Limitations of the push and pull model

We have to recognise that the push/pull is not just about a balance or an imbalance. It is actually something much more fundamental than that. It is about a nurse’s place and status in some societies.

Buchan 2006: 21S

Many models fail to capture the complexity of migration, and the push and pull model is considered to be no exception (Lessinger 1995 cited in Brettell 2000). Despite its widespread use, it has a number of limitations which the literature commonly fails to discuss (Mackintosh 2003). Criticisms of the model relate mainly to its simplicity, and to the fact that it takes into account neither the circumstances of the migrant nor the dynamics between push and pull factors (Cohen 1996 cited in Oderth 2002, Boyle et al 1998). In addition, many have argued that push and pull factors are not mutually exclusive (IOM 2007a) and that they operate in both source and destination countries (Boyle et al 1998), making it difficult to assess their relative impact.

Enabling factors such as admission policies are often downplayed in the push and pull model despite their importance (Boyle et al 1998, Schiff and Ozden 2005 cited in Mitchell 2006). Research has shown that ‘nothing shapes migratory flows and types more than admission policies’ (Arango 2000:293). International agreements between countries have an important role in determining migration patterns and can either facilitate or discourage nurse migration. Whereas the agreement between the UK and the Philippines encourages migration (DoH 2007), the NHS banned list has potentially limited the numbers of nurses entering the UK workforce. The recruitment ban in combination with stricter immigration controls could potentially override other push and pull factors, as nurses can struggle to enter the destination country despite the strong presence of push and pull factors.

Another important factor overlooked by the push and pull model is the role of

‘networks’ (with the exception of some literature which places networks in the enabling factors category). Douglas Massey was one of the first sociologists to point out the importance of social networks in linking sending and destination countries (Massey 1987, 1998 cited in Hollifield 2000). Networks play a key role in structuring and moulding migration patterns (Arango 2000, Findlay 1992, Nash 1994 cited in Boyle et al 1998). They ease migration by providing help with work or other needs such as

housing, and acting as a basis for adaptation and community formation (Castles 2007). Networks also act as information conduits, for example passing on job market information (Tanner 2005, Boyle et al 1998). Their ability to rapidly exchange

information means that such networks can easily bypass official efforts to suppress migrant flows (Portes and De Wind 2007). In fact, networks are thought to stimulate further migration (Bach 2003, Tanner 2005) through a multiplier effect (Arango 2000), especially as entry into destination countries becomes more difficult. Yet, despite the increased recognition of the role of networks in assisting migration, some

commentators believe that their reach may be overestimated (Koser 2007).

Another limitation of the model is that it fails to consider that there is no single profile of a typical migrant (Lessinger 1995 cited in Brettell 2000), although researchers have attempted to categorise migrant groups. Kingma (2006) categorised different types of nurse migrants:

 Economic migrant: attracted by better standard of living;  Quality of life migrant: interested in safety and wellbeing;

 Career move migrant: motivated by enhanced career opportunities;  Partner migrant: following their partner;

 Adventure migrant: uses their nursing qualifications to finance travel to a destination country to gain new experiences.

Even within categories there may be individual differences. Research has shown that although nurses may have much in common, such as the low status of their

profession and dissatisfaction with salaries, their reasons for migration can vary. This variability can result from an individual’s context, such as family circumstances (Connell and Brown 2004), or from differences in the source country context

(Kangasiniemi et al 2007). Studies (including Allan and Larsen 2003, Aboderin 2007, Moran et al 2005) have shown that (typically white) nurses from high-income countries commonly cite a working holiday strategy or travel as reasons for migration, whereas nurses from low-income countries are often motivated more by financial and familial obligations, and by professional development. Economic conditions are an important push factor in nurse migration from sub-Saharan Africa, as nurses seek to improve their financial situations. Slow or stagnant economic growth and Structural Adjustment Programmes have been shown to encourage greater health worker migration

(Robinson 2007). This supports the earlier connection made between nurse migration and poor economic conditions in Malawi. Overall source country conditions, including economic conditions, are an important factor often overlooked in the push and pull

model. One study found that Zimbabwean nurses were migrating not only to improve their income but also because of the political and economic situation (Gaidzanwa 1999 cited in Oderth 2002). In addition, nurses may not wish to migrate, but circumstances give them little choice (Ogilvie et al 2007). This means that the circumstances can in some cases be more significant in the migration decision than other factors. The push and pull model does not allow us to measure the relative dominance of each factor.

2.10.3 Conclusion

When tracing patterns of nurse migration a number of factors including source country circumstances, individual circumstances, and enabling factors (such as admission policies) can affect migration trends. This suggests that the nurse migration is complex, and migration decisions may be influenced by multiple spheres of the migrant’s life (Alonso-Garbayo and Maben 2009). Despite criticisms of the push and pull model for being too simplistic and not taking into account additional factors, there are currently few alternative comprehensive and solid frameworks available to assess health worker migration (Mackintosh 2003). In addition, the push and pull model has important strengths, such as its ability to take into account the many source country and destination country influences. This may explain why it is commonly used in the nurse migration literature. It is difficult to capture the complexity of migration in a definition, and even more so in a model. Therefore, I shall build upon the push and pull model as a framework through which to present my own findings about the migration of Malawian nurses.