Perspectives in Health Magazine The Magazine of the Pan American Health Organization Volume 8, Number 2, 2003

More and more, nurses in the Caribbean have been packing their bags and heading for countries with less-than-perfect climates to get better pay and more respect. Now the region is looking for ways to keep them from leaving—and even to lure those abroad back home.

Back in the 1980s, Glenda Caesar worked as a staff nurse in a hospital on the island of Trinidad. She earned the equivalent of about $250 per month. Given the cost of living, it left her with virtually no disposable income. To make matters worse, she says her working conditions were "deplorable," with extreme patient overcrowding and serious shortages of medicines and equipment.

So in 1990, along with three other nurses from Trinidad, Caesar accepted a job offer in Saudi Arabia that paid her more than four times her Trinidad salary. Leaving behind her tropical island home, she traveled to the harsh desert climate of Riyadh, where she enjoyed perks such as a "rest and recreation" allowance, had much better working conditions and earned enough to live comfortably and still send money back to her family in Trinidad.

Eventually homesickness compelled Caesar to give it all up and return home. But her fellow Trinidadians and other nurses from the Caribbean are still there. Moreover, others are following in their footsteps, emigrating to the Middle East, Europe, Canada and the United States. As fast as you can sing "Working for the Yankee Dollar," nurses from throughout the Caribbean have been packing their bags and saying, "Farewell, paradise!"

As early as the 1970s, the World Future Society was predicting that the global demand for nurses would be virtually infinite. Today, the shortage of trained nurses has become one of the most serious crises facing the health care industry worldwide. The World Health Organization (WHO) reports a shortage of nursing personnel in each of the six regions of the world it represents. If the trend is not reversed, "the ability of many health systems to function will be seriously jeopardized," says a 2000 WHO report.

Gloria Noel, a health systems management consultant and former nurse advisor to the Pan American Health Organization (PAHO), says three labor trends are feeding the problem: "Nurses are not entering the profession, those who are there are not staying, and those remaining are not happy. This crisis preoccupies health services policymakers, planners, educators, employers, managers and employees. Experts are studying the impact of the global nursing shortage on world health status and the quality of health care."

The fact that these trends are not confined to the Caribbean provides little consolation to the region. In certain ways, its problem is worse. Because English is the native language of most Caribbean countries, their nurses are highly desirable to North American and British recruiters. This exacerbates the region's homegrown shortage.

Noel says recruitment agencies from these and other countries send representatives who in some cases try to lure nurses right off hospital floors. She finds it "interesting" that "a country with the highest ratio of nurses, the United States, which has 97.2 nurses per 10,000 people, is recruiting nurses from Jamaica, where the ratio is just 11.3 nurses per 10,000, and from Guyana, with 8.6 nurses per 10,000." She cites U.S. Bureau of Labor Statistics projections that estimate U.S. demand at an additional 800,000 registered nurses by the year 2020.

The growing demand is due to several complementary factors. People are living longer than before, increasing the numbers of infirm and chronically ill. Improved lifestyles and greater health promotion reduce premature death and illness but add to the health care burden of an aging population. So, too, do seemingly endless medical-scientific discoveries and technological advances in health care.

And that's the good news.

On the downside, Noel points to increases in antibiotic-resistant infections and "cost-cutting pressures of managed care." There is also HIV/AIDS. While antiretroviral therapy increases the numbers of people living with HIV/AIDS, it also increases their need for trained caregivers. The Caribbean is second only to sub-Saharan Africa in terms of HIV rates, with an estimated 2.2 percent of Caribbean nationals living with the virus, according to the Joint United Nations Program for HIV/AIDS (UNAIDS).

Studies have identified other factors underlying the nursing crisis. In the Caribbean, these include inadequate workplace environments, with facilities that are in disrepair and lacking essential equipment. The problem is compounded by inadequate compensation and benefits. Most Caribbean countries have suffered severe economic downturns and have implemented structural adjustment programs that have brought major reductions in health-care budgets.

Nurses also complain of a lack of recognition and professional power, which leads to unsatisfactory social relations at work. "There is no respect for nurses who stay and who make the sacrifices," says Caesar. Under such conditions, even family commitment, patriotism and the opportunity to contribute to national development are insufficient motivators for trained nurses to remain in the national health service.

Caesar has been a nurse for 26 years and is now an assistant secretary with the Public Services Association of Trinidad and Tobago, the industrial relations representative of most local nurses. She says she understands well why many nurses want to leave.

"It is not only for the money. For the most part, it is a matter of improving themselves and their families. Many of us have children at university. We have mortgage payments. We have the car, food, phones and a salary that can barely feed us and pay off the bank. Our colleagues abroad have enough money to pay their mortgages and still have something left for the rainy day. This is why so many of my colleagues think, 'maybe I should get out too.'

"When you look at the hospital where I was trained and worked, there is severe overcrowding. There used to be a staff ratio of five nurses to 109 patients in the medical wards, and that is low by international standards. Now you get three nurses to one ward, if you're lucky."

Contrast that with conditions in recruiting countries such as Saudi Arabia. "All the support facilities are available—the equipment, the staff, are all there," she says. "The linens and packs are changed regularly. This is the big difference." Asked about language and cultural differences, she says, "Patients are patients everywhere. Whatever the language, their needs are the same."

Nursing brain drain
The impact of the nursing crisis is being felt throughout the Caribbean region. Many of the most experienced, skilled and specialized nurses have left for greener and more professionally rewarding pastures. Many of those remaining are nurses near retirement (mandatory at age 55 in most Caribbean countries), and the number of new nursing graduates is declining. About 35 percent of nursing posts in the region's health sector are currently vacant. Many patient care units have had to be merged and elective surgery often cancelled in many hospitals. "Sick outs" by nurses demanding better pay and working conditions have cost governments almost $3 million.

Year of the nurse As part of their stepped-up efforts to keep trained nurses from leaving home, the countries of the Caribbean recently declared a "Year of the Caribbean Nurse" from May 2003 to August 2004. The 16-month-long "celebration of nursing and nurses" is aimed at increasing recruitment and retention, strengthening nursing and midwifery services and "recognizing the best of nursing and nurses in the region." "I cannot overstate the significance or potential that the Year of the Caribbean Nurse holds for all people in the region," says Marjorie Parkes, chairperson of the Regional Nursing Body. The year was kicked off at a gala event in May in St. Kitts, with Prime Minister Denzil Douglas presiding. Each month throughout the year, two different countries will host special events showcasing nurses' contributions. Among the highlights will be special welcoming ceremonies—complete with media coverage—for nurses returning to the Caribbean from abroad, whether for vacations or for good. In return, they will be asked to contribute "a few days to a week" of mentoring activities to pass their skills on to more junior nurses. With the theme of "Nurses Lighting the Way to Professional Excellence," organizers have produced a special Caribbean nursing symbol featuring a lighted lamp against a backdrop of the flags of all the region's countries. It will be passed from one country to the next until the celebration culminates in Curaçao in August 2004 at a meeting of an estimated 400 nurses from throughout the region. The main organizers of the year are the Caribbean Nurses Organization and the Regional Nursing Body, also lead actors in the region's Managed Migration program. Supporters include the Pan American Health Organization, Johnson and Johnson, the Lillian Carter Centre for International Nursing and the Department of Advanced Nursing Education at the University of the West Indies.

As a result of the nursing brain drain, the loss in public investment in training nurses at the basic level is estimated at nearly $17 million. One senior nurse in Trinidad, who prefers that her name not be used, says that many young nurse trainees make no effort to disguise their intention of using the profession as a means of getting a "green card" to work in the United States.

"It makes me upset," she says, noting that this further reduces the standard and quality of nursing care.

In the larger sense, the nursing crisis feeds widespread fears among the taxpaying public about the availability, safety and quality of health care. "It has, and will continue to have, a profound impact on nursing services both quantitatively and qualitatively," says Noel. "This shortage is unlike those of the past and requires bold action and innovative and creative solutions."

With the problem gaining attention, a Caribbean response to the challenge has now emerged. At the national level, ministries of health, with support from PAHO, are partnering with local nursing associations and other stakeholders to address the roots of the problem. At the regional level, the Regional Nursing Body, the Caribbean Nurses Organization, other professional associations and teaching institutions are similarly involved. Also participating are the ministries of health and nursing and health organizations in recruiting countries, as well as private companies and foundations.

A central focus of these efforts has been the development of a new Managed Migration program, defined as "a regional strategy for retaining adequate numbers of competent nursing personnel to deliver health programs and services to Caribbean nationals at the highest level of quality." It addresses the recruitment, retention, deployment and succession-planning issues inherent in the exodus of nurses from the Caribbean. A newly established "implemention team" is coordinating efforts in several priority areas, including the terms and conditions of work; use and deployment of nurses; recruitment, education and training; management practices and the value of nursing.

Nursing "sick-outs" for better wages and working conditions have cost the Caribbean nearly $3 million. Now nurses are getting more respect. (Photo courtesy Trinidad Express)

Carl Browne, former permanent secretary in the Ministry of Health of St. Vincent and the Grenadines and now project manager for a European Community HIV/AIDS project in the region, supports the initiative but is adamant that at the base of the problem is the need for more training institutions for nursing.

He says, "We need to produce more nurses. Nursing should be on the curriculum of our community colleges and other tertiary institutions. We should also establish some kind of compensation arrangement with organizations that recruit our nurses and use the funds from this to train more nurses.

"We have to recognize that the demand for trained nurses in the developed countries will continue indefinitely. Instead of viewing the situation as a crisis, we must analyze it for the opportunities that it undoubtedly contains. There are benefits that we can exploit for our countries and for our nurses. Most of those who leave remit money to relations here and buy property, intending to return home when they retire."

Gloria Noel believes the solution must be as multifaceted as the problem. She says the Caribbean and other regions with this problem, such as Africa, need to implement sound long-range human resources planning; improve the image of nursing; increase enrollment of male and female students and marginal groups in nursing schools; redesign curricula to make nursing education programs more exciting and challenging, including adding mentoring programs; enhance opportunities for professional development and career progression; improve working conditions; match clinical practice opportunities and responsibilities with nurses' knowledge and skills; recognize nurses as equal partners with physicians in the health team; and compensate nurses commensurately with their education, experience, responsibilities and contributions to health care.

"These reforms require commitment, cooperation, mutual trust, respect and sustained action on the part of all stakeholders," says Noel. "These include policymakers, health systems planners, and the nursing profession, with input from consumers of health care."

Whether sheer necessity will prompt these needed interventions remains to be seen, but whatever happens, the role of nurses in the development of health care will continue to be pivotal. They are the wheel and hub of health services.

As Noel told nurses at a recent conference on the future of nursing in Guyana: "It takes a special person to be a nurse. You are the unsung heroes, the unseen angels. Be the best that you can be. Celebrate each other, be strong, view the many frustrations as challenges, take care of yourselves, as you are the fabric and future of health care in this country and the world."

Tony Deyal is a former advisor to the Pan American Health Organization and currently an underpaid newspaper columnist in Trinidad. He was last seen trying to find the help-wanted ads in Arab News.

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