Migration is the movement of people from one country to another (international or external migration) or from one region of a country to another (internal migration). In general, five main trends characterize migration in the twenty-first century:

As of 2008, immigrants made up 12.5% (38 million) of the total U.S. population. Mexican-born immigrants accounted for 30.1% of all foreign-born individuals living in the U.S., followed by immigrants born in the Philippines (4.4%), India (4.3%), and China (3.6%). These four countries, combined with Vietnam, El Salvador, Korea, Cuba, Canada, and the Dominican Republic, made up 57.7% of all foreign-born individuals living in the U.S. in 2008 (Terrazas & Batalova, 2009). This pattern of Asian and Mexican immigration is quite different from the migration of Europeans in the previous century.

A number of “push” factors (reasons for leaving one’s own country) and “pull” factors (reason for choosing a receiving country) motivate nurses to migrate. Some countries, despite their own domestic health care needs, cannot create enough jobs to employ the nurses they educate. Policies and restrictions related to pay and career structure, retention, recruitment, deployment, transfer, promotion, and the planning framework are other factors that “push” nurses to leave (Vujicic, Ohiri, & Sparkes, 2009).

Governmental policies on return migration and remittances also encourage nurses to seek employment in other countries. Return migration enables the source country to benefit from the skills acquired by the nurse while working in another country and thus provides an incentive for nurse migration. Remittance refers to the portion of an immigrant’s income that returns to the source country in the form of either funds or goods. The World Bank estimates that global remittances reached $328 billion in 2008 (Orozco & Ferro, 2009). Nurses are more likely to be remitters than other migrants, remitting $8 billion to the Philippines and $5 billion to India in 2008. Remittances, which are the second most important source of external funding for developing countries (after direct investment), are generally used to provide financial support, decrease poverty, and improve education and health for families back home (Focus Migration, 2006).

Factors that “pull” nurses to developed countries include higher wages, improved living and working conditions, and opportunities for advancing their education and clinical skills. The continuing existence of gender-based discrimination in many cultures and countries, with nursing being undervalued as “women’s work” relative to other professions, also encourages nurses to migrate. Table 52-1 presents the common push/pull factors that precipitate global nurse migration.

The U.S. is one of the top receiving countries for migrating nurses. Foreign-educated nurses entering the U.S. workforce tend to be female, 30 to 35 years of age, and educated in baccalaureate programs. Generally, they have worked for 1 to 5 years in their home countries prior to migrating. When practicing in the U.S., the majority work in hospital settings (critical care and adult health), with long-term care being the second venue of choice (CGFNS, 2002).

Source countries that traditionally have provided nurses to the U.S. are the Philippines, Canada, and India. This pattern continues today and is augmented by emerging suppliers such as China, South Korea, sub-Saharan Africa, and the Caribbean. Foreign-educated nurses can be found in all areas of the country; however, five states receive the majority of migrating nurses (California, New York, Texas, Florida, and Illinois), though other states have begun seeing an increase—most notably Georgia and North Carolina.

In 1994, foreign-born nurses made up 9% of the U.S. workforce, but, by 2008, this percentage had increased to 16.3% (Buerhaus, Auerbach, & Staiger, 2009). It should be noted that “foreign-born” does not mean that the individual also was educated outside the U.S. Many foreign-born students enter the U.S. on a student visa to attend nursing school and then either return home or adjust their visa status to permanent and become part of the U.S. workforce. Initial findings from the 2008 National Sample Survey of Registered Nurses (NSSRN) indicate an increase in foreign-educated nurses in the workforce from 3.7% in 2004 to 5.6% in 2008, despite periods of retrogression implemented by the U.S. State Department (Health Resources and Services Administration [HRSA], 2010).

Retrogression, the procedural delay in issuing visas when more visa applications have been received than visa slots exist, has limited the number of foreign-educated nurses who can obtain occupational visas to practice in the U.S. The Department of State determines when it is necessary to impose limits on the allocation of immigrant visas and to which countries retrogression will apply. Under retrogression, visa applications are not processed until the backlog is completed (Richardson & Davis, 2009). When retrogression was ordered in 2004, it applied only to China, India, and the Philippines and lasted for several months. The most recent retrogression (November 2006) was for all countries and continues as of 2010, causing a major decrease in the recruitment and visa certification of foreign-educated nurses (Richardson & Davis, 2009). A source country’s economy may be dependent on how many of its citizens work overseas—a fact that fuels the push for changes in U.S. immigration and economic policies, which are needed to open the doors closed by retrogression and the downturn in the U.S. economy.