the downward occupational mobility of internationally educated nurses to domestic workers

R e v i e w

The downward occupational mobilityof internationally educated nurses to

domestic workers

Bukola Salami and Sioban Nelson

University of Toronto, Toronto, ON, Canada

Accepted for publication 18 February 2013

DOI: 10.1111/nin.12029

SALAMI B and NELSON S. Nursing Inquiry 2014; 21: 153–161

The downward occupational mobility of internationally educated nurses to domestic workers

Despite the fact that there is unmet demand for nurses in health services around the world, some nurses migrate to destination

countries to work as domestic workers. According to the literature, these nurses experience contradictions in class mobility and

are at increased risk of exploitation and abuse. This article presents a critical discussion of the migration of nurses as domestic

workers using the concept of ‘global care chain’. Although several scholars have used the concept of global care chains to illus-

trate south to north migration of domestic workers and nurses, there is a paucity of literature on the migration of nurses to des-

tination countries as domestic workers. The migration of nurses to destination countries as domestic workers involves the

extraction of reproductive and skilled care labor without adequate compensatory mechanisms to such skilled nurses. Using the

case of the Canadian Live-in Caregiver Program, the study illustrates how the global movement of internationally educated

nurses as migrant domestic workers reinforces inequities that are structured along the power gradient of gender, class, race,

nationality, and ethnicity, especially within an era of global nursing shortage.

Key words: Canada, health human resources, home care, immigrant nurses, internationally educated nurses, live-in caregivers,

migration, Philippines.

The migration of nurses across the globe has been well docu-

mented in the literature (World Health Organization 2006;

Kawi and Xu 2009; Nichols and Campbell 2010) and is

fueled by the global nursing shortage (World Health Organi-

zation 2006; Nichols, Davis and Richardson 2010). While

there are no data on the global deficit of nurses, the World

Health Organization (2006) estimates that the global short-

age of healthcare professionals overall is 4.3 million. This

alarmingly high figure presents a conservative estimate as

the calculation only includes the 57 countries, which the

WHO declared to be experiencing a critical shortage of

healthcare professionals and does not factor in the shortage

of healthcare professionals in developed countries (O’Brien

and Gostin 2011).

With respect to developed countries, in the United

States, Buerhaus, Auerbach and Staiger (2009) predict that

there will be a shortage of 260,000 Registered Nurses by the

year 2025. However, the Institute of Medicine (2011) warns

that this is a conservative estimate as current United States

policy is highly likely to increase demand for nurses in the

future. In Canada, in the year 2007, there was an estimated

shortage of 11,000 full-time equivalent Registered Nurses

(Tomblin Murphy et al. 2009). Considering past trends in

population health needs of Canadians, the registered nurs-

ing shortage in Canada is projected to increase to 60,000 Full

Time Equivalent Registered Nurses by 2022.

Amidst the global shortage of nurses, ethical issues sur-

rounding migration of nurses have been the subject of much

discussion (International Council of Nurses 2007; Runnels,

Correspondence: Bukola Salami, RN, BScN, MN, PhD Candidate, Lawrence S.

Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite

130, Toronto, ON, Canada. E-mail: [email protected]

Nursing Inquiry 2014; 21(2): 153–161

© 2013 John Wiley & Sons Ltd

Labonte and Packer 2011). The International Council of

Nurses (2007) does explicitly acknowledge the right of

nurses to migrate; at the same time, it denounces practices

that mislead or exploit immigrant nurses. However, Pittman,

Folson, Bass and Leonhardy’s (2007) interviews with interna-

tionally educated nurses, especially those who work in nurs-

ing homes, exposed various forms of unethical practices.

These practices included imposing excessive demand to work

overtime, paying internationally educated nurses below the

wages of domestic workers, threatening deportation if nurses

do not comply with excessive demands, retaining immigra-

tion and travel documents, delaying payments, and requiring

excessive fees from those who breach their contract.

The deskilling of nurses through employment below

their skill and qualification levels has also been the subject of

much scholarly debate (Allan 2007; Henry 2007; O’Brien

2007). O’Brien’s (2007) interview of 40 internationally edu-

cated nurses in the United Kingdom National Health System

found that internationally educated nurses were often

deskilled and prevented from performing nursing skills,

which they were qualified to perform (such as initiating an

intravenous infusion and performing a phlebotomy). She

explained one of the reasons for this deskilling was that

internationally educated nurses tended to be recruited to

the bottom grades within nursing in the National Health

System. In Australia, Hawthorne (2001) found that interna-

tionally educated nurses were often segregated to areas of

nursing that were generally least desirable places of employ-

ment in nursing, such as nursing homes. However, even

though literature has commented on the deskilling of nurses

(for example, registered nurses working as lesser skilled

nurses) and the need to prevent a global skills waste, there

remains a paucity of literature on the migration of interna-

tionally educated nurses to work as domestic workers in

destination countries.

Although there are currently no data available on the

number of internationally educated nurses working as

domestic workers in destination countries, researchers have

suggested that there is an overrepresentation of trained

nurses in domestic work and lower skilled home-care work

(Bourgeault et al. 2010; Cuban 2010). Browne, Braun and

Arnsberger’s (2007) study of 173 Filipina residential long-

term care providers in Hawai’i found that 74% had com-

pleted education above the high school level. Of the 107

(88% of 121) women who had studied in health-care, 55 (or

46%) had studied nursing. Similarly, Bourgeault and collea-

gues’ (2010) survey of 75 migrant low-skilled migrant home-

care workers in Canada corroborates this downward occupa-

tional mobility of internationally educated nurses with the

finding that 44% of participants in their study were nurses

prior to migrating to Canada. Moreover, a survey by Kelly,

Astorga-Garcia and Esguerra (2009) found that 79% of those

doing domestic work in Canada have a baccalaureate degree.

The International Labour Organization (2011) estimates

that there are over 100 million domestic workers worldwide,

the majority of whom are immigrant women. There are vari-

ations across and within countries on what constitutes

‘domestic worker’ services (International Labour Organiza-

tion 2010). For instance, while Paraguay, France, South

Africa and British Columbia (Canada) specifically include

caregivers for the disabled in their definition of domestic

workers, this category of service provision is excluded in Swit-

zerland, Finland and Argentina. In line with the Interna-

tional Labour Organization’s (2011) definition, this study

defines domestic work as ‘work performed in and for a

household or households’ (4). A domestic worker is ‘any

person engaged in domestic work within an employment

relationship’ (4). This definition includes individuals who

provide diverse services in the home such as cooking, clean-

ing, childcare, food shopping and elder care.

The concept of global care chain has been used to theo-

rize domestic worker migration (Hochschild 2000) and

nurse migration (Yeates 2005). Extending her work on emo-

tional labor, Hochschild (2000) described global care chains

as personal links across the globe based on paid and unpaid

work of caring. Hochschild (2000) utilized research findings

on domestic worker migration from the Philippines to

describe how the recruitment of individuals to work as

domestic workers in destination countries involves an extrac-

tion of care work by the north from the south, creating a glo-

bal network of unequal exchange (Valiani 2012) in the

division of reproductive care (Hochschild 2000). Therefore,

global care chains link individuals across the globe along a

power gradient of gender, race, class and nationality (Fudge

2012). Even though scholars have described both domestic

worker and nurse migration using the concept of global care

chains, there is a paucity of literature that links these two

migration trends, that is, the migration of nurses to destina-

tion countries as domestic workers.

NURSE AND DOMESTIC WORKER

MIGRATION FROM THE PHILIPPINES

Migrant domestic care workers are increasingly in demand

as caregivers for older adults in several countries of the devel-

oped world, including the United States, Canada, the United

Kingdom and Ireland (Spencer et al. 2010). This demand is

largely driven by the aging population, the diminishing state

provision of care services, as well as the incorporation of

women into the labor force without policies in place to

B Salami and S Nelson

© 2013 John Wiley & Sons Ltd154

reconcile the demands of family life (such as childcare) and

work (International Labour Organization 2010; Spencer

et al. 2010). The Philippines remains the top source country

of migrant care workers (Spencer et al. 2010). In 2006,

according to the Philippines Overseas Employment Adminis-

tration (2009), 91,412 domestic workers (98.3% of whom

were women) and 13,525 professional nurses emigrated

from the Philippines.

The Philippines is a major source country of internation-

ally educated nurses. Filipino nurses are highly sought in the

global marketplace because they are often fluent in the Eng-

lish language and are educated in the North American sys-

tem of nursing. Also, the case of the Philippines is unique

among source nations of skilled nurses, as the government

of the Philippines actively encourages out-migration of

nurses. This formal policy of assisting emigration is due to

the fact that remittances represent 11.7% of the GDP (or

$21.3 billion) of the Philippines (World Bank 2011). A high

number of Filipino professionals in other countries equates

to a high amount of remittance, thus boosting the Philip-

pine economy.

As a result of this booming industry of preparing nurses

for export, private colleges have sprung up in the Philip-

pines over the last decade to train nurses for the global work-

force. In the year 1970, there were 40 nursing schools; by the

year 2003, there were 230 nursing schools; and by the year

2007, there were 460 nursing schools (Asis 2007; Lorenzo

et al. 2007). A further driver of migration is domestic unem-

ployment. In 2012, over 200,000 Registered Nurses in the

Philippines could not find work (McGeown 2012). Lorenzo

et al. (2007) also blamed the deliberate oversupply of nurses

in the Philippines, noting that the stock of nurses in the Phil-

ippines in 2007 was 332,206, the demand (both in the Philip-

pines and internationally) was 193,223, and the resulting

oversupply was 139,083. Of the 193,223 employed nurses,

29,467 (15.25%) were working locally or nationally, while

163,756 (or 84.75%) were working internationally.

Lorenzo et al. (2007) raise concerns over the 42% of

Philippine educated nurses who are not employed as nurses,

either in the Philippines or internationally. According to

Lorenzo et al. (2007), there are no data on what they are

doing outside the profession. One possible explanation

comes from the chairman of the board of conveners of the

Asia-Pacific Research Network, who explained that the

declining trend in the number of Filipino nurses registered

to practice is due primarily to the emigration of nurses either

to work as nurses in other countries or because some nurses

‘deskill to emigrate to more affluent countries as caregivers

or even domestic aides’ (Choo 2003, 1356). This hypothesis

corroborates research by Browne, Braun and Arnsberger

(2007) and Bourgeault and colleagues (2010) who found an

overrepresentation of nurses in domestic work and personal

care aide sectors. Next, we present this emigration pattern

using the case of the Canadian Live-in Caregiver Program.

DOWNWARD OCCUPATIONAL MOBILITY

AND CANADA’S LIVE-IN CAREGIVER

PROGRAM

Although there remains a paucity of literature on the migra-

tion of nurses as domestic workers, several researchers have

commented on the migration of nurses through the Cana-

dian Live-in Caregiver Program (Zaman 2006; Sochan and

Singh 2007; Kelly, Astorga-Garcia and Esguerra 2009). The

Live-in Caregiver Program allows qualified individuals to

migrate temporarily to Canada to provide care to children,

the elderly or the disabled, while living in the client’s home.

To qualify to migrate through the Live-in Caregiver Pro-

gram, live-in caregivers must have the equivalent of high

school education (12 years of education). In addition, appli-

cants must receive either six months full-time premigration

classroom training or have 12 months’ work experience in a

field or occupation in which they will be practising as live-in

caregivers (Citizenship and Immigration Canada 2011).

According to Citizenship and Immigration Canada (2011),

‘areas of study could be childhood education, geriatric care,

pediatric nursing or first aid’. After a period of 3,900 hours

of employment, which must be completed between a mini-

mum of 22 months and a maximum of four years, live-in

caregivers can apply for permanent residency. Thus, the

Live-in Caregiver Program represents a ‘two-step’ immigra-

tion pathway, as described by Hawthorne (2010), which

allows individuals to migrate to Canada as temporary workers

and subsequently achieve permanent residency after a per-

iod of work as a temporary migrant worker.

Research on workforce integration of internationally

educated nurses in Canada found that nurses who migrate

to Canada through the Live-in Caregiver Program face the

most significant risk to workforce integration (Baumann

et al. 2006; Sochan and Singh 2007). Baumann and collea-

gues (2006) completed semi-structured focus groups and

individual interviews with 39 internationally educated nurses

and 32 key informants in Ontario and found that immigra-

tion status posed a barrier for internationally educated

nurses migrating under the Live-in Caregiver Program, who

may not have the time to prepare for the licensing examina-

tion. These findings are consistent with a study by Sochan

and Singh (2007), who found that nurses who migrate

through the Live-in Caregiver Program face additional

Downward occupational mobility

© 2013 John Wiley & Sons Ltd 155

challenges with nursing workforce integration due to inabil-

ity to take refresher courses during the program. Moreover,

they experience deskilling as they are unable to maintain

their nursing skills while working as a live-in caregiver (So-

chan and Singh 2007).

In an interview of 26 nurses who migrated to British

Columbia (Canada) through the Live-in Caregiver Program,

the Philippine Women Centre of British Columbia (2000)

found that this group of nurses was motivated to migrate to

Canada as part of the Philippine government sponsored pro-

gram that supports emigration. The Philippine Women Cen-

tre of British Columbia (2000) found that there was lack of

awareness on the role of live-in caregivers in Canada among

nurses who migrated through this program. Similarly,

Cuban’s (2010) interview of 20 nurses in the United King-

dom who had migrated to that country as ‘carers’ found that

these nurses thought that being a ‘carer’ was a form of pri-

vate healthcare provider, similar to private home-care nurs-

ing rather than domestic work.

According to the Philippine Women Centre of British

Columbia (2000), once in Canada, the policy of the Live-in

Caregiver Program, particularly the mandatory two-year tem-

porary migrant Live-in Caregiver Program requirement, cre-

ated systemic barriers to becoming licensed to practice as a

nurse in British Columbia as it extended the time before

they were able to practice. Furthermore, this study found

that many caregivers had worked in other countries as

domestic workers before coming to Canada. This employ-

ment history further extended the time since active practice

and thus adversely affected their eligibility, as they were

unable to demonstrate the minimum hours of nursing prac-

tice over the previous five years. The Philippine Women

Centre study identified additional structural barriers to

credential recognition for these workers. These barriers

included high costs associated with the credentialing pro-

cess, lack of information to prepare for the examination, as

well as ‘systemic racism’. As a consequence, the Philippine

Women Centre argued that on migration to Canada, this

group of Filipina nurses typically become deskilled with lim-

ited employment prospects.

Pratt (1999) documented the plight of live-in caregivers,

some of whom were nurses, in their struggle to become

permanent residents in Canada. She interviewed 14 live-in

caregivers, 10 live-in caregiver agents and 52 families who

had advertised for nannies. Some of the caregivers noted

the restrictions in the Live-in Caregiver Program that

restrict their ability to become a nurse in Canada, including

the restriction on enrolling in educational programs during

the first two years. Over this two-year period, Pratt reported

that nurses who migrate as live-in caregivers begin to doubt

their competence and lose their skills and occupational

identity.

Similar to Pratt’s (1999) findings, Zaman’s (2006) inter-

views of 50 Filipina women (most of whom migrated

through the Live-in Caregiver Program and were nurses)

found that after some time working as a live-in caregiver,

many lose their self-esteem and confidence in becoming

Registered Nurses in Canada. Writing about the experience

and deskilling of Filipinas in Canada, Zaman (2006) stated

that ‘the Live-in Caregiver Program (LCP) perpetuates com-

modification of labor that ties a domestic worker to a private

home, free from the provincial government’s labor regula-

tions’ (81). This mandatory live-in requirement contributes

to the deskilling of nurses who migrate to Canada as live-in

caregivers.

Zaman (2006) also found that even though many nurses

migrating as live-in caregivers take care of the chronically ill

elderly, thus in effect utilizing their professional experience

and educational training, this educational training and expe-

rience is not recognized in the Canadian job market. These

nurses reported that often times when employers hiring live-

in caregivers for elder care realize that they are educated

nurses, employers increase the complexity of skills that these

workers perform in the home (Zaman 2006). Zaman argues

that the nurses’ professional skills were exploited to the

advantage of employers without financial or professional

gains for the women, effectively trapping nurses migrating as

live-in caregivers into low wages and long hours of unac-

knowledged skilled work.

Zaman’s findings are echoed in Tung’s (2000) study of

home-care workers in the United States. Tung (2000) noted

that while the cost of caring for an elderly person with tra-

cheostomy in the United States by a Filipino live-in caregiver

is $70 a day, if performed by a practical nurse, the cost would

have been $756 a day. Similarly, Constable (2007) found

individuals with training as medical technicians were hired

and paid as domestic workers in China with the additional

responsibility of conducting ultrasound examinations in the

employer’s medical office.

According to Zaman (2006), before migrating to Can-

ada, professionally qualified individuals assume that they will

receive credit for their professional experience and qualifica-

tions after completing the Live-in Caregiver Program. The

experience and qualifications in question include both those

gained in the Philippines as well as experiences in Canada.

According to Brigham and Bernardino (2003), live-in care-

givers continue to build their experience and skill set as they

receive informal learning in the workplace about the culture

of care in Canada, learn to build relationships, and also

improve their communication skills. With respect to formal



learning opportunities, Zaman (2006) found that while

some live-in caregivers went back to school for reskilling,

these nurses faced great financial barriers in completing the

registration process due to financial and time demands;

these pressures were compounded by the need to send

remittances back to the Philippines.

Eight years after she interviewed women in the Live-in

Caregiver Program (Pratt 1999), Pratt (2005) interviewed fif-

teen of the original participants. Most of those women, who

were former professionals from the Philippines, continued

to work as lower skilled home-care health workers and

housekeepers. Only one of the fifteen women interviewed

was able to return to her previous nursing profession in the

interim. Moreover, the live-in caregiver who was able to enter

the nursing workforce experienced great challenges includ-

ing the completion of a one year refresher course, while at

the same time, working in numerous unskilled roles such as

waitress, live-out nanny, cashier and cleaner (Pratt 2005).

Pratt (2005) finding on the long-term deskilling of inter-

nationally educated nurses who migrate to Canada through

the Live-in Caregiver Program corroborates Kelly, Astorga-

Garcia and Esguerra (2009) research finding that 66% of

live-in caregivers experience downward occupational mobil-

ity, even after the completion of the Live-in Caregiver Pro-

gram. These authors attributed this downward mobility

partly to the lengthy separation from professional work, due

to the mandatory two-year temporary migrant live-in care-

giver requirement. This downward mobility is further exacer-

bated by the fact that some live-in caregivers first migrate to

other countries, especially to Middle Eastern countries,

before migrating to Canada. This multicountry mobility is

also noted by Constable (2007) who found that many indi-

viduals she interviewed in the early 1990s in Hong Kong had

migrated to Canada or the United States to work as live-in

caregivers by the year 2005. This multicountry migration as

live-in caregivers or domestic workers increases the amount

of time of separation from nursing practice, further imped-

ing registration.

EXPERIENCE OF DOMESTIC WORKERS:

EXPLOITATION, SOCIAL EXCLUSION AND

ABUSE

In addition to the deskilling and barriers faced by nurses

who migrate to Canada through the Live-in Caregiver Pro-

gram, they also experience the exploitation and social exclu-

sion of noncitizenship. Stasiulis and Bakan’s (2005) study

exposes the financial exploitation of live-in caregivers in Can-

ada. For instance, when the minimum wage in Ontario was

$6.85 per hour, on average live-in caregivers from the Philip-

pines were paid an average of $4.73 per hour (Stasiulis and

Bakan 2005). Moreover, some domestic workers from the

Philippines were paid as low as $1.91 per hour. Note that

despite this low pay, there are still further deductions for

room and board. Financial exploitation creates challenges

for live-in caregivers who are struggling to integrate profes-

sionally in Canada and, at the same time, send remittances

home to their families.

Furthermore, Constable’s (2007) research on Filipina

domestics in Hong Kong and Pratt’s (1999) research on live-

in caregivers in Canada found this group of workers experi-

ence social exclusion. According to Pratt (1999), live-in care-

givers experience stigma both within the Filipino

community and in the general population. This stigma has

the potential to exclude live-in caregivers from valuable

social and employment networks. Moreover, Pratt (1997)

noted that the marginalization and social exclusion of live-in

caregivers begins before they migrate to Canada. In a study

that sought to examine racial stereotypes among agents who

placed nannies, Pratt (1997) interviewed 10 nanny recruit-

ment agents in British Columbia. She found agents often

socially constructed live-in caregivers from Europe as profes-

sionals, while live-in caregivers from the Philippines were

often socially constructed as uncivilized servants. For

instance, while Filipina live-in caregivers were instructed by

recruiters to include pictures of them cleaning in applica-

tions for employment, European nannies were never

instructed to include such pictures. Pratt argues such prac-

tices lead to the deprofessionalization of the live-in caregiver,

even before arriving in Canada.

Coupled with exploitation and social exclusion, domestic

workers are at risk of abuse by their employers. Constable

(2007) observed and was informed by participants in an eth-

nographic field work in China about the abuses and negative

experiences of domestic workers, particularly Filipinas and

Indonesians, including demands for eighteen hours of work

per day, being shouted at, burned with an iron by the

employer, made to sleep on the floor, starved or fed with

leftovers, forced to cut their hair, locked in their room, sexu-

ally abused, forced to do illegal work and physically abused.

She also found issues of racism in the recruitment of live-in

caregivers. In extreme cases, deaths have been reported. For

instance, Human Rights Watch (2008) noted that from Janu-

ary 2007 to August 2008, over 95 migrant domestic workers

died in Lebanon. Of these known cases, only 14 were due to

health or disease conditions, while 40 were due to suicide,

and 24 were caused by domestic workers falling from build-

ings, usually in an attempt to escape from their employers.

Tragically, an Indonesian domestic worker was beheaded in



Saudi Arabia after she was convicted of murdering her

employer (Telegraph 2011).

DISCUSSION: GLOBAL CARE CHAINS

The phenomenon underlying the experience and exploita-

tion of migrant care workers has been examined by Arlie

Hochschild (2000) who extended her idea of emotional

labor to the work of domestic workers in the home. Hochs-

child relates the idea of emotional labor to what she termed

‘global care chain’. An example of this chain may involve

someone (such as a live-in caregiver or domestic worker)

from a developing country caring for a child of a family in a

developed country. This domestic worker, consequently,

hires someone in her native country (such as the Philip-

pines) to care for the child she leaves behind. The domestic

worker in the developing country may have to rely on her

older daughter or mother to care for her own child. This

separation between mothers and children results in a further

displacement of feelings and emotions across the globe,

where a nanny’s love for her own child is displaced to

another child for whom she is paid to care. What exists here

is a series of chains that transfer the caring work from the

rich to the poor, a ‘care drain’ as Hochschild (2002) calls it,

brought about by ‘emotional imperialism’ under late capital-

ism. In coining the term emotional imperialism, Hochschild

argues that just as gold and physical resources were extracted

by the North from the South in the nineteenth century,

today the new gold is the love and care which are extracted

from the South for use in the North. Thus, structured by

gender, class, nationality and ethnicity, the global movement

of migrant workers reinforces inequities in the distribution

of care resources and reproductive labor (Yeates 2005).

The case of live-in caregiver migration from the Philip-

pines to Canada is exemplary of Hochschild’s (2000) con-

cept of the global care chain. For the Live-in Caregiver

Program, individuals (mostly women) leave their families

behind (usually in the Philippines) to care for children, the

elderly or the disabled in Canada. Even more significant is

the issue of emotional imperialism when one considers the

case of highly skilled nurses from the Philippines who

migrate to Canada to work as domestic workers. As Hochs-

child (2002) argues, individuals can work as teachers, nurses

or administrators for $176 per month in the Philippines, or

they can migrate to North America and perform less skilled,

but not less difficult work, as domestic workers, nannies or

live-in caregivers, earning around $1,400 a month.

Parrenas (2001) termed this increase in financial status

coupled with decrease in social status as the dislocation of

contradictory class mobility. This contradictory class mobility

is a result of the structural forces that shape globalization as

well as global capitalism. Global capitalism maintains and

organizes nations into unequal relations and unequal struc-

tural linkages between sending countries and receiving

countries (Sassen 1997; Parrenas 2001). For instance, multi-

national institutions maintain economic centers, in such

places in North America as New York, Los Angeles and Tor-

onto. The rise of these economic centers creates a need for

low wage labor to maintain the lifestyle of their professional

population. However, even though the demand is for low

wage labor and the work required to be performed is domes-

tic work, employers in developed countries often prefer to

hire highly skilled migrants to perform such work.

In this sense, individuals from developing countries with

high educational attainment migrate to developed countries,

increasing their income status while simultaneously decreas-

ing their social status. This contradiction leads to the deskil-

ling of immigrant women’s labor and relegation to low-value

sectors. As Sassen contends, in the global economy, devalor-

ized or low-value sectors are where immigrant women pre-

dominate, where ‘immigration and ethnicity are constituted

as otherness’ (1997, 21). Coupled with noncitizenship or par-

tial citizenship of domestic workers in most destination coun-

tries, global cities render immigrant women invisible, a form

of off-shore proletariat (Sassen 1997) and create a perma-

nent laboring class (Butler and Spivak 2007). Therefore, the

migration of highly skilled nurses as domestic workers accen-

tuates the interlocking ‘triple jeopardy’ of gender, race and

class in the lives of these immigrant women (Pessar 1999)

and mutually leads to power inequities (Hill Collins 2000).

Parrenas (1998) further argues that this downward occu-

pational mobility, along with the inability to provide emo-

tionally for the children left behind in the Philippines,

results in emotional assaults for domestic workers. The nega-

tive experience of these domestic workers resulting from

downward occupational mobility is then further aggravated

by the authority of employers and employers’ children

within the home. Furthermore, the increased risk of abuse

and exploitation is aggravated by spatial inequality, where

there is inequality between employers and domestic workers

in the control of space (Parrenas 2001), as live-in caregivers

are required to live in their employer’s home.

Carens (2008) argues that the devaluing of care work is

the major contributing factor to the issue of justice for live-in

caregivers. Similarly, Hochschild (2002) explains the devalu-

ing of female and caregiving work contributes to the need to

recruit migrants to do caregiving work. Global capitalism,

inequalities around the globe and the increasing participa-

tion of women in the workforce create a need to hire highly

skilled women in developing countries to work as domestic



workers in developed countries. With global inequities and

increasing reliance on third world women to provide care

work, there is a decline in the value given to care work as the

status of women who do it (i.e. immigrant women) is kept

low. Similar to Carens’ view, Hochschild (2002) argues that

one solution to solve the problem is to raise the pay for live-

in caregivers to a level that values care work, so that individu-

als who are engaged in the work of caring receive more value

and credit for doing it. In addition, Hochschild (2000) and

Folbre (2001) argue that the participation of men in caring

work needs to be increased.

IMPLICATIONS AND CONCLUSION

The migration of nurses as domestic workers results from

global capitalism and reinforces racial and gendered

inequalities as these nurses experience contradictions in

class mobility. While these caregivers increase their income

by migrating to Canada as live-in caregivers, they also

decrease their social status. Moreover, like other live-in care-

givers and domestic workers, they are at risk of abuse and

exploitation. Most of the negative experiences of this group

of nurses result from the policies of domestic worker pro-

grams. Hence, internationally, there is a need to re-examine

immigration policies and their effects on the social and eco-

nomic integration of nurses.

In Canada, several programs have been created that

would enhance the integration of these nurses. One such

recent change is a faster processing of open work permits for

live-in caregivers in Canada. An open work permit allows

live-in caregivers to work in any occupation and thus facili-

tates their integration in Canada. Furthermore, over the past

10 years, several bridging and upgrading programs have

been created in Canada to further integrate this group of

workers into the nursing profession. Moreover, several schol-

arships have been created to integrate internationally edu-

cated nurses into the workforce in Canada. Although these

programs are in the right direction, live-in caregivers con-

tinue to experience barriers in accessing the programs until

they become permanent residents in Canada.

Cuban (2010) and Tung (2000) found that similar levels

of deskilling of nurses exist in the United Kingdom and the

United States, through other immigration programs in these

countries. Therefore, it is important to consider the deskil-

ling of nurses as domestic workers within an era of global

nursing shortage. Moreover, as the case of nurse migration

through the Live-in Caregiver Program illustrates, contradic-

tions between immigration policies and nursing policies

have the potential to further marginalize internationally

educated nurses. One way to deal with this issue is to address

issues of global social economic inequities and the economic

stratifications. A vision in line with Hochschild’s (2002) view

is an improved socioeconomic life in sending countries. In

this case, nurses will not choose to leave their country of ori-

gin to work in destination countries as domestic workers.

However, global capitalism and inequities continue to spur

economic motivation for migration. Considering current

global socioeconomic realities, mechanisms should be cre-

ated in receiving countries to ensure the integration of inter-

nationally educated nurses into the workforce.

To tackle issues related to international nurse migration,

it is imperative that nursing policy-makers look beyond

health policies to consider the wider public policy influences

on the nursing workforce, locally, nationally and globally.

Such a review necessitates a careful consideration of the influ-

ence of health human resource policies on diverse streams of

migrants. There is also a need for national and international

nursing professional bodies to speak out against the recruit-

ment of internationally educated nurses as domestic workers

as well as to advocate for the maximum utilization of interna-

tionally educated nurses’ knowledge and skills.

Finally, although research has been conducted on the

deskilling of internationally educated nurses within the nurs-

ing profession (O’Brien 2007), there remains a paucity of

research globally on nurses working as unskilled caregivers.

More research is needed in this area to bring to light such

inequities and ensure health human resource and immigra-

tion policies give full consideration and credit to the skills of

internationally educated nurses. One way for the nursing pro-

fession to achieve this is to continue to bring to light the value

of care work, especially in home care, so as to ensure that

those who provide such work receive appropriate value for it.

ACKNOWLEDGEMENTS

Thisworkwas supportedby theSocial ScienceandHumanities

Research Council of Canada Doctoral Award, the Ontario

Graduate Scholarship, the Canadian Institute of Health

Research Ontario Training Centre in Health Service and Pol-

icyResearchFellowship,andseveral internalawardsat theLaw-

renceS.BloombergFacultyofNursing,UniversityofToronto.

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