Nurses are a vital part of New Zealand’s health system, but there aren’t enough trained here to meet demand. International recruitment helps fill the gap, but for many, Aotearoa is just one stop on a pathway to somewhere that pays better.
A red background and bold letters describe the migration route efficiently. “How to move from the UK to Australia as a nurse via the New Zealand route”. It’s a two-part YouTube video posted by a Filipino nurse who says in his profile that he’s based in the UK. He has thousands of subscribers. In the recommended videos list, there are dozens of others: a channel dedicated to nurses moving from New Zealand to Australia, a Hindi-language video with the hashtag #NewZealandPathwaytoBecomeANurseInAustralia, a video proclaiming a “2024 update” to How to be a Nurse in New Zealand – even though the channel is called “Move 2 Australia with Veronica”.
Facebook groups, some run by nursing influencers, are filled with nurses asking specific migration questions, and the nursing influencers have links in their bios to exclusive notes about how to migrate as a nurse and Discord chats for people to join. The production values on these videos are low, but they serve as brightly coloured, click-here demonstrations of a well-established phenomenon: there’s a clear pathway for internationally qualified nurses to come to New Zealand – but for many, staying here is not the ultimate goal.
A new report from Te Tāhū Hauora, the Health Quality and Safety Commission, backs up the explosion of nursing immigration content with hard numbers. New Zealand’s nursing workforce grew by 1,300 full-time equivalent nurses between March and September 2023 – enough to significantly reduce the nursing shortfall, with Te Whatu Ora saying the country now has 2,000 nurses above expectations. (Nurses, meanwhile, still describe “horrible” conditions on the job.) More than 36% of New Zealand’s nurses have trained overseas. That proportion means we are second only to Ireland in a ranking of OECD countries by percentage of foreign-trained nurses.
The report shows how internationally qualified nurses (IQNs) are used to make up for health workforce shortages – but nurses from other countries sometimes end up leaving New Zealand after they’ve qualified here. This has several direct consequences for New Zealand’s health system: first, that Māori and Pacific populations are notably under-represented in the nursing workforce, and secondly that the effort and expense of recruiting and registering nurses from other systems must be maintained because of the high outflow. More broadly, the system of importing nurses suggests chronic health inequities between richer and poorer countries, creates conditions for sometimes-exploitative recruiters to flourish and means that New Zealand’s health system is not self-sufficient.
“There’s an absence of data about outflows,” says James Buchan, an Edinburgh-based senior fellow at independent organisation The Health Foundation, who has had a long-term interest in health workforce trends. “In New Zealand, the volume of nurses coming in and leaving, compared to the number of nurses in the country as a whole, is relatively high.” In the UK, Buchan says there has been “insufficient” attention paid to nurses recruited from overseas who end up leaving.
When nurses register with a professional body, like the nursing councils in the UK or New Zealand, the system gathers data about where they’re from, where they’ve worked and trained, and what qualifications they hold. When nurses leave, the data gathered isn’t as systematic.
In the UK, a first step for a nurse thinking of leaving is applying for a Certificate of Current Professional Status, which allows them to work in other countries: of the 12,000 nurses who left the UK’s NHS in 2022-23, more than 80% were intending to work in New Zealand, Australia or the US. Nurses eligible to practise in New Zealand can also practise in Australia under a mutual partnership, but they need a “Verification of Good Standing” (VOGS) to do so. Data from the Australian Health Practitioner Regulation agency shows a steep rise in New Zealand nurses granted registration in Australia since 2021.
“A lot of people, if they get a good job in New Zealand, will stay here, but there are a percentage who move to Australia,” says Saju Cherian, a member of the New Zealand Nurses Organisation (NZNO) who works with IQNs. He says New Zealand is used as a pathway partially because of the structure of the exam nurses sit to qualify, where an individual is allowed to sit the exam multiple times, and if they pass the first section once, and the second section a separate time, these scores can be combined.
Cherian is from Kerala, a state in the south of India. While he studied after moving to New Zealand, he says that training as a nurse, usually at a private university in India, is a widely known pathway to move overseas. “Kerala is a nurse-producing machine – in each family there will be one or two nurses,” he says. He’s observed many nurses who he has worked with moving initially to the Middle East – Kuwait or the United Arab Emirates – or the UK, then applying to work in New Zealand, partially due to technicalities of which kinds of Indian nursing qualifications these countries accept. Data from the Nursing Council, presented in the Te Tāhū Hauora report, shows a growing number of new IQNs coming to New Zealand from India, with the number rapidly increasing since 2021.
Why is Australia the ultimate destination for some nurses? Simply put: money. OECD data, which Buchan describes as a “league table”, shows that in 2021, the US and Australia (as well as Belgium, Luxembourg and the Netherlands) were the countries where hospital nurses' earnings were highest, as measured in $USD and accounting for purchasing power parity. New Zealand was 14th down the list, and the UK was 22nd.
To Cherian the biggest risk of these enormous payment disparities is how individual nurses get caught up in exploitative recruitment scams. “People believe [the [recruitment] agency, the colourful pictures – you come here and it’s all good,” he says. International recruiters, who particularly target nurses working in the Middle East, promise that people coming to New Zealand on a visitor’s visa to take the Nursing Council assessments will instantly get a job. Instead, many end up stuck in limbo, paying for expensive accommodation, unable to work or get a job, as employers do not want to sponsor their work visas. Changes to the qualification requirements have left some experienced international nurses without work.
Cherian argues that treating international nurses well shouldn’t depend on the mercy of a good employer, but instead the power of expensive recruitment agencies could be reduced by a job search visa that can easily be transitioned to a work visa. He also recommends further regulation of the qualification providers and the recruiters, who can ask nurses to pay thousands of dollars without guaranteeing a job or a work visa. Finally, he’d like to see employers – especially non-hospital employers like aged care facilities – supported to provide better orientation and care for internationally qualified nurses. To him, there’s a clear link between supporting nurses and supporting the patients nurses care for.
The global view
Beyond the experiences of individual nurses, and even New Zealand’s need for well-supported nurses to provide essential care to our ageing population, there is the question of what impact migrating health workers have on the health of the world as a whole.
The WHO, which New Zealand is a member of, has a global code of practice on the international recruitment of health personnel, which is a voluntary code for states to use to ensure the strength of health systems, especially those in poorer countries. The organisation also has a list of 55 countries it has identified as vulnerable to losing health workers, where there is less healthcare available. This is a voluntary, technical solution to a pressing concern: are wealthy countries attracting health workers away from the places they’re needed most?
The list, known informally as the “red list”, includes several Pacific countries like Samoa, Tuvalu and Vanuatu, and much of Africa. “Since the pandemic, high-income countries have done much more active recruitment,” Buchan says. However, there is limited information about whether the voluntary code works as intended, as countries do not have to provide information about their recruitment to the WHO, and many don’t contribute to the biannual process of monitoring and reporting. Less than half of European countries responded to the last reporting round, for instance.
The NHS has a specific ethical recruitment standard, yet last year, more than 6,000 nurses registered in the UK from “red list” countries. Buchan says that many of the countries on the list, such as those in sub-Saharan Africa, use government-funded resources to train nurses and doctors, but some of those nurses then move overseas. Nurses sometimes also move to work as health assistants, meaning they’re not noticed in the data: for instance, nurses from Pacific countries take up aged care jobs in Australia, potentially leaving big gaps in those countries’ health systems.
Many nurses in India and the Philippines instead pay for training themselves, or with help from their family, rather than out of the public purse. Recruiting internationally “saves money for the [New Zealand] government”, says nurse advocate Cherian. “It’s all self-funded: families think ‘if I train my children as a nurse, it is definitely a pathway to financial flourishing.'”
The thousands of people making and watching YouTube videos and joining Facebook groups about how to move countries as a qualified nurse certainly seem to agree. One video, poignantly, is split into five sections: "Intro, Philippines to Australia, Cheaper Flights, Rich Country and Dream". It's hard to put it more succinctly than that.