Excerpts from: Deskilling Migrant Women in the Global Care Industry (about former nurses turned care assistants turned nurses again in England)
please see video Deskilling Workshop
Nursing schools: returns on investments?
Universities in emerging countries are central actors in nurse migration, with the purpose of exporting nurse graduates—a common promotional slogan is ‘your cap is your passport’ (Kingma, 2006, p. 23). Mirelle Kingma refers to this system as an ‘education export industry’ (p. 90) and claims, ‘no nurse can move either internally or externally if she does not have the proper education’ (p. 81). Many developing countries’ governments are more reluctant to fund nursing schools especially if students leave and never return. This void forces many women to pay for their own education, making nursing, ‘one of the expensive careers for girls to take […] since they spend so much for their education, naturally their tendency after graduation is to go abroad.’ (p. 85). There is also a demand for overseas graduates in economically advanced countries, like the UK and U.S. In the UK, for example, in the mid 2000s, it was cheaper for hospitals to receive and adapt a migrant nurse from a developing country than to train one in their own (p. 192).
But these migrant nurses bear the costs of having to retrain as nurses once they migrate. This is because adaptation and conversion systems for these nurses are quagmires. In the USA, for example, many foreign-educated nurses are left to ‘sink or swim’ due to the hoops they are expected to jump through (Xu, 2008). Post-arrival certification (adaptation) programmes have been characterized as ‘hit or miss,’ and there is a high failure rate for qualifying and licensing exams. In Canada nurses are given temporary licences but the time restriction is short and the national licensing exam takes so much time and effort to upgrade their credentials to the point that some ‘nurses never re-establish their professional careers’ (Baumann and Blythe, 2008). What makes Canada different, however, is that these nurses can count prior learning as part of the Canadian assessment system. They end up as caregivers and care assistants (see the work of Geraldine Pratt, 2004).
The skilled migration chains that recruiters start, in targeting these highly skilled women, cross borders virtually through technologies. Susan Maybud and Christiane Wiskow (2006, p. 223) claim that, overseas private recruitment agencies, which many governments turn a blind eye to:
Invite the loggers-on to explore a myriad of opportunities. Go ahead, they entice, just click on this website and you are one step closer to a better life.
The promises of the recruiters signalled ‘greener pastures’ for the prospective migrants, although they were more like red flags.
Experiences of former nurses in England
I remember there was a time—an incident where this nurse was trying to find the vein of the client and she really pricked and pricked, and I could see the vein. And I was like, we do that in Zambia. But I can’t do anything about it here because I’m just a carer. They consider us as someone who doesn’t know anything.
This former nurse was currently a care assistant in England. She observed a nurse in her residential care home inserting a needle into a client’s arm to the point of causing him injury but was paralyzed to intervene because she felt that she was viewed as ‘someone who doesn’t know anything.’ Her primary identity, as a nurse in Zambia, was overshadowed by her role of being ‘just a carer’ in England. Despite her extensive nursing knowledge, she was rendered helpless in England’s occupational hierarchy. Her silence was not self-imposed, however, for it was illegal for her to dispense medical advice. In another case, when a care assistant in a nursing home did offer guidance to a nurse who had forgotten the amount of medicine needed for a diabetic shot, she was told, ‘What do you know, you’re just a carer.’ These care assistants were heavily monitored and prevented from taking action in their institutionalized work settings and sought to change their situations where they could. I present the issues of some successful participants as each one moved from being ‘just a carer’ to a nurse.
Advancement or Carousel?
Any type of advancement in the care labour market in England was viewed as part of ‘stepping up’ in the world of care like one newly minted nurse: ‘It meant getting a better job, stepping up, you know, moving on, whatever you want to call it.
They also viewed this move, according to this nurse, as ‘a chance to have a life.’ Yet for many, their work lives were sub-standard as nurses, being paid only a fraction above what it was to be a care assistant. One care-assistant-turned-nurse, Anya, from Romania, was in her early 50s. She was given all night shifts totalling 42 hours a week, part of which were care assistant duties to fill a shortage in her care home. She said, ‘42 … I think that’s enough for me, I’m getting older!’ She felt uncomfortable about having so many responsibilities that were over and beyond her nursing role with colleagues that did not always follow her lead. It was overwhelming. Kingma found that the global elder care industry, from nursing and residential homes to home-based care, depends on the labour of migrant nurses to such an extent that it is often referred to as a migrant ‘ghetto’ from which it is hard to escape. Other studies have concurred that being a nurse is hardly the end point in integrating into the labour market or host society (Winkelmann-Gleed, 2004).
The act of becoming a nurse was difficult and the length of time it took to convert qualifications was relative to the country where the participants were trained. Also the rationale for the amount and types of documents that were demanded from the participants was not clearly explained, including confirmation letters from top officials and doctors in their countries that they had indeed practised and that the documents were authentic.
These participants were then issued pin numbers (a professional validation from the NMC that enabled them to apply for jobs as nurses). For those participants from non-EU countries (only two in this group), it was necessary to undergo a costly and labour-intensive process of: testing, adaptation training, mentoring, licensing, and then, with visas, a process of locating work. These steps involved, if they had at least three years in a nursing degree programme, first, taking the IELTS exam and passing it, applying to the NMC, and if accepted, enrolling in an overseas adaptation programme through an accredited university (of which there is a small number) and which consists of 20 days of protected learning time which is about 150 hours plus supervised practice. Then they were allowed to register, which means they earned their pin numbers only to be subject to a fickle market. These nurses paid their recruiters a lump sum that included payment to the nursing home for mentoring. One successful nurse described the process:
I paid £1,500 for adaptation, £2,000 for agency and £1,000 for nursing home. I spent 20 days at the University. Teaching is set up with classes halfway and clinical assessment is here [in the nursing home]. B. is my mentor. The programme leader came here to assess and my mentor, myself, and manager did it. I sent the paperwork to NMC and got the declaration form for £76. They sent it back and then I received my pin number.
This nurse was lucky whereas another one could not locate a position, once she obtained her pin number. Jayanti, from Kerala, India, was 26 and in England for ten months working as a care assistant. She migrated to ‘do adaptation—that was my main ambition and to get a pin number to work as a nurse and after a time being I thought I can do some master’s and that was my ambition.’ She began her adaptation in April at a university over a two-week period but completed the process in November, which she referred to as ‘a long time’ with ‘many things we had to do.’ After returning to her nursing home and completing her mentoring she created a portfolio that included an essay of 2,000 words. She had it signed off, sent in her materials, and had to wait for them to publish the results. One month passed and they made the declaration, after which she received her pin number, by ‘God’s grace.’ Jayanti went to the library on a daily basis to use the Internet for job-hunting but without success. Her visa needed to be renewed and she worried that she would not locate a job and did not ‘want to make trouble.’ She reasoned that ‘she still has a job’ and would stay in it until she could move up. Kingma (2006) discusses the delaying tactic of nursing professional associations and programmes as part of exploitation. Meanwhile, Jayanti felt that working long hours as a care assistant while undergoing adaptation was ‘too difficult for me—morning to night, 8 a.m. to 8 p.m. It’s hard work.’
After undergoing all of these hardships, the participants who had located nursing posts reinstated their professional identities and were adamant that this move reaffirmed their initial migration decisions. One participant felt she had ‘arrived’ in nursing when she ‘could get my job again’ as a nurse. Their newness, however, made them feel as if they were in entry-level positions. This nurse went on to say, ‘I’m going back to square one practically.’ Most of these new nurses in England felt that it would be difficult to get a job at a high-paying NHS hospital and were hesitant to apply based on the fact that they were only just certified. One nurse wondered, ‘What are the chances of me getting a job as a nurse in the hospital now, when I wasn’t actually a nurse in the UK?’ The NHS seemed impenetrable to these new nurses and only private hospitals were hiring. They also endured much discrimination.
The primary identities of the new nurses were restored when they moved into these positions, despite the difficulties they faced. They saw themselves in entry positions willing to do whatever it took to prove themselves in their new roles. But only a few of the former nurses advanced and while they became ‘integrated’ into the systems of nursing in England, their own knowledge bases did not count (Raghuram, 2007). This issue went beyond the critique of the positivist culture of ‘measuring’ qualifications (Miller, 2008, pp. 22–23). It pointed to a real deprivation of these women’s livelihoods.
please see also a National Geographic article, “Far From Home’ on Filipino guest workers