Table 1 Data extraction and appraisal of selected articles in chronologic order (n = 16)

Yan, 2006 [29]

Caribbean

To describe the CARICOM MMP as an intervention to reduce negative repercussions of nurse migration.

Commentary/Level VIII

1. High income countries aggressively recruit from CARICOM countries.

2. Nursing shortages in CARICOM countries lead to negative impacts in healthcare quality, loss of money, and undesirable working conditions for remaining nurses.

3. MMP guiding principles; observe nurses’ rights while balancing obligations to provide high quality healthcare.

4. MMP critical areas; (1) terms and conditions of work, (2) recruitment, retention, and training, (3) value of nursing, (4) utilization and deployment, (5) management practices, and (6) policy development.

5. Jamaica/Florida partnership; 2 weeks alternating in each country.

6. Brain gain: Caribbean nurses return home to share knowledge and skills.

7. Health and tourism; bring nurses from wealthy countries to tourist destinations in the Caribbean for 6 mo. to 1 yr.; pay is same as for local nurses.

- Recruitment

- Imbalance/inequity

- Mitigation strategies (partnership, policy)

Salmon et al. (2007) [30]

Caribbean

To describe the nursing workforce issues in the Caribbean and the MMP as a framework for addressing nurse migration.

Commentary

1. Out-migration of nurses from the Caribbean is due to many (p. 1357).

2. The Caribbean feels the loss of highly trained nurses and nurse educators.

3. Jamaica has a critical shortage of nurses (58% vacancy rate in 2003) that compromises the quality of care. Some of the void This void is partially filled by recruiting from Cuba, Guyana, India, Ghana, Burma, Russia, and Nigeria.

4. Regional and international nurse collaborations offer some hope in addressing nurse migration (p. 1361).

5. The most significant regional achievement is the MMP.

6. Factors supporting and detracting from MMP success are outlined (p. 1367).

7. GATS as a framework for nurse migration includes incentives for nurse to stay in-country.

8. Align MMP with SDGs and MMP must be in CARICOM agenda.

- Recruitment

- Imbalance/inequity

- Mitigation strategies (partnership/policy)

Jones et al. (2009) [53]

Caribbean

To explore the significance of gender in nurse migration from the Caribbean to the U.K.

Literature review/Level VII

1. Gender issues are significant in all aspects of the migratory process.

2. Migrant nurses contribute to social progress in the Caribbean on their return, but an overall negative impact exists, particularly for women.

3. Women experience gender inequalities driving migration and gain economic freedom.

4. Gender inequalities persist in some higher economic environments upon migration.

5. ‘Feminization of migration.”

6. Women left behind pick up care responsibilities for family members, sick, elderly.

7. Female migrants are more reliable remitters than men.

8. Migration leads to family separation and emotional costs.

- Imbalance/inequity

World Bank (2009) [54]

English-Speaking Caribbean

To produce a comprehensive assessment of the nurse labor and education markets of the English-Speaking CARICOM

Expert Opinion/Level VIII

1. Nurses are a globally scarce human resource

2. Data limitations are a significant issue

3. < 10% of nurses in primary care

4. > 90% of nurses employed in the public sector

5. Nurse to population ratios ten times lower than in wealthier regions

6. Demand for nurses exceeds supply

7. 8% annual attrition mainly due to outmigration

8. The brightest nurses out-migrate driven by wage differentials, network effects, and worker dissatisfaction

9. Nursing schools are public, semi-autonomous, and private

10. Trend towards students paying for their own tuition

11. Approximately 50% of students never complete their program – concerns for poor quality of education

12. Insufficient nurse tutors

13. Average of three qualified candidates competing for every position in nurse training programs

14. Each CARICOM country has improved the quality of their programs (curricula, pedagogical approaches, harmony across programs)

15. Estimated gap between demand for and supply of nurses will widen from 3400 (2009) to 10,700 in 2025

16. Strategy to mitigate nurse shortages = expand training capacity, maximize program completion rates

17. Financing nurse training through students, local, and foreign governments

18. Policy must address training completion rates, training capacity, managed migration, mobilizing the inactive supply of nurses

- Recruitment

- Imbalance/inequity

- Mitigation strategies (partnership, policy, education)

Senior (2010) [32]

Caribbean

To highlight the shortage of nurses in developing countries for International Nurses Day, 2010.

Commentary

1. The Caribbean will have a nursing shortage of 10,000 by 2025.

2. Push factors to leave the Caribbean, increased pay, better conditions, professional incentives.

3. Nurse migration leads to poorer quality healthcare and worse health indicators (e.g., infant mortality).

4. Paucity of educational opportunities is a major factor in nurse migration.

5. Loss of nurse faculty; retirement. Nurse to faculty ratios in Caribbean 45:1 and in wealthy countries 12:1.

6. ICN, International Education Network in collaboration with the National League for Nurses; a collaboration to address nurse shortages.

7. WHO global standards for professional nurse education.

8. Bologna Process allowing academic exchange in Europe.

- Imbalance/inequity

- Mitigation strategies (policy, education)

Adelberger et al. (2011) [50]

Bahamas

To collect nurse migration data from the Bahamas from 1994 to 2005.

Exploratory descriptive/Level VI

1. Nurse migration in the Bahamas is lower than in the surrounding Caribbean; stronger economy, better pay, a robust public health core contribute.

- Imbalance/inequity

- Mitigation strategies (policy)

Evans and Tulaney (2011) [56]

Jamaica and Philippines

To examine the impact of nurse migration.

Commentary

1. To understand migration, one must first understand globalization.

2. Geographic maldistribution of nurses; barriers to care for rural dwellers.

3. Recruitment from the U.S.A. is problematic.

4. Push factors are related to education and practice.

5. Estimating the severity of nurse migration in Jamaica is challenged by poor registration data.

6. Philippine nurses encouraged to migrate and remit, Jamaican nurses leave related to push-pull factors.

7. Strategies like MMP are needed as is scientific investigation.

- Globalization

- Recruitment

- Imbalance/inequity

- Mitigation strategies (partnership/policy)

Lewis (2011) [33]

Jamaica

To discuss training nurses for export and the implications of this practice, using Jamaica as an example,

Commentary

1. Nurse and educator migration from Jamaica accounts for 70% of nurse attrition.

2. Remittances account for 12% of the gross domestic product.

3. Shift from brain drain to brain circulation and diaspora; focus on positives of migration (e.g., economic, skill, lower fertility, lower unemployment, etc.)

4. Negative implications of migration are significant (e.g., split families especially in poor households).

5. Nursing crisis: push factors outweigh pull factors.

6. Lack of professional autonomy and authority; pay not tied to level of education and experience so nurses demotivated to stay.

7. Aging of nurses; leaving workforce.

8. Training capacity in Jamaica is critical and well described in this article including costs and Ministry of Health and Wellness involvement.

9. Training for export; hemorrhaging of skilled people in trade for remittances and hope for return migration and skill.

10. Formal partnerships between U.S.A. and Jamaica.

11. National, regional, and international strategies

 - National; training for export, focus on education

 - Regional; MMP

 - International; Commonwealth Code of Practice for the International Recruitment of Health Workers, GATS

- Recruitment

- Imbalance/inequity

- Mitigation strategies (partnership, policy, education, incentives)

Lansiquot et al. (2012) [51]

Eastern Caribbean

To describe the relationship between practice environment and intention to leave in hospital-based nurses.

Descriptive correlation/Level VI

1. The practice environment was described as generally unfavorable but had little to do with nurse intention to leave. Most nurses were single, young, and had entry-level nursing education. There is a high intention to leave overall

- Imbalance/inequity

- Mitigation strategies (education)

Lofters (2012) [59]

Jamaica

To describe “brain drain” in developing countries, highlighting Jamaica as a country that illustrates the complexity of the issue, and to discuss creative and sustainable solutions to the problem.

Commentary

1. The loss of health workers from developing countries has devastating impacts.

2. $500 million annually to train health workers who leave to higher income countries.

3. Moving within country to urban from rural areas is a predictor for overseas migration.

4. Active recruitment by wealthy countries, poor conditions in home countries.

5. ‘Brain drain perpetuates brain drain.’

6. Solutions are not simple or clear. Global Forums on Human Resources, Global Health Workforce Alliance, 2008 and 2011. Goal to improve resources for health to reach SDGs. WHO Global Code of Practice on the International Recruitment of Health Personnel.

7. Wealthy countries need to take responsibility and not take advantage.

8. Jamaica as an example: It is hardest hit by migration. About 80% of all Jamaicans with higher education have migrated out. Nurse migration of 8% of registered nurses and 20% of specialists; two thirds have migrated. High vacancy rates for all nurses; overall 58% in 2003.

9. Nurse migration negatively impacts healthcare quality and outcomes, production, economy. With so many females leaving their families behind, “barrel” children do more poorly in school, have delinquent behaviors, and are more likely to be sexually abused.

10. Jamaica has resorted to recruiting nurses from other countries (Ghana, Nigeria, etc.). Cyclical, perpetual effect.

11. Jamaica and partners invested in ethical solutions; MMP, IOM national migration policy, etc.

- Imbalance/inequity

- Mitigation strategies (partnership, policy)

Clark et al. (2015) [48]

Haiti

To highlight nursing continuation education as a strategy to retain nurses in developing countries providing an example of this in Haiti.

Case study/Level VI

1. Haiti and other developing countries suffer nurse shortages partly due to migration and lack of retention.

2. Nursing continuing education has the potential to positively impact nurse retention and to enhance nurse performance but is underutilized.

3. Eight dimensions of nursing continuing education for success.

 - involve key stakeholders

 - target to nurse participant level and area of care

 - base course content on local context

 - use diverse nursing topics

 - use participatory teaching techniques

 - address resource constraints in time and scheduling

 - evaluate and monitor outcomes

 - establish partnerships

4. This continuing education process is possible with commitment and engagement and is an important strategy in retaining nurses.

- Imbalance/inequity

- Mitigation strategies (education, partnerships)

Johnston et al. (2015) [60]

Barbados

To determine perceptions of medical tourism; an expanding industry.

Qualitative/Level VI

1. Three core concerns about medical tourism.

 - incentivizes migration

 - burdens the tertiary healthcare system

 - produces different tiers of quality of care

2. These concerns are framed by:

 - both universal public and private medical insurance-based medical sectors

 - international mobility between health workers and patients

 - a large recreational tourism sector

- Imbalance/inequity

- Mitigation strategies (incentives)

Jacobson (2015) [58]

Latin America and the English-speaking Caribbean

To discuss nurse migration

Commentary

1. Nursing shortages are severe.

2. Globalization of nursing; migration has benefits.

3. Nurses remit part of pay back home and boost economy.

4. Training and education are not uniform across countries.

5. Nurses do not leave for better salaries only. It has more to do with deficient work environments.

6. Nursing education is an investment that is key to retention, educational pathways and opportunities for advanced practice education.

7. Nurses also need to be integrated in policy decisions, but education must be prioritized.

- Globalization

- Imbalance/inequity

- Mitigation strategies (education, policy)

Tomblin Murphy et al. (2016) [52]

Jamaica

To determine drivers of health worker migration

Mixed methods/Level VI

1. Health worker migration from Jamaica is prevalent and due to differences in working and living conditions in Jamaica and ‘destination’ countries.

2. Formal tracking of HCW from Jamaica is lacking.

3. Outcomes from multiple efforts to reduce migration have not been well described.

4. Additional strategies that may be helpful: information systems to formally monitor migration, updating the national cadre system that tracks health worker employment, enforce existing personnel management strategies, use formal and informal health worker recognition.

- Imbalance/inequity

- Mitigation strategies (partnership, policy, incentives)

George et al. (2019) [57]

Caribbean

To describe the wage gap and financial incentives leading to human resources for health (HRH) migration within and from the Caribbean.

Commentary

1. Medical doctors, registered nurses, and specialists are included in the analysis of salaries.

2. Nurses who migrate to destination countries have substantially higher earning power (214.2% more in the U.S.A.).

3. When strategizing to reduce nurse migration, governments have to consider earning potential in destination countries.

- Imbalance/inequity

- Mitigation strategies (incentives)

International Organization for Migration – UN (2019) [55]

Jamaica

To provide a descriptive analysis of the main migration characteristics and trends in Jamaica from 2011 to 2015

Expert Opinion/Level VIII

1. Globalization has had significant negative impacts on Jamaica’s economy.

2. 2256 registered nurses in Jamaica (2005), 58.3% vacancy rate (2009).

3. Nurses recruited to the USA and Canada through private institutions.

4. Gaps in specialized nursing – 74% in public health, 70% in nurse anesthesia, 68% in psychiatry, 106% in critical care, 111% in pediatrics, 113% in emergency settings, 32% in oncology…

5. Overall, 54% nursing shortage – ‘depletion of nurses in some specializations,’

6. ‘Bonding’ as a strategy to keep nurses in Jamaica but nurses just pay off their bonds and out-migrate

7. Increase training output to bolster nurse retention

- Globalization

- Recruitment

- Imbalance/inequity

- Mitigation strategies (partnership, policy, education, incentives)