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Abstract
Background There has been a notable rise in the number of African nurses and midwives migrating to high-income countries despite varying policies and restrictions to promote retention. The need to comprehensively evaluate existing policies addressing the exodus is crucial to future policy formulation and steps in addressing drivers of nurses and midwives brain drain in Africa.
Aim To explore the existence of migration policies that address the drivers of nurse and midwives’ migration outside Africa and determine the characteristics and implementation of these policies.
Methods The review would be guided by the JBI methodology for systematic reviews of text and non-research evidence. Databases including CINAHL, PubMed, Academic Search Complete via Ebscohost and ISI Web of Science will be searched using a PICOS selection criteria framework. Grey literature would be gathered from Google Scholar, government and organisational websites. Two independent reviewers would be involved in searching, study selection, data extraction and data analysis. A third reviewer would provide an arbitrary judgement during conflicts when disagreements persist after discussion. A meta-synthesis would be used to identify and report emerging themes in the literature.
Ethics and dissemination The study does not require ethical approval. The findings would be published in peer-review journals and presented at research conferences.
PROSPERO registration number CRD42023395013.
- Nursing Care
- Health policy
- Health Equity
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study would shed a comprehensive light on the existing policies that target the drivers of nurses’ and midwives’ migration in Africa. This is relevant in informing future policies that promote retention.
The review is conducted following the Systematic Reviews of Text and Opinion guidelines by the Joanna Briggs Institute (JBI) and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). The methodology is rigorous and meets the standards of the PRISMA guidelines.
The study uses a comprehensive search strategy to identify relevant sources from electronic databases and grey literature sources. There may be limited access to unpublished policy documents which could provide additional insights and perspectives.
Background
Nursing migration from low-income and middle-income countries (LMICs) in Africa to more developed nations has become an increasingly ubiquitous phenomenon.1 According to the Organisation for Economic Co-operation and Development (OECD),2 LMICs, especially Ghana, Nigeria, Kenya and Zimbabwe, have become relatively prominent contributors of foreign-trained nurses to OECD countries, which are mostly high-income countries.
The migration of healthcare professionals, particularly nurses, from Africa to developed countries is a significant issue that has far-reaching consequences for both the sending and receiving countries. As it stands, the global distribution of nurses is highly unequal, with Africa having the highest shortage and the worst ratio of nurses to patients.3 This imbalance is further exacerbated by the migration of African nurses to more developed countries, which results in domestic shortages of nurses and worsens the nurse–patient ratio.4 Although the migration of African nurses mostly favours the receiving countries, there are certainly ethical implications and the issue of offsetting the standards of practice in these countries.5
There are a myriad of factors influencing the increasing exodus of nurses outside Africa. In a recent systematic review, Toyin-Thomas et al6 revealed that macro-level factors such as remuneration and security issues, and meso-level drivers such as working environment and job satisfactions were major contributors to healthcare worker migration in LMICs. Other studies also reported that these factors are multifaceted and stems from financial, professional, social, political and personal contributors.7 8 Nair and Webster9 stipulated that pull factors including growing demand in receiving countries which are mostly high-income nations, attractive wages and even readiness of receiving countries to contribute financial support to the countries of these migrant workers are all significant contributors of health worker migration.
Over the years, African nations and global institutions have been establishing policies and restrictions to regulate the influx of African nurses to developed nations. Of such policies is the notable WHO ‘red list’ which bans active recruitment of nurses and other healthcare professionals from 47 countries with most pressing healthcare workforce challenges. About 70% of the listed nations are countries from the African region.10 As indicated earlier, different policies are being instituted at national level. Examples include Namibia incentives (subsidised cars and home ownership) for nursing students and registered nurses, bonding methods by countries like Ghana, South Africa, Zimbabwe and Lesotho, which require nurse graduates to repay their training cost to their governments before they can migrate.11
However, it appears that these measures have not been entirely effective in mitigating the nurses’ and midwives’ exodus in droves. Between 2021 and 2022, countries such as Ghana, Nigeria and Nepal, which are all on the WHO ban list, contributed 19% of nurses and midwives recruited to the UK.12 Additionally, governments of Ghana and Kenya are partnering with the UK and other countries in the form of memorandums that support nursing recruitments.13 Although these memorandums provide financial benefits to the sending countries, perhaps they are informed by the relentless determination of nurses and midwives to migrate regardless of how disincentive the process has become.
It is apparent that evaluation of these policies is crucially needed, however, there is notably a lack of systematic review data on the characteristics and effectiveness of these policies especially in African nations. The current systematic review aims to explore the existence of migration policies that address the drivers of nurse and midwives’ migration outside Africa and to determine the characteristics of these policies and their implementation strategies. This review is significant in guiding the development and implementation of robust strategies and policies needed for addressing nurses’ and midwives’ migration in the region, and mitigating the looming crisis this exodus could exert on healthcare systems in the continent. The review would be guided by the following questions (1) what push or pull factors are these policies addressing? (2) what strategies are provided by these policies? (3) what are the barriers and or facilitators of these policies? (4) what are the indicators of effectiveness of these policies?
Objective
The objective of this systematic review is to explore the existing migration policies that address the drivers of nurse and midwife migration from African countries to more developed nations. The study aims to determine the characteristics and implementation of these policies and their effectiveness in mitigating the exodus of healthcare professionals, providing valuable insights for developing robust strategies to address the issue and its potential impact on healthcare systems in Africa.
Method
The systematic review would be conducted in accordance with the Joana Briggs Institute (JBI) methodology for systematic reviews of text and non-research evidence.14 The reporting of the protocol was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).15
Patient and public involvement
This research was conducted without patient and public involvement. The review questions and objectives were determined solely by the research team, with no input from patients or public perspectives.
Search strategy
Two researchers will independently conduct a comprehensive search of electronic databases using a four-step search strategy. An initial limited search would be conducted on PubMed. Initial Boolean logic nurs* OR “nurse clinician*” OR “nurse practioner” OR midwife OR midwives OR “nurse-midwife” OR “nurse midwife” AND migrate OR “migration” OR “emigration” OR “immigration” OR “emigrate” AND “policy” OR “action plan” OR “retention strateg*” OR regulat*) will be used. The authors would review the text words and index terms contained in the title and abstracts of output articles. A second search would be conducted using all the identified text words and index terms on PubMed, CINAHL via EbscoHost, Academic Search Complete Via Ebscohost and ISI Web of Science. A grey literature search for government policy documents and reports will be undertaken by searching Google Scholar, organisational websites such as that of the WHO, ECOWAS, AU, Ministries and Departments of Health of individual countries, AFROLIB (WHO Regional Office Database for Africa). Finally, a handsearch of reference lists of identified documents and studies will be carried out to retrieve additional studies and documents that did not emerge during the electronic database search.
Selection criteria
Population
The population of interest is registered nurses and registered midwives. There is a variability in how these nurses and midwives are titled in their various countries. The review would consider including these professionals if they hold appropriate entitlement to practice in the capacity of a nurse or midwives as recognised by the main regulatory bodies of their countries.
Issues
The issues are rooted in nurse and midwife migration out of Africa due to varying factors. There will be a key focus on the role of policies in addressing these factors including poor remuneration, security issues, poor working environments and opportunities for career growth.
Context
The context is focused on establishing policy imperatives mitigating increased migration tendencies of African nurses and midwives. This includes mostly national and regional positions on nurses and midwives’ migration as far as policy is concerned. Policy changes and trends are also of significance to the current study.
Outcomes
The outcomes of interest include the push and pull factors that the various policies are targeting, retention strategies proposed by the policies, barriers and facilitators of implementing the said policies and their markers for effectiveness.
Types of sources
The review will consider government reports, policy documents and strategy documents that relate to nurses and midwife migration outside Africa. Additionally, opinion papers, discussion papers and other reports examining policy formulation and addressing the topic under focus would be considered. If available, primary studies that describe the implementation of these policies and perspectives of various subjects (especially nurses and midwives) would be included in the review.
Selection method
All records identified would be Rayyan (https://rayyan.ai/)—a web app for article screening and filtering.16 Records would be screened for duplicate studies and all duplicates would be deleted using Rayyan. Four pairs of independent reviewers (MBO and SF, DDB and CFA, DO and DNA-M, SKB and JKEA) would screen 25% of the total number of titles, abstracts and executive summaries of documents and studies identified to ascertain their suitability for analysis based on the eligibility criteria. We would then obtain the full text articles and documents of potentially relevant studies for further screening (see figure 1). All conflicts associated with selection of study and text would be resolved through discussions and if these issues persist, an arbitrary decision would be made by SKJO.
PRISMA flow diagram for systematic review. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses. *database or search source**
Quality assessment
Original studies would be appraised by JBI’s critical appraisal tools for cross-sectional studies and qualitative research (online supplemental appendices 1 and 2).17 18 Textual (reports and documents) and opinion pieces would be assessed for authenticity using the JBI Narrative, Opinion and Text Assessment and Review Instrument (see online supplemental appendix 3).18 The appraisal would be carried out by two independent reviews (SKJO and BDAA). Any disagreements that arise between these two reviewers would be resolved with the involvement of a third reviewer (MBO).
Supplemental material
Supplemental material
Supplemental material
Data extraction
Data will be extracted by two or more reviewers using standardised data extraction tools from JBI: JBI-NOTARI, JBI-QARI and JBI Data Extraction form for Observational studies (see online supplemental appendices 4-6). The extracted data will include information of the population, policy issues, context, study design and key findings that are relevant to answering the review questions.
Supplemental material
Supplemental material
Supplemental material
Data analysis and synthesis
The extracted conclusions, if possible, would be pooled using meta-synthesis approach and thematic analysis. The analysis would be guided by Braun and Clarke19 six phases of thematic analysis (figure 2). Two independent authors would familiarise themselves with details of the policies from respective studies and documents by repeated reading and then an active reading of the extracted data on these policies. Initial open codes would be produced from the data after familiarisation managed using Microsoft Excel 2016. Codes would then be compared and organised into subcategories and broader themes to identify patterns and common policy characteristics. Themes may further under revision and refine (broken down or collapsed into each other. The emerged themes would be discussed by the entire team until a final consensus is reached. If pooling by meta-synthesis is not possible, a narrative synthesis of conclusions would be presented.
Thematic analysis: Braun and Clarke six interactive phases.
Ethics and dissemination
Ethical approval is not applicable to this study as data would be gathered from already published studies and documents. The current protocol has been reported by PRISMA-Protocol guidelines for transparency and completeness (see online supplemental appendix 7). We intend to disseminate the findings through peer-reviewed journals and conference presentations. Protocol amendments would be conducted in the registry (PROSPERO) should there be any.
Supplemental material
Discussion
As the exodus of African nurses and midwives from the continent continues to escalate, there is the crucial need to develop and implement effective policies and retention strategies.8 The increasing migration of healthcare professionals poses significant challenges to the healthcare systems in Africa.
In this protocol, we have outlined the background information and design of a systematic review and meta-synthesis of exploring policies targeting the migration of African nurses and midwives. The review is projected to unnerve the characteristics of these policies and their strategies to resolve contributing factors to the imploded exodus. The results are intended to inform arising global, national and facility policies to improve the retention of nurses and midwives in Africa. The study findings would be reported in concordance with the guidelines from PRISMA statement.
One limitation of this research study is the absence of involvement from a health science or medical librarian in constructing the search strategy. While the expertise of librarians in information retrieval and systematic literature searches is widely recognised, we were unable to collaborate with a librarian due to resource and time constraints.
As a result, the design of our search strategy may not have fully optimised the identification of all relevant literature pertaining to our research objectives. Although we made efforts to adhere to existing guidelines and best practices for systematic literature reviews, the absence of a librarian’s input could potentially lead to the omission of some pertinent studies or introduce bias in the selection process
Conclusion
Our research protocol aims to systematically review and meta-synthesise policies that mitigate the determinants of African nurses’ and midwives’ migration. Despite varying policies and restrictions, there has been a significant rise in migration to high-income countries. This phenomenon highlights the urgent need to understand the underlying factors and challenges in promoting retention. By comprehensively examining the existing literature, we hope to identify limitations, gaps and effective strategies to address this critical issue. Our findings will contribute to evidence-based policy-making and support efforts to improve healthcare workforce retention in Africa.
Ethics statements
Patient consent for publication
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
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Contributors SKJO was responsible for formulating the idea of the study. SKJO, MBO, DO, SF and DNA-M were responsible for literature review, and identifying research gaps. SKJO was responsible for the study design. SKB, JKEA, BDAA, DDB, SKJO, MBO, DO, SF, DNA-M and CFA would review evidence and are responsible for report writing.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.