Deskilling and International Recruitment of Nurses: Why Do We Need to Understand It?

As the healthcare systems in the world begin to slowly recover from the Covid-19 pandemic, a lot of attention is again turned to international recruitment as a “quick-fix” solution to the long-standing shortage of healthcare professionals, and Finland is understandably one of the countries pursuing this option. (Grekula, 2021; Keränen, 2021; Ketonen, 2021; Starkman, 2021).

International recruitment is considered as a response to a particular need – addressing the employment shortages in the receiving countries while offering economic advantages not only for the immediate families of the recruited workers but for the whole country of origin. This “win-win-win scenario” mainly emphasizes the rewards gained by those involved in the process.

However, behind this process is the deskilling of recruited healthcare professionals, which often is globally framed as “the normal path to migrate overseas”.

Every nurse is needed in the world

The global shortage of nurses is estimated at 5.9 million, and 89% of these shortages are concentrated in low- and lower-middle-income countries (Buchan & Catton, 2020). With these high numbers, a better understanding of how we can make the best possible use of the skills of trained nurses is of critical concern. Deskilling can be broadly defined as a situation where one’s job does not commensurate with their qualifications and experience (Mollard & Umar, 2013).

In the context of international migration, it is related to the ways in which human capital is underutilized in the destination countries of migrants (e.g., Vaittinen, Sakilayan-Latvala & Vartiainen, 2021). High-income destination countries of nurse migrants (for example, Finland) rarely have a systematic understanding of the skill sets that they possess, particularly in the beginning of the migration process.

Deskilling can be detrimental to the health and wellbeing of the nurse migrants. This will directly impact their work performance and, most importantly, their integration process. In addition, deskilling internationally recruited nurses during a healthcare crisis can damage the sending countries’ the healthcare systems.

For instance, high-income destination countries tend to recruit “the best and the brightest” nurses in the sending countries for jobs that are lower than what they were trained for. This leads to a decrease in the sending country’s capacity to respond to the health needs of its population, which consequently affects its overall health profile.

Deskilling of Filipino nurses in Finland

Let us take the case of the Filipino nurses recruited to work in Finland. The recruitment of Filipino nurses to Finland began in 2008, and since then, Filipino nurses have managed to find various migration paths to Finland (Näre, 2013; Vaittinen, 2014; Vartiainen ym., 2016).

Most of the research done on the recruitment of Filipino nurses to Finland has identified that inadequate language skills and the tedious process of recognition of nurse qualifications are the justifications for deskilling Filipino nurses (Näre & Cleveland-Silva, 2020; Olakivi, 2013; Pirilä, 2021; Vaittinen, 2017; Vartiainen ym., 2018; Vartiainen, 2019).

Finland also has strict regulations regarding recognition of nursing qualifications, which limit the possibilities of Filipinos aspiring to work as licensed nurses in the country. Thus, most of the foreign nurses in Finland end up going through the whole nursing degree again to qualify as nurses or are driven to work for positions that are lower than what they are qualified for, such as practical nurses, nursing assistants and cleaners (Näre & Cleveland-Silva, 2020; Vartiainen ym., 2018; Vaittinen, Sakilayan-Latvala & Vartiainen, 2021).

This deskilling process is usually viewed as a “normal path” for Filipino nurses to get jobs in Finland and is usually framed in the context of “re- and up-skilling” possibilities (Cleland-Silva, 2016; Vartiainen, 2019). Filipino nurses are “encouraged” to pursue a nursing education and other training opportunities in Finland.

Recently, several universities of applied sciences in Finland have also ventured to offer “top-up” courses that aim to help foreign nurses get their degrees and skills recognized. However, Korzeniewska and Erdal (2020) claimed that this uphill struggle towards re- and upskilling may not be the path nurse migrants want to pursue, and even if some of them may want to, the challenges of financial responsibilities and experiences of racism and discrimination may prevent them from doing so.

Philippines – country of “nurse exporting”

What needs to be added in the discourse of Filipino nurse recruitment in Finland is an understanding of the context of the Philippines as a sending country.

The fact is that the Philippines is the world’s primary source of migrant nurses. Choy (2003) wrote the rich history of the development of the profession within the Philippines and how colonial ties established migration pathways between the Philippines and the US.

Guevarra (2010), on the other hand, showed how the movement of nurses has been reinforced and facilitated by commercial agencies and how the Philippine government itself has enabled all these agencies. In addition, Ortiga (2014; 2018) highlighted the challenges involved when nurses are treated as commodities for export and what gets lost in the process of dealing with recruitment agencies and organizations that are merely facilitating their migration overseas.

Many studies aim to understand the experiences of Filipino nurses and how these experiences are shaped by the various legislations, policies and practices of the institutions and systems involved in the international recruitment process. (E.g., Asis, 2006; Ortiga, 2014; Rodriguez, 2010; Sakilayan-Latvala, 2015; Cleveland-Silva, 2016; Näre & Cleveland-Silva, 2020; Vaittinen, 2017; Vartiainen, 2019). Therefore, we can assume that the Philippines already has extensive experience, existing structures and institutions that focus on deploying migrants, particularly nurses, all over the world.

Globally competitive education

In addition, the idea of training “globally competitive nurses” is also the basis of the curriculum of nurse education in the Philippines and is structurally embedded in the educational system. Filipino nurses are trained locally, but the main goal of their education is for them to work in global contexts, meaning outside of the Philippines.

This can be seen from the textbooks used, course objectives, pedagogical implementations and to some extent, the teaching staff are also required to have relevant work experience outside of the Philippines before they can be hired as lecturers/teachers.

Now, why are we subjecting Filipino nurses to the process of deskilling, when they were trained to be “globally competitive nurses”? Or do we think our systems and our health in Finland are so different from the rest of the world?

Let us not fool ourselves into thinking that international nurse recruitment is a win-win-win scenario. The process is more complex than what this simplistic win-win-win scenario describes. Instead, a more intentional focus is needed to mitigate the possible damage done by recruiting nurses from developing countries. How can we do this?

According to the WHO’s code of practice for ethical recruitment of healthcare professionals (2011), migrant health personnel should be hired, promoted, and remunerated based on objective criteria, such as levels of qualification, years of experience and degrees of professional responsibility based on equal treatment with the domestically trained health workforce.

However, migration and recognition policies are different for every country, which complicates the whole process. In addition, monitoring and evaluating recruitment practices of sending and receiving nations have been suboptimal (Korzeniewska& Erdal, 2020).

If the goal is to ensure that recruitment practices are ethical, there is a need to scrutinize these migration, recruitment, and recognition policies. In Finland, where private recruitment firms cover the bulk of international recruitment work and strategies, the government tends to have a limited perspective of what happens during the recruitment process.

Suppose international recruitment is considered a solution to address the current employment gaps in Finland. In that case, the government should take up its share of the bargain, which means that it should focus on the monitoring aspects of recruitment and not just on creating working models and pathways to enable private companies and organizations to venture on international recruitment.

Transparency on the modes of assessment and verification of competencies of nurses is needed in each specific country context – including Finland, where the state presently fails to monitor the recruitment processes (Vaittinen, 2017).

Deskilling is discrimination

I argue that to develop an ethical approach to international recruitment, it is important to uncover how internationally trained nurses, as well as the key actors in the recruitment process, understand deskilling and its impact.

It is also essential to account for the often-subtle practices of racialization in the processes of deskilling. Previous research on Filipino nurse migration to Finland has uncovered different practices of racially motivated institutional discrimination, at times referred to as structural discrimination (e.g., Cleland Silva, 2016; Näre & Cleland Silva, 2020; Vaittinen, 2017; Vaittinen, Sakilayan-Latvala & Vartiainen, 2021; Vartiainen, 2019).

Why does recognizing nurses’ professional qualifications seem too complicated and difficult? Is it a question of lack of resources or budget? Or are we blinded by the idea that our educational and health system in Finland is the best in the world, so we find it difficult to imagine that the professionals trained outside of Finland are at par and maybe even better than the professionals trained in Finland?

In line with Parrenas’ (2015) argument that “racial inequalities are structural forces that determine the subject-positions of Filipino migrants in globalization”, I contend that deskilling is a racist practice, and it should be understood beyond the acquisition of language skills, credentials, and recognition process.

There is a need to recognize that crossing international borders do not diminish the existing skills and competencies of internationally recruited healthcare professionals and that at the center of deskilling and devaluating their professional skills in the migration process is structural racism.

The current pandemic clearly highlighted healthcare inequalities globally. We have already witnessed overwhelmed hospitals, exhausted healthcare professionals and healthcare systems on the brink of collapse. Deskilling qualified nurses amid a global healthcare crisis and at any point is not a sustainable solution and will never be it.

Let us answer the call long made by academics and activists- there is a need to address the research and societal gaps concerning the international recruitment of healthcare workers. Hopefully, we will be able to move towards developing ethical and anti-racist practices for their recruitment process.

 

References

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