of health worker motivation and job satisfaction on turnover intention found motivation and job satisfaction have been identified as key factors for health worker retention and turnover in low‑and middle‑income countries.[23]Moreover, this present study shows that there is a significant difference between the gender of nurses and the reason for emigration, which is in agreement with a study that investigates the prevalence and underlying reasons for emigration intentions among physicians,nurses, residents, and medical students in Lithuania (totalN= 1080), and found that that emigration decisions are linked to sociodemographic (age, gender, family situation),financial, organizational (teamwork climate in hospital) and social (perceived social worth) factors.[24]

Limitations

Nevertheless, this study was faced with some limitations,such as; the research only covered one state out of 36 states in Nigeria; probably, there is a peculiarity in the state that affects the outcome of the study.This study will be better generalized if extended to more hospitals in other states of the country.

CONCLUSION

In summary, this study shows that one of the paramount hurdles to Nigeria’s health sector is the emigration of Nurses to developed countries.We recommend that given directive for training schools to increase their training capacity and the number of students’ intake can only be a short time measures and however, could further trigger or encourage more nurses to traveling abroad on the long run.Therefore, to find a permanent solution to this problem, the hospital managers and the government should provide a conducive‑working environment, better remuneration, attractive retirement benefits, and other incentives as a push in factor for nurses to stay back in their home countries.

Acknowledgments

The authors wish to sincerely thank all nurses who participated in the study.The staff nurses from University of Benin Teaching Hospital (UBTH), Edo State central Hospital and Nurses from Faith mediplex hospital Benin City, Edo State.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.