FACTORS THAT MAY INFLUENCE SOUTH AFRICAN NURSES’ DECISIONS TO EMI- GRATE

Although no accurate statistics about the number of South African nurses working in other countries are available, the Organisation of Economic Cooperation and Development estimated that 35 000 South African nurses were working outside South Africa and/or outside the health care system (Horning, 2005:58). The global shortage of nurses, creating opportunities for South African nurses to work in foreign countries, as well as a variety of factors related to nursing, health care and the general living conditions in South Africa influence nurses’ decisions to emigrate. The purpose of this study was to explore and describe the factors that influence nurses’ decisions to emigrate. Maslow’s Hierarchy of Needs Theory was used as a point of departure to establish what motivates the behaviour of nurses to emigrate from South Africa. A quantitative approach was used. The target population comprised all the nurses (n=3 331) on the registers of the South African Nursing Council (SANC) who completed their basic training during 2002. A random sample of 15% (n=501) of the total population of nurses who completed their basic training during 2002 was selected. Data were collected by structured questionnaires. The analysis of the data indicated that nurses’ inadequate remuneration, poor working conditions, excessive workloads, lack of personal growth and career advancement possibilities and inability to meet their safety and security needs were major factors that influenced nurses’ decisions to emigrate. The recommendations include improved remuneration for nurses, enhanced working conditions with adequate supplies and equipment, reduced workloads by employing more nurses, expanded career prospects and improved safety.

Globalisation has fundamental implications for the mobility of people in general and skilled persons in particular.The migration of human capital (skills and labour) is one of the key features of the globalisation process.South Africa is part of the global network and therefore shares in the exchange of skills and labour.
The move from one country to another could be either temporary or permanent depending on the person's reason(s) for leaving (Iredale, 1999:90).
The emigration of skilled people is known as "brain drain".McDonald and Crush (2000:5) explain that the "brain drain" implies a depletion of skilled people who are vital to the functional core of a national economy.
Although definitions of skilled people vary, they all tend to focus on people who have received some sort of specialised training that results in superior technical competence.It is maintained that without these people the operation and development of the economy would be severely hindered.Furthermore, Brown, Kaplan and Meyer (2000:42) emphasise the fact that the brain drain, by definition, is not simply a question of absolute numbers, but that the skills profile of emigrants is also an important determinant of the impact on a country and its economy.Nurses leaving South Africa could be seen as contributing to the "brain drain".

THEORETICAL FOUNDATION OF THE STUDY
In this section the assumptions and the theoretical framework (Maslow's Hierarchy of Needs Theory) will be addressed.Burns and Grove (1997:48) define assumptions as statements that are taken for granted or are considered true, even though these statements have not been scientifically tested.This study was based on the assumptions that:

Assumptions
• newspaper reports of an exodus of South African nurses were true; • there were internal factors, related to nursing and health care in South Africa, and external factors, related to living in South Africa, that could influence nurses' decisions to emigrate; and • certain needs of South African nurses were not satisfied and those unsatisfied needs may motivate them to emigrate.

Theoretical framework
Maslow's Hierarchy of Needs Theory was used as a point of departure in this study to establish what motivates the behaviour of South African nurses to emigrate from South Africa.Hersey and Blanchard (1993:33) argue that this theory is concerned with an individual's needs and how satisfaction of needs, as well as deficits and unsatisfied needs, can change behaviour.These authors argue that the behaviour of individuals at a particular moment is usually determined by their strongest need.This Hierarchy of Needs Theory provides both a theory of human motives, by classifying basic human needs in a hierarchy, and a theory of human motivation relating these needs to general behaviour innate desires to satisfy a given set of needs, which are arranged in a hierarchy of importance, with the most basic needs at the bottom of the hierarchy.Maslow's Hierarchy of Needs is depicted on five levels; the three sets of needs at the lower levels are called deficiency needs because they must be satisfied for the individual to be fundamentally comfortable, while the top two sets of needs are termed growth needs because they focus on personal growth and development.According to Maslow (1987:15) the hierarchy into which human needs arrange themselves includes physiological, safety, belonging, esteem and self-actualisation needs.Hersey, Blanchard and Johnson (2001:37) explain that once physiological needs become gratified the safety needs become predominant, and only when these needs are fairly well satisfied will social needs emerge as dominant.After individuals have satisfied these needs to some extent, they feel the need for esteem; both self-esteem and recognition from others, and once esteem needs begin to be adequately satisfied, the self-actualisation needs become more dominant.
Human beings are motivated by unsatisfied needs, not by those that have been gratified (Moorhead & Griffin, 1995:78).Therefore nurses' unsatisfied needs could be seen as the push factors influencing the emigration of South African nurses.Gratification of needs in a foreign country could be seen as pull factors influencing the emigration of South African nurses.

External factors that influence skilled emigration
When individuals experience a deficiency in safety needs it may trigger their decision to leave the country in search of a safer homeland.South Africa experiences high levels of violent crime influencing emigration (Hamber, 2000:7-8;Rogerson & Rogerson, 2000:35;Van der Vyver & De Villiers, 2000:19;Van Rooyen, 2000:73) Nurses living and working in South Africa may become victims of crime and violence like any other citizen of this country, while on the other hand they have to care for victims of violence and crime.Thus nurses are exposed to the effects of violence and crime in their personal as well as their professional capacities.
The level of people's satisfaction with the quality of life influences their decisions to emigrate.According to Van Rooyen (2000:102) the perceptions of falling standards, mismanagement, incompetence and a growing decline in morality are issues which make South Africans desperate about their future.Distinct problems frequently cited by emigrants as a rationale for leaving the country concern the South African currency, the high personal income tax rate, as well as unemployment and affirmative action issues (Van Rooyen, 2000:99).Mattes and Richmond (2000:16) found that high levels of dissatisfaction with the cost of living and the standard of public and commercial services in South Africa, falling within physiological needs, influenced the emigration of South Africans.People who are concerned about the satisfaction of physiological and safety needs are too busy attempting to satisfy these needs to be concerned about higher-level needs (Schultz & Schultz, 1998:240).Such people might perceive emigration as a viable option to meet their physiological and safety needs in countries other than South Africa.This also applies to registered nurses who may be unable to meet their financial obligations with their South African salaries, and who then seek better remuneration packages in other countries.
If an individual's job is threatened, his or her need for security is in danger of being unsatisfied.Concerns about financial prospects and affirmative action relate to people's physiological, safety, esteem and selfactualisation needs.

Internal factors that may influence the emigration of nurses
The internal factors refer to factors in the nursing profession and health care that may influence nurses' global migration.A global shortage of nurses exists.Gray South African nurses are recruited to practise in Australia, New Zealand, the United Arab Emirates, Saudi Arabia, Ireland, the Netherlands, the UK and the USA (Buchan, 2002:18;Porter, 1998:35).The most serious shortages of nurses in these countries are in speciality care areas, particularly intensive care units (ICUs) and in operating rooms (ORs) (Buerhaus, Staiger & Auerbach, 2000:112).Brown et al. (2000:42) emphasise that the skills profile of emigrants, not merely their numbers, impact on a country's economy and its ability to

DEFINITIONS OF CONCEPTS
Emigration: Leaving one country to settle or to live in another country (Procter, 1995:450).In this study it refers to South African nurses leaving their country to practise in other countries.

External factors:
For the purpose of this study external factors refer to factors indirectly related to nursing and health care, such as political, economic or personal factors (Hersey & Blanchard 1993:20) that influence South African nurses' decisions to emigrate.

Internal factors:
For the purpose of this study internal factors are directly related to nursing and health care, influencing South African nurses' decisions to emigrate.
Needs: Needs are deficiencies that an individual experiences at a particular time (Ivancevich & Matteson, 1996:158).

The problem statement
Nurses constitute the largest professional group in South Africa's health care services and form the backbone of primary health care (PHC) in South Africa.Consequently, if large numbers of nurses emigrate from South Africa the entire health care service suffers.Adverse effects for the nursing profession include that the workloads of the decreased numbers of remaining professional nurses will increase, the quality of nursing care rendered will decline, the education and training of student nurses might be compromised, and larger numbers of enrolled and auxiliary nurses need to be employed.
Nursing shortages in first-world countries and the ability of these countries to offer attractive remuneration packages to nurses from South Africa, active recruitment by recruitment agencies and various economic,

RESEARCH OBJECTIVES
The objectives of the study were to:  the study.Random sampling implies that the sample has been selected in such a manner that "each member of the population has an equal probability of being included" (Polit & Hungler, 1999:653).According to Burns and Grove (1997:807) this 'equal probability' must be greater than zero.By using random sampling, im-plying that every person in the target population had an equal, non-zero, computer-calculated chance of being selected, no bias was introduced into the sampling process, enhancing the probability that the sample would be representative of the population enabling generalisations to be made from the sample to the population.

Validity and reliability
Before implementing the study the instrument was pretested to ensure that the measurement procedures and the measurement instrument had acceptable levels of reliability and validity.Five registered nurses were asked to complete the questionnaire and comment on the questions and instructions given on the questionnaire.
They did not form part of the research sample.The purpose of pre-testing the questionnaire was to ensure that respondents would understand the questions, and identify possible problems with the completion of the questionnaire.Minor problems related to wording in an instruction to the respondents and more space for comments at the end of the questionnaire were pointed out.
These revisions to the questionnaire were made.
The content validity of the questionnaire was determined by the literature review, the judgement of experienced research academics and a statistician (De Vos, Strydom, Fouche & Delport, 2002:167).Construct validity is more concerned with the underlying attribute than with the scores that the instrument produces.Its significance is in its linkage with theory and theoretical conceptualisation (Polit & Hungler, 1999:420).It involves validation of not only the instrument but also the theory underlying it (De Vos et al. 2002:168).Maslow's Hierarchy of Needs Theory, underlying the research, was linked to the items in the questionnaire.
The reliability of a measuring tool depends on the nature of the instrument but also on the aspects of stability, internal consistency and equivalence (Polit & Hungler, 1999:412).Research experts and a statistician assessed the instrument and the homogeneity of the variables before it was used.Reliability was further enhanced through conducting a pre-test.

Ethical considerations
Respondents were informed about the nature of the

RESULTS
Some of the respondents' biographic information will be supplied as these might influence some respondents' intentions to emigrate.

Biographic data
As

South African registered professional nurses' considerations to emigrate
As many as 81.0% of respondents indicated that they had considered temporary moves to some extent or a great deal, but were unable to predict the duration of their anticipated moves.Only 10.5% of the respondents indicated that they had given a great deal of consideration to moving permanently to foreign countries.
These responses indicated that respondents were more likely to consider moving to foreign countries to live and work there temporarily.Mattes and Richmond (2000:15)

Factors that might influence registered professional nurses to emigrate from South Africa
Following the major tenets of Maslow's Hierarchy of Needs Theory, factors that might influence registered professional nurses to emigrate from South Africa will be related to financial and general well-being (physiological, social and esteem needs); workload and working conditions (physiological and safety needs); personal growth, career advancement and achievement in nursing (esteem and self-actualisation needs) as well as safety and security needs.

Factors related to financial and general well-being (physiological, social and esteem needs)
A large majority of respondents indicated that they considered leaving for financial reasons."At the end of the day we will be sued by patients because we will be unable to provide effective care to them".

Workload and working conditions (physiological and safety needs)
The deleterious effects of poor staffing were documented in a report by the WHO (2003:2).Lowered staffing levels and high workloads increased the likelihood of needle-stick injuries to hospital nurses by 50%, while a higher death rate among patients was also associated

Personal growth, career advancement and achievement in nursing (esteem and selfactualisation needs)
Registered professional nurses who perceive possibilities of personal growth, career advancements and po-tential achievements within the nursing profession might be less likely to consider emigration than South African nurses without these perceptions.
The data depicted in The system really wants to strip us of all our pride…".

Safety and security (safety needs)
Reports (Geyer, 2004:36;Xaba & Philips, 2001:6) have confirmed that the safety of nurses in SA is compromised, while little is done to protect them from harm.
Table 4 indicates the extent to which specific safety and security issues might influence registered professional nurses to consider emigration from South Africa.
Issues related to safety, the lack of security, crime and violence were not the most important reasons why South African nurses were considering emigration (see Table 4).Only 42.4% respondents in this study indicated that high levels of crime and violence in SA would influence

RECOMMENDATIONS
In order to address some of the present study's limita-

CONCLUSIONS
The data obtained in this study indicate that the most important factors that may influence South African nurses' decisions to emigrate could be categorised into four major groups: • Nurses' inability to meet their financial and general well-being needs as the majority of the se Hiërargie van Behoeftes Teorie was die vertrekpunt om te bepaal wat die gedrag van verpleegkundiges motiveer om uit Suid-Afrika te emigreer.'n Kwantitatiewe benadering is gevolg.Die populasie vir hierdie studie was al die verpleegkundiges (n=3 331) op die registers van die Suid-Afrikaanse Raad op Verpleging (SARV) wat hulle basiese verpleegopleiding gedurende 2002 voltooi het.'n Ewekansige steekproef van 15% (n=501) van die totale populasie van verpleegkundiges, wat hulle basiese opleiding gedurende 2002 voltooi het, is gekies.'n Gestruktureerde vraelys is gebruik om data in te samel.Die analise van die data het aangedui dat ontoereikende salarisse van RESEARCH INTRODUCTION Although it is impossible to provide accurate statistics about the number of South African nurses working in other countries, the Organisation of Economic Cooperation and Development estimated that in 2005 as many as 35 000 South African nurses were working outside During 1974 the International Council of Nurses (ICN) expressed concern about the migration of nurses and in 1979, Mejia conducted a study, designed primarily by the World Health Organization (WHO), to determine the factors which influence the migration of health workers (Logan, 1980:119-121).Serious nursing shortages in many developed countries and the active recruitment of South African nurses to address the shortfall in these countries, have contributed to an exodus of South African nurses.However, the recruitment of South African nurses is only one factor that contributes to their emigration.Both internal factors (directly related to nursing and health care) and external factors (indirectly related to nursing and health care, such as political, economic or personal) may influence South African nurses' decisions to emi-grate.
(2001:3) pointed out that the United Kingdom (UK) was experiencing the worst nursing shortage the National Health System (NHS) had known while the National Institute of Nursing Research (NINR News, 2001:1) warns that the projected shortage of registered nurses threatens the health of the people and the survival of the profession in the United States of America (USA).
Africa's nursing shortage is the result of multiple factors which include inadequate salaries and limited career progression opportunities, alternative career opportunities, the lack of visible nursing leadership, the poor public image of nursing and a huge workload due to insufficient numbers of nurses.The shortage of nurses in developed countries and the recruitment of nurses to practise in these countries could be pull factors influencing the emigration of South African nurses.
In the context of this article, a registered professional nurse is a person who completed his/her basic nursing training and became registered with the SANC during 2002.South African nurse: A South African nurse is registered with the SANC and is legally authorised to practise nursing as set out by the Nursing Act (no 50 of 1978, as amended).
political and professional factors in South Africa may influence nurses' decisions to leave South Africa to work in other countries.The research question is stated as: what are the factors that influence South African registered professional nurses' decisions to emigrate?What recommendations could help to address this problem?

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identify and describe the internal and external factors that might contribute to the emigration of South African nurses; and • make recommendations for enabling larger numbers of South African nurses to continue working in South Africa (by addressing the in ternal and external factors that may contribute to their emigration potential).
A quantitative, descriptive survey research design was used to identify and describe the factors that may contribute to the emigration of South African registered professional nurses.The target population comprised all the nurses on the registers of the SANC (n=3 331) who completed their basic training during 2002.These included nurses completing basic degrees and diplomas at universities and basic diplomas at nursing colleges and nurses completing bridging courses enabling them to register at the SANC.Cost and time considerations necessitated using a sample of the registered professional nurses (who completed their basic nursing courses during 2002) on the register of SANC and not the entire population of 3 331 of these nurses.A computerised random sample of 15% (n=501) of the total population (n=3 331) of nurses who completed their basic nursing courses during 2002 was compiled by the SANC's statistician.Respondents' selection was solely based upon the selection criteria for inclusion in Data were collected by a structured questionnaire containing both open-ended questions, based on a literature review that required written responses, and closedended questions providing pre-determined options.A cover letter with a description of the purpose and the importance of the study was attached to each questionnaire comprising six sections containing mostly closed-ended questions: research and could decide whether or not to participate.The data provided by the respondents could help to identify and address factors that influence professional registered South African nurses' emigration.Respondents' selection was solely based upon the selection criteria for inclusion in the study.Anonymity and confidentiality were ensured by requesting respondents to refrain from writing their names or those of their employers on the questionnaires.As each respondent decided independently whether or not to complete the questionnaire, no foreseeable risk was involved, and respondents could withhold and/or withdraw their participation.A telephone number and an address were included in the cover letter thus ensuring accessibility of the researcher should any respondent wish to discuss anything and/or obtain a copy of the research report.Data analysisDuring April 2004, questionnaires were posted, with stamped addressed return envelopes, to 501 registered nurses who completed their basic training during 2002, and 105 (20,9%) completed questionnaires were returned to the researcher.Data capture was done by statistical analysts at the University of South Africa (UNISA) using the SPSS (version12) computer program.Frequencies distributions, portrayed in tables and graphs, summarise the data systematically.Descriptive statistics, including measures of central tendency (mean, median and mode), are used to describe specific characteristics of the data, indicating where the central values of the distribution lie and providing information about its spread and shape.Percentages and proportions are also used to describe the data.Percentages standardise the data, facilitating comparisons with data obtained in other studies' samples."A proportion is a numerical expression that compares onepart of the study unit to the whole and can be expressed as a fraction or in decimal numbers"(Katzenellenbogen,   Joubert & Abdool Karim, 1999:103).The responses to the open-ended question were analysed quantitatively by grouping and counting similar responses.However, verbatim statements were incorporated into the research report to reflect some of the respondents' comments in their own words.
argue that one of the firmest indicators of a person's emigration potential is whether the process of application for basic emigration documentation has been started.Only 12.5% respondents indicated that they had attended recruitment agencies' seminars while 34.4% (n=33) respondents had consulted recruitment agencies to obtain emigration information.Only 8.2% (n=8) respondents had requested verification of their qualifications from the SANC and had applied for work permits in other countries, while 2.0% (n=2) indicated that they had applied for permanent residency in other countries.As only 19.0% (n=20) of the respondents were not considering either temporary or permanent emigration, the implication is that 81.0% of the nurses who registered with the SANC during 2002, considered emigration within a year of completing their basic nursing training.Indeed, 68.0% of the respondents considered leaving South Africa within the foreseeable future, ranging from within six months to five years from the time of participating in this survey.One of the respondents commented, in response to an open-ended question: "Nursing has become a torment in SA.It is about time more or all of us leave this country".
with lowered staffing levels(WHO, 2003:2).The respondents in this study completed their basic nursing training during 2002.As many as 35.7% of the respondents reported inadequate support from more experienced nursing colleagues.Gowell and Boverie   (1992:18)  found that years of experience affected the stress levels of nurses.A supportive supervisor or senior colleague could reduce the stress experienced by nurses confronted by heavy workloads and adverse working conditions, whilst the opposite could also be true, as stated by two different respondents: "Poor nursing service managers are driving nurses abroad"."… no one takes us seriously … we are always threatened with dismissal".

A
low response rate was achieved despite the inclusion of self-addressed stamped envelopes and the sending out of reminders.The researcher attempted to raise the response rate by including a cover letter in which the objectives of the study were explained, including self-addressed stamped envelopes with each questionnaire and sending out reminders eight weeks after the initial despatch of the questionnaires.The sample comprised only nurses who registered with the SANC during 2002.This limits the generalisability of the research results as nurses who registered at other times might be influenced by similar and/or other factors to emigrate.Only Maslow's Hierarchy of Needs Theory was utilised to contextualise the study which might have limited the interpretation of the findings.Postal questionnaires were used to obtain data.Personal and/or focus group interviews with registered pro-fessional nurses might have yielded more in-depth information.

Figure 1 :
Figure 1: Factors contributing to the emigration of South African nurses contextualised within Maslow's Hierarchy of Needs

Table 1 : Factors that might contribute to registered professional nurses' considerations to emigrate: finan- cial and general well-being Table 2: Factors that might contribute to registered professional nurses' considerations to emigrate: Work- load and working conditions FACTOR %
Under-staffing and heavy workloads constitute intense stressors.The majority, 94.2% of the respondents who considered leaving South Africa, agreed that the stress resulting from inadequate staffing influenced these de-

Table 3 : Factors that might contribute to registered professional nurses' considerations to emigrate: Per- sonal growth, career advancement and achievement in nursing FACTOR %
periences concerning nurses' working conditions: "Poor working conditions with poor money income.Where I am working we don't have electricity, water, telephone…I have to use my own cell phone to meet clients' needs…Solution is to leave SA for greener pastures"."Nursing Equity and affirmative action is the primary cause for the shortage of nurses in my institution… posts … filled by people from designated groups who unfortunately leave the institution in groups every month to go abroad".

Table 4 : Factors that might contribute to registered professional nurses' considerations to emigrate: Safety and security
rica.Thus nurses may continue to be motivated to emigrate by physiological needs as long as nurses' salaries in South Africa continue to be unsatisfactory.