International nurses in health care system: deskilling to upskilling

1. Introduction

The World Health Organization [WHO] estimates a   global shortage of 4.5 million nurses by the year 2030 (WHO, 3 May 2024). According to the Finnish Nurses Association, immigrant nurses account for 3.3% of health care professionals in Finland. Nurses from EU countries are 31% and 69 % are from outside the EU.  Among those from EU countries, 65% work in healthcare settings, while 30% work in the social sector. Currently, the global recruitment of international nurses has surged, driven by healthcare workers retirements, an aging population, chronic diseases and a general shortage of healthcare professionals. Developed countries are increasingly recruiting international nurses as solutions in addressing nursing shortages, viewing it as a beneficial arrangement for both the source and host countries. This recruitment strategy is often perceived as a win-win situation for all parties involved. However, it has also led to the deskilling of healthcare professionals, a common issue in the migration process, which undermines the professional qualifications of those recruited, the human capital is underutilized. For example, A registered nurse with 4 years of study and several years of work experiences might end up working as a care assistant in an aged care due to the high-income destination countries having less systematic understanding of the skill sets the nurses have in the beginning of the migration process.

Some research has also highlighted the significant structural differences in the migration experiences and processes of the non-EU nurses seeking work in European countries. These nurses with international nursing degrees often face a long, expensive, and unpredictable path to obtain the necessary authorization, residence, and work permits due to the host countries’ stringent migration and authorization regimes. The general shortage of nurses and concerns about the potential deskilling of nurses migrating from Asian countries to other developed country possibly leading to them leaving the profession that matches their study path, is also identified as a significant policy issue.

Given this situation, it becomes equally important to gain further insights into the best international recruitment process and develop a better understanding of how to effectively utilize the skills of foreign nurses in the new countries. On the other hand, social and health care system of the source country may also be affected, potentially struggling to meet its own populations´ healthcare needs, if its education system focuses primarily on exporting highly skilled nurses abroad.

2. Understanding deskilling in the context of nursing

Deskilling refers to a situation in which the individual’s profession does not meet their qualification and experience (Mollard & Umar, 2013). The concerns over deskilling in nursing focus on situations where nurses’ education, experience, skills, and knowledge are not being fully used in their roles and scope of practice. The migrant skills, particularly those from the Global South, are often devalued in destination countries like Europe and North America. This devaluation, which can lead to deskilling, is influenced by employers, recruitment agencies as well as the process involved in authorization of the earlier nursing degrees and securing the occupational licensing. The issue is especially prominent in care work, as seen with Filipino nurses in Canada, and nurses from other continents in North-West England, and Polish migrant nurses in Norway. These examples highlight the broader trend of skilled nurse migrants being underutilized in their new countries (Cuban, 2013; King & Williams, 2018)

There are several factors that contribute to deskilling among internationally educated nurses. Internationally educated nurses encounter significant challenges when transitioning to global healthcare contexts, including cultural displacement, deskilling, and discrimination. Deskilling involves difficulties in maintaining and recognizing professional skills and identities in a new country. Both EU/ETA and non-EU migrants face threats to their professional identities despite structural differences in migration processes. Deskilling is a dynamic and subjective process, influenced by factors such as national authorization regimes and ethnic or racial hierarchies (Newton et al., 2012; Belmonte et al., 2020; Korzeniewska & Erdal, 2021. p.3).

• Licensing Barriers: Many destination countries have stringent licensing and authorization processes that can hinder the recognition of foreign qualifications, forcing nurses to work in roles below their skill level.
• Language Difficulties: Language barriers can prevent nurses from fully demonstrating their professional competencies and integrating into the healthcare system.
• Racial or Ethnic Biases: Discrimination and biases based on race or ethnicity can affect how migrant nurses’ skills and qualifications are perceived and valued.
• Cultural Displacement: Migrant nurses often face challenges related to cultural adjustment and integration, impacting their professional roles and recognition.

Many nurses migrate to destination countries seeking better personal and professional opportunities but often face barriers to practicing as registered nurses. Consequently, they may opt for roles as licensed practical nurses, experiencing deskilling and ambiguous recognition of their skills, which can lead to job dissatisfaction (Salami et al., 2017). Research in the EU indicates that foreign qualifications are frequently less transferable than domestic ones, resulting in poorer labor market outcomes. For instance, while Sweden shows minimal premium for domestic degrees over foreign ones, Germany sees significant skill downgrading for immigrants with non-German qualifications. The impact varies based on education type, migrant admission category, and national recognition measures. Although the EU has established frameworks for recognizing intra-EU qualifications, the process for non-EU qualifications remains fragmented and reliant on national practices and employer acceptance (Belmonte et al., 2020). Another article of (Näre & Cleland, 2021) examined how organizational practices perpetuate inequality, focusing on Filipino nurses in Finland highlighting the racialized perception of Filipino nurses as a labor resource. It also highlighted how their limited Finnish language proficiency and precarious legal status make them compliant and vulnerable within the organization.

3. The impact of deskilling on immigrant nurses

Studies have shown that deskilling and discrimination significantly impact the professional identity and career satisfaction of immigrant nurses (Newton et al., 2012).

Nepali migrant nurses, skilled in critical care, management, and education, are frequently employed in the UK’s long-term care facility but often lack career choices and professional development opportunities. That leads to frustration and job dissatisfaction (Adhikari & Melia, 2015). Deskilling is a dynamic issue, though opportunities for upskilling and reskilling can enhance their agency and well-being (Korzeniwska & Erdal, 2019). Challenges related to immigration and occupational licenses, recognition of the previous degrees, communication problems, and racism can hinder their integration, leading to circular migration and negatively affecting career development. Deskilling may harm migrant nurses’ health, work performance, and job satisfaction, ultimately affecting their overall integration and utilization of skills (Moyce et al., 2016). The observational study of Wojczewski et al. (2015), revealed that most healthcare professionals face temporary  or permanent career inability due to migration, with few reporting positive post -migration career development. Discrimination based on country of origin, race, or gender is common, and many healthcare workers face deskilling due to non-recognition of their previous diplomas. Coping mechanisms used by nurses may also unintentionally lead to deskilling.

Finnish language learning is crucial for foreign nurses to work in the healthcare system. Language barriers and demanding RN roles often lead to underutilization of nurses’ qualifications. Choosing practical nursing positions instead of registered nurse roles can also lead to deskilling, hindering professional growth and hindering their integration into the healthcare system.

4. Enhancing integration from deskilling to reskilling

The growing presence of immigrant nurses in nursing homes worldwide, often undervalued despite their rich multicultural and educational backgrounds, offers a unique strength. A study examining competence perceptions among staffs in a multicultural nursing home in Norway reveals that competence is not determined solely by educational level, racial background, or language proficiency. Instead, it is defined by professional knowledge, the ability to communicate effectively in the majority language, genuine interest in the role despite challenging conditions, and task prioritization. This finding underscores that competence intersects with educational, racial, linguistic, and social dimensions in complex ways, promoting ethnic equality and highlighting the valuable contributions of diverse staff in enhancing care quality and integration (Munkejord & Tingvold, 2019; Gotehus, 2021; Korzeniewska & Erdal, 2021).

Racism and social isolation are major problems that migrant workers frequently encounter, and social support networks and cultural orientation initiatives are essential in lessening their effects. By addressing the barriers and policies that contribute to deskilling, these programs can facilitate smoother, safer, and more effective transitions for internationally educated nurses into host countries (Moyce et al., 2016). Proficiency in local language is essential for integrating into the labor market, as it enables individuals to develop language skills, acquire generic competencies, gain work expertise, and pursue further education (Landolt & Thieme, 2018). In Finland, many universities of applied sciences offer bridging programs specifically designed for internationally educated or immigrant nurses or the nurses whose occupation is mismatched. These Top-up nursing programs provide opportunities for reskilling, upgrading education, and gaining practical work experience in the host country’s healthcare system through internships in local health care organizations.

A supportive work environment is crucial for retaining migrant nurses, where career development plans and informed recruitment campaigns play a significant role in their retention (Goh & Lopez, 2016). Nurse managers and policymakers should align their policies with workforce plans to better utilize the skills and competencies of these nurses (Adhikari & Melia, 2015). Additionally, social support systems and cultural orientation programs are essential in mitigating the effects of social isolation and instilling a sense of belongingness.  This can enable safer and more effective transitions for migrant nurses into host countries and reduce circular migration (Moyce et al., 2016). Furthermore, organizational strategic measures that increase collaboration and connection among health care professionals promote inclusive work environment

This approach acknowledges and values the diverse skills and competencies of workers from multicultural, educational and migration backgrounds (Munkejord, 2019).

Intercultural knowledge empowers individuals to navigate and respect cultural differences, enhancing communication and collaboration. Diversity brings varied perspectives that drive innovation and inclusivity. Multiculturalism fosters the coexistence of different traditions, promoting mutual respect and enriching society. A language-aware society values multilingualism, key to improving communication and deepening cross-cultural understanding. These principles help in removing deskilling by ensuring that diverse skills and experiences are recognized and valued, enabling migrant workers to fully utilize their qualifications and contribute meaningfully to their workplaces.

5. Conclusion

The global migration of nurses, driven by several factors, presents both benefits and challenges in international recruitment. Despite their diverse backgrounds, many nurses face deskilling, a mismatch between their qualifications and job responsibilities, which can lead to job dissatisfaction and underutilization of skills. Addressing deskilling requires a multifaceted approach, including supportive systems, cultural orientation programs, mentorship programs, and language proficiency initiatives as well as bridging nursing courses. These reskilling and bridging programs can facilitate smoother transitions for internationally educated nurses. To achieve meaningful progress, policymakers, healthcare organizations, and educational institutions must collaborate to create inclusive environments that recognize and value the diverse competencies of immigrant nurses. This will enhance nursing retention, career opportunities, and improve quality of care in healthcare settings. Overcoming deskilling is crucial for ensuring the positive contribution of nurses to both destination and source countries.

The article was prepared as part of the Culture and language-aware nursing in South Ostrobothnia, CareEP. The project is co-funded by the European union. 

Binu Acharya
Expert, RDI
CareEP-project
SeAMK

The author of the article works as an expert in the Culture and language-aware nursing in South Ostrobothnia, CareEP project. 

Culture and language-aware nursing – SeAMK Projects