Migration of Healthcare Professionals: Exploring Self-Perception about Midwifery Professional Life and Continued Education ()
1. Introduction
Global migration of healthcare workers is one of the most studied issues in healthcare worldwide. Driven by the global shortage of health care workers, this move is considered a crisis in the human resources of the health sector [1] .
Albania is characterized by a very high level of migration, ranking it among the top countries in the world for the share (as a percentage of the current population) and intensity of international migration [2] .
In total, Albania has approximately 23,866 licensed nurses today. According to the data obtained from the Albanian Order of Nurses’, in year 2016, 67 health care professionals left country, and in 2017, 131 health care professionals migrate, and in 2018, 211 health care professionals left country, and in 2020, 614 health care professionals left country, and in 2021, 1073 health care professionals left the country. Approximately 9% of nurses have left Albania and this number is increasing constantly.
In the latest report published by the Civil Right Center, a non-profit organization, which refers to data gathered from the Nurses’ Order, only for 2020 and 2021, a total of 1687 nurses and midwiferies have requested the certificate of “good conduct” from the Nurses’ Order. This document is needed in order to apply to work as part of the health care system in other countries [3] .
The countries where the nurses and midwiferies graduated in Albania prefer to practice are Germany (mostly), England, USA, Canada, etc. Germany is the largest migration market for health workers. According to the Federal Government of Germany, 1.7 million people are employed in the nursing field and there are 40,000 vacancies in health care institutions [4] .
On the official website of the German Embassy in Tirana we see that: “Germany has a stable health care system; however, nursing professionals remain in demand and their contribution is more important than ever. Hospitals, nursing homes, and other health care facilities are always looking for nursing staff with various skills to meet the growing demand in the health care and nursing professions. This demand is expected to increase in the upcoming years.” [5]
The trend of emigration of health care workers seems to have affected not only Albania but the entire region. According to an article published on June 20, 2022, in Journalift, the number of immigrants varies from country to country; it is estimated that in 2020, 8724 healthcare workers left Kosovo and 23,854 people in total, left Albania [6] .
This trend is reflected not only in health but also in education. The opportunity created to work abroad is being used by the younger generations, being reflected in the increase in the number of applicants seeking to study in technical medical sciences, especially nursing and midwifery. Most of them mention the possibility of emigration that this profession allows as the reason for choosing this study program. Throughout the years, the admission quotas at Tirana University of Medicine have been increasing for the bachelor’s level of study, while strangely the requirements to continue the master’s program have been decreasing.
In order to control the growing emigration of health professionals, the Ministry of Health and Social Protection has increased salaries and incentives for health care professionals. The Minister of Health, during her speech at the opening of the Socialist Party Congress, affirmed that by the end of this governing mandate, the salaries of Doctors and Nurses will increase by up to 40% [7] .
According to a report published by European Training Foundation, Albanian migration continues and is likely to do so into the future [8] . The majority of member states of the World Health Organization report a shortage, misdistribution and misutilisation of nurses [9] . According to the WHO World Health Statistics 2022 report, many countries continued to face shortages of health staff in key workplaces and struggled to achieve a balance in the distribution of health care workers… [10] This climate has stimulated the emigration of health workers to developed countries [11] . According to the CGFNS Nurse Migration Report 2022: CGFNS received over 17,000 applications for 116 openings, a 44% increase from 2021 and a 109% increase from 2018 [12] . CGFNS International Inc. (CGFNS) is an immigration-neutral non-profit organization that helps foreign-educated health care professionals live and work in their chosen country by evaluating and validating their academic and professional credentials [13] .
According to predictions, nursing workforce shortages are an issue of international concern, with the gap between demand for services and limited supply of nurses widening. Countries impacted by nursing shortages have recruited internationally to fill vacancies, with many countries now dependent on international nurses to meet domestic shortages [14] . Migration is predicted to continue until developed countries address the underlying causes of nurse shortages and until developing countries address conditions that cause nurses to leave [15] .
In the studies was found that international nurses from low-income countries cited unfavorable working conditions and poor pay in their country of origin as motivations to migrate (Salami, 2018; Lin, 2014; Kishi et al., 2014), with motivations driven primarily by the need to improve social and economic conditions (Higginbottom, 2011). According to the Albania economy briefing: Albanian economy in 2022: the situation in Albania has been dire for the entire population, burdened by inflation, lack of income opportunities, low pay, and more, but most impacted of all are the low-income strata of society [16] .
According to a study conducted about the emigration of doctors in Romania, the factors that influence doctors’ decision to migrate are multiple; they can be grouped into five motivational pillars: economic context, demographic factors, remuneration policy, political instability, and working conditions [17] [18] [19] .
In general, health care professionals from developing countries migrate to countries with strong health systems and more opportunities for advancement [20] .
2. Objectives
The purpose of the study was to explore the opinions of Midwifery Students studying at Bachelor degree, regarding their professional future and continuing education.
In order to understand the approaches and wishes of midwifery students regarding the choice of study and continuing education, the following questions were raised:
1) What do students think about the chosen profession?
2) What are their professional expectations?
3) Nurse or midwife?
4) What are the reasons why students were not registered to continue their studies at the master’s level?
3. Methodology and Data Analysis
This is a cross-sectional study. In this study are included the students of the first cycle of study in the Midwifery branch for the academic year 2022-2023, Faculty of Medical Sciences at the University of Medicine.
We have distributed 145 questionnaires mainly with closed questions. The questionnaire is built based on the expertise of 10 experts. The validity was tested from a champion of 40 students. After the test the relevant changes were reflected in the questionnaire. The questionnaire was with self-administration. The sampling was done at random. The time of completion was October-November 2022.
The selection criteria of the students in the study were: to be a student of the first cycle of study in the Midwifery branch, students who are available and students who wish to participate in the study.
The exclusionary criteria of the students in the study were: being a student of other branches at Faculty of Medical Sciences, the student refuses to participate in study.
The data are calculated with the SPSS 15.00 program. Chi-Square test and Correlation were used for statistical analysis. It was considered statistically significant at a p value of ≤0.05 (5%).
The research proposal was approved by the ethics council. The students recruited in the study were informed about the study and its purpose, the preservation of anonymity and were assured that the collected data will be used for study purposes only.
4. Results
Results were presented based on a summary of demographic data and statistics found for each defined study objective.
The age of the participants in our study ranges from 17 years to 21 years. The average age is 18.94 years ± 0.922 years. The highest percentage is made up of 18-year-old individuals with 37.5% and the lowest percentage is made up of 17-year-old individuals with 0.7%. In terms of gender, 97% are female and 3% are male. Referring to the year of study that they are currently attending, 54.9% of the participants in our study are in the first year, 24.3% in the second year and 20.8% in the third year. Of these participants, 72% live at home with their parents and 28% in a dormitory.
What do students think about their preferred profession?
In response to the question related to career security as a midwife, the majority of them (38.2%) refer that on average the career in this profession is secure and always secure (14.6%), followed by often secure (30.6%), and a not so secure (14.6%) and not at all secure (2.1%). Our respondents in 50% of cases refer that the profession of midwife provides on average economic well-being, and 10.4% think that the profession always provides economic well-being, and that this profession often provides economic well-being (25%), 13.9% of them thinks a little, and 0.7% not at all. About 40% refer that the profession of midwife often belongs to a satisfactory social status, followed by 33.3% an average of, 19.4% always and 9% a little.
Only 15% of the participants in our study affirm that they chose the midwifery branch because one of their family members or a relative works as a midwife, and 85% say that this was not a deciding factor for them.
What are their professional expectations?
The students participating in our study in 62% of cases affirm that they chose the midwifery branch because they can immediately find a job. Regarding the choice of midwifery studies as it can provide you with a good career in the future, 84% affirm and 16% deny this finding. 80% of the respondents claim that they chose the midwifery branch because it can provide you with social-economic well-being. While 20% deny that they chose this branch for such a reason.
Nurse or midwife?
In response to the question, whether the profession of midwife was recommended to you or was it a personal choice, 24.3% refer that there was no recommendation at all, 23.6% said that is was mentioned to them but was not a major deciding factor, 18.1% said recommendation was the major deciding factor, 18% said that recommendations did not factor into their decision and 16% said that it was a factor in the overall decision.
Over 60% of the participants in our study report that they are not at all ready to transfer their studies to nursing. Our respondents in 54.9% of cases do not agree at all that being a nurse is better than being a midwife.
The students were asked if they started the midwife program with the intentions of switching to the nursing program later on in their studies, 70% said they did not plan on doing this while 30% said they did.
In a general perspective, in terms of expectations for choosing the profession of midwife, it turns out that students in over 60% of cases have chosen it themselves as a fild of study, without being pushed by a family member or relative who practices the same profession, and not because of the fact that creates opportunities for you to transfer to the nursing study. Compared to the nursing study program, the students participating in our study do not think that they would transfer to this study program and do not think that this study program is better than the midwifery study program.
What are the reasons that students were not registered to continue their studies at the master’s level?
The majority, 90%, affirm that they have chosen the midwifery branch because they can secure a job as a midwife in the countries of the European Union. While 10% reject this as a reason. In response to the question of whether it is worth working as a midwife in Albania, 34% refer that it is worth it on average, 33.3% it is worth it a little, followed by 13.9% often, 13.2% not at all and 5.6% always.
Asked where they would like to work as a midwife, and the three most desired countries are respectively: Germany 44.4%, England 18.8% and Italy 12.5% (Table 1).
In response to the question if, after completing the first level of study, they plan to continue pursuing master’s studies, 80% of students refer that they will not continue and only 20% refer that they will continue their master’s studies. Also, in over 50% of cases, they claim that they have chosen this field because they can immediately find a job, and it provides you with a good career in the future, and it offers you a social-economic well-being and the opportunity to find a job in a European Union country. The majority, 90%, affirm that they have chosen the midwifery field of study because they can secure a job as a midwife in the countries of the European Union. While 10% reject this as being a motivating factor.
Among the individuals who have referred that they will not continue their master’s studies in midwifery, the main reason they will not continue in 69.6% of cases is the desire to leave Albania, followed by starting a job 15.7%, this master’s degree is unaccredited/unrecognized 7.8%, master’s degree is expensive 5.2% and will change profession 1.7% (Table 2).
In a general look at the perception of the midwifery profession, it results that
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Table 1. Most desired countries to work in.
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Table 2. Distribution according to question 17/a.
students who follow the midwifery study program generally have a neutral opinion with a positive tendency about this profession. They consider it moderately easy to find work in this profession.
5. Discussion
This study provided new insights into the thoughts and perceptions of students studying at the Faculty of Technical Medical Sciences in Tirana, Albania. Given the reduced number of students who applied to study in the master’s degree, (this is unusual for the faculty) the purpose of the study was to explore the reasons and thoughts that led students to this decision. In a general look at the perception of the midwifery profession in the study, it turns out that students who follow the midwifery study program generally have a neutral opinion with a positive tendency about this profession. They partly admit that the choice was personal and also recommended.
They consider it moderately difficult to find a job in this profession. This profession can offer for them, on average, a secure career and economic well-being. Students are more optimistic about the satisfactory social and economic status that this profession can offer for them. However, they are more skeptical if it is worth it to work as a midwife in Albania. They admit that the choice was made freely and that they would recommend it as a profession to others. The majority do not consider transferring to the nursing program of study and choose to stick to their choice. But in the study it was discovered that most of them (90%), claim that they have chosen the midwifery study program, since they can secure a job as a midwife in the countries of the European Union.
Their decision about the continuing the study seems to come as a result of their dissatisfaction with the salaries, which according to the students do not provide them with enough income to afford living in Albania. Likewise, better working conditions hoped for in the chosen country are likely to increase their willingness to emigrate. Our findings also agree with previous studies, in which it has been reported that workplace dissatisfaction is seen as a factor that stimulates emigration [21] .
It seems that this phenomenon has also affected the region in general, because in a study conducted in Kosovo [22] [23] reported that dissatisfaction with wages and working conditions is strongly associated with migration preference among health workers [24] . Bidwell in this study reported that better working conditions are a decisive factor in keeping doctors in their countries of origin. In the study it was observed that students do not have good expectations regarding their employment in the country of origin and this is one of the reasons that students do not prefer to continue their studies in Albania.
In the study of the question asked where they would like to practice the profession of midwife, it was noticed that a high percentage of students were very clear about the place where they would like to emigrate. They preferred developed countries of the European Union. In the study it was observed that the three most desired countries are respectively: Germany, England, and Italy. The emigration of health care workers to these countries has been established for a long time and their employment offices have continual activities for outreach happening in Albania [25] .
In our study, it was observed that students affirmed that they wanted to continue their master’s studies (80%) in their preferred field. So the closure of the midwifery study program is not related to the current desire of students to pursue studies, but to immigration, security and accreditation of the diploma. As a result of the enrolment of a small number of students, the faculty chose to close the midwifery branch and merge the midwifery students with another program (nursing), deviating the professional future of students and bringing into question the future of the program. From the answers of the students, it was found that most of them have chosen willingly the midwifery program, because they can immediately find a job as midwife. They also think that emigrating to a European Union country will ensure a better career in the future and social-economic well-being.
Although midwives agreed to study nursing, they do not at all agree that being a nurse is better than being a midwife, and the majority of respondents (60%) in the study report that they are not at all ready, to transfer their studies to nursing. This explains that they had preferred midwifery, but the current conditions forced them to accept the option offered by the faculty.
The large number of respondents (62%), admitted that the choice coincided with the possibility of employment and also brought to light another fact that the expectations of students regarding this program were high when they started their studies, but they decreased during further years of study. This coincides with the fact that over the years they have had the opportunity to get to know the profession, and it has been possible to contact professionals in the field.
The trend of mass movement of health care workers is very sensitive in Albania as well. The mass exodus of health care workers, even though the number of graduates meets the country’s needs today, will affect the future.
The trend of mass movement of health care workers is very sensitive in Albania as well. The mass exodus of health care workers, even though the number of graduates meets the country’s needs today, will affect the future. Our study highlights that if government policies would pay more attention to the dignified treatment of health care workers, including increased wages and improved working conditions, mass emigration could be controlled without affecting quality and the country’s health care staffing needs.
Despite the desire of students to emigrate and the growing trend of nurses and midwives leaving Albania, a study has not yet been conducted regarding the professionals who left today with the desire to return later.
It seems that the government’s promise to increase the salaries of health workers has not had any effect on reducing the number of workers who want to leave the country.
6. Conclusions
As market demand for nurses around the globe escalates, the changes and consequences associated with nurse migration increasingly need policy solutions that reflect the needs and motivations of all actors.
Our study highlights that if government policies paid more attention to the dignified treatment of health care workers, including increased wages and improving working conditions, the mass exodus of workers could be controlled without affecting quality and the country’s health care staffing needs.
The reasons for emigration are not just a simple desire for more incomes, but health care workers require much more than that. Today, employee satisfaction includes not just better salaries but also the satisfaction of working in a place with suitable working conditions, opportunities for the future, accredited education and much more. Safety and security lead to further life issues accomplishment, and this is a clear desire among health care professionals in Albania.