Does the mutual recognition agreement on nursing services accelerate nurse migration in member countries of the Association of Southeast Asian Nations?

Abstract Aim To clarify the situations of nursing education and activity, its affecting factors and the nursing educators’ views on nurse migration relating Mutual Recognition Agreement on Nursing Services in the Association of Southeast Asian Nations. Design: Descriptive qualitative research. Methods The individual semi‐structured interviews with 11 nursing educators, analysed using thematic analysis. Results Nursing educators acknowledged that the change in nursing was mainly due to the creation and amendment of laws, acts and regulations regarding nursing and improvements in nursing education systems. Some of these improvements occurred by this mutual agreement. The conceptualization of the progress indicated an improvement in the quality of nursing. Nurse migration to the outside of Southeast Asian countries might be accelerated due to concurrent improvements in the quality of nursing. New trends among nurses working as caregivers in surrounding countries such as China, South Korea and Japan to deal with demographic ageing should be considered.


| INTRODUC TI ON
Nurse migration began in the early 1940s. It became widespread during the 1990s when nurse shortages became a major issue due to rapid ageing worldwide and the ageing of nurses. Nurses migrated mainly from developing countries to developed countries for better wages (Chen et al., 2004). It has been pointed out that, in the 1990s, a widening gap in health care between source and destination countries (Stilwell et al., 2003) and unprofitable investments in nursing education due to the loss of strong visionary leaders in source countries (Buchan, 2001) arose as some negative aspects of nurse migration. Later, securing improvements in pay, working conditions, scheduling, career prospects and the security and prestige of nurses in their own countries were suggested (Buchan & Sochalski, 2004).
Additionally, the following steps were proposed: encouraging and facilitating bilateral or multilateral flow management of nurses between countries and facilitating compensation flows from the recruiting country to the home country, the flow of remittances from nurses, educational support as part of a donor package, or the return flow of better-trained staff (Buchan & Sochalski, 2004). Developed countries are still the main destinations for such nurses (Organisation for Economic Co-operation & Development, 2018). The international rules for recruiting health professionals have been instated (World Health Organization, 2010). Therefore, nurse migration has developed within regional frameworks including the European Union (EU) and The Eastern Asia and Pacific region is estimated to have the severest health worker shortage (Liu, Goryakin, Maeda, Bruckner, & Scheffler, 2017), mostly due to ageing. Japan, South Korea and China are experiencing extremely low birth rates and becoming super-ageing societies (United Nations, 2019). This explains the rising healthcare needs among the neighbours of the ASEAN countries. Obtaining a job as a care worker in Japan is mainly based on two requirements. The first is adequate knowledge and skill in both the Japanese language and how to be a care worker in general. The second involves obtaining a certification as a care worker, by passing the national examination in Japanese to obtain permanent employment in Japan. Therefore, acquisition of basic nursing education is an advantage for foreigners desiring a care worker job in Japan. It could also be an incentive to migrate to Japan. Moreover, schools for care workers have not yet been established in most ASEAN countries.
The number of certified care worker candidates accepted by JEPA increased dramatically as compared with the acceptance of nurses.
In 2018, the number of nurse candidates was 97 and caregivers was 773, as compared with 112 for nurses and 109 for caregivers in 2013 (Japan International Corporation of Welfare Services, 2019). This is because the certified care worker candidates include graduates from nursing school in the home country. It has already been pointed out that well-skilled Indonesian nurses are being "drained" to Japan as nurse aides or caregivers (Efendi, Chen, Nursalam, Indarwati, & Ulfiana, 2016;Kurniati, Chen, Efendi, & Ogawa, 2017). Its potential impacts should not be denied. This study focused on nurse migration, although the broader framework of health workforce including care workers should be considered.
The purpose of the study was to clarify the actual situations of nursing education and activity, the affecting factors in ASEAN countries and the ASEAN nursing educators' views on nurse migration to verify whether AMoNS accelerated nurse migration among the ASEAN countries.

| ME THODS
We conducted a qualitative study based on individual semi-structured interviews with 11 nursing educators from the ASEAN countries from March to October 2017 (see Table 2).
The participants were students of a graduate course in Thailand with nursing work experience and basic nursing education from their own countries. We targeted the ASEAN nurses from the supposed source countries. The largest number of migrants in Thailand came from the ASEAN countries. Thailand was a leader in nursing education not only in the ASEAN region but also around the world, and the Thai government had accepted international students from the ASEAN countries, especially Cambodia, Lao PDR and Myanmar.
Indonesia and the Philippines also concluded the JEPA. Moreover, we supposed that nurses studying in the graduate course would take We used content analysis (Krippendorff, 2004)

| RE SULTS
Data from the interviews were categorized into five themes: "Laws, Acts and Regulations"; "Nursing education system"; "Quality of nursing in clinical settings"; "Effect of ASEAN Mutual recognition on Nursing Services"; and "Factors affecting nurse migration." The themes and represented codes extracted are shown in Table 3.
The nursing educators who were interviewed recognized that situational changes in nursing in recent decades had resulted mainly from amendments to nursing laws, acts and regulations and also from improvements in the nursing education system.
This finding corresponded to the facts gathered from the document review, which assured that implementation had taken place.
However, they were sceptical about the improvement in the quality of nursing in clinical settings. They believed that the effect of AMoNS had generated some improvements. Although AMoNS stimulated the intention to study or work abroad, other factors also affected nurse migration.
This section contains excerpts from the interview transcripts modified to improve grammar. Excerpts are integrated into paragraphs below for matters of flow and are indicated with italics.

| Laws, acts and regulations
Relevant laws existed in each country and had been amended to fit

| Nursing education system
All of the participants recognized the importance of upgrading basic nursing education: In the 1990s, our nurses were almost at secondary level… from 2000 until now, our government upgraded nursing schools to colleges and universities [and] recently, the Ministry of Health has made a new regulation to stop recruiting the nurses who were educated within the two-year curriculum system by 2021.
(Vietnam) Participants also recognized that the curriculum had been improved to cultivate professionalism, such as nursing leadership and management, ethics and legal concepts and nursing competency. A course for nurse specialists was started:

TA B L E 3 Themes and contents extracted
We must teach ethics even in diploma curriculums.
We discuss the different concepts at the hospital in the leadership and management course…as students could assume managerial roles when they become nurses in clinical settings. New teaching methods were introduced. The equipment and materials for teaching were also changed: The active participation of students in lecturers and group discussion has improved and is encouraged… audiovisuals or teaching aids in the skills lab are adequately provided [so that] students can learn with visual data or other simulated materials.
They implement new teaching methods such as case studies, more interactions and critical thinking.
Every university has an online system; universities are creating new websites to provide information. (Indonesia).
Nursing educators perceived the necessity of further improving nursing education:

| The quality of nursing in clinical settings
The quality of nursing activity seemed to improve, but nursing educators felt that the next step required more consideration. They implied that improvements in nursing quality in clinical settings proceeded at a slower pace than in nursing education: The quality of nursing is changing and creating a good impact…being a nurse professional, it is necessary to continue learning.

(Lao PDR)
We are struggling for autonomy, but it is much better than before. Other professionals also appreciate the importance of nursing, care techniques, collaboration skills and management. (Myanmar) Before, we only were functionally a team. Now, we have become able to work as a team.
We have to know our responsibility and our own as well as the patients' rights under law,…but nurses don't want to know them, though they face many troubles due to their lack of awareness. (Indonesia)

| The effect of ASEAN mutual recognition on nursing services (AMoNS)
Nursing educators believed that nursing education had improved due to AMoNS: The university has to accredit nursing educators to meet the ASEAN standards [and] try to produce higher level nurses who meet those criteria. Every year, we sit together with nurse leaders from different countries…so I know that they know the situation in Cambodia very well. (Cambodia) From this MRA, our government recognized the position of nurses in the healthcare system and put in more efforts to send nurses to study abroad or to invite international organizations. I think this is a very good chance or a trigger to improve nursing.

(Vietnam)
Training outside leads to improvement in nurses… We are a low-income country, so it is good for us if nurses can work abroad.

(Lao PDR)
We are trying to send our students to Indonesia and other countries…. It has a kind of relation to MRA, I think. (Myanmar) The Philippines is known as a market for nurses all over the world a long time before this issue came up…I think that now the nursing labor market is becoming more open to other countries like here in Thailand. (Philippines) However, AMoNS did not seem to accelerate nurse migration within ASEAN or other countries: Nurses go to Thailand and Singapore but not to Malaysia; some go to Japan for a short term. If they are allowed by the government, it is easy, but usually there is no support, so nurse migration is limited.
(Lao PDR) MRA was concluded with ten nations, but it is very difficult for our nurses to move to other countries for work. (Vietnam) Even if the door will open for ASEAN countries, I think nurses will have to consider the currency [for] they will not opt to work in that country if the currency is worth a lower value compared to the Philippines' currency. (Philippines)

| Factors affecting nurse migration
According to nursing educators, the factors affecting nurse migration were basic nursing education, the education system before entering nursing school, financial limits, language barriers, national policy, other agreements and people's demands to study or work abroad: Earlier, elementary education was for six years and high school was four years-so 10 years in total-but now it has changed to 12 years. The curriculum has been revised again because of this impact of compulsory education" (Philippines) We don't have the budget to implement MRA activities. (Cambodia) Nobody wants to go, as their English isn't good" (Lao On the other hand, the increasing motivation to work abroad has also indirectly led to improvements in the quality of nursing.
Opportunities to work as a nurse abroad such as the country, which has a working environment requiring expertise and skill and patients' high demand for disciplined interaction with health workers, may increase once the quality of nursing improves.

| The relationship between nursing quality and nurse migration
Nurse migration within the ASEAN region was premised on the standards of each ASEAN country according to AMoNS. This European Union under EU regulations. In the EU, which has cultural diversity, free mobilization for nurses is also allowed and member countries provide special programmes such as language support and "a career ladder" to support migrant nurses (Keighley, 2009;Sumption, Papademetriou, & Flamm, 2013;Zander, Blumel, & Busse, 2013). Generally, international nurse migrations rarely occur if there is a significant gap in the quality of skill and knowledge between countries and there is no monetary incentive for migration (Asadi et al., 2017;Bidwell et al., 2014;Santric-Milicevic et al., 2015).
Nursing educators concurred with this view based on their observations of actual ASEAN-related migration situations. A differential in the progress of AMoNS and an unresolved initial gap that we found during the interviewing may explain the acceleration of nurse migration within the ASEAN region.
We attempted to conceptualize the progress of AMoNS by reviewing other documents and the interviews. As shown in Figure 1,

| Nurse migration trends in the ASEAN countries
International movement of unskilled/low-skilled workers from Cambodia, Lao PDR and Myanmar to Malaysia, Thailand and Singapore has been occurring because of various pull and push factors within the ASEAN region (Sugiyarto & Agunias, 2014). Nevertheless, nurse migration within the ASEAN region still faces challenges (Hofmeister, Rueppel, Pascouau, & Frontini, 2014;Matsuno, 2009

| Limitations
Participant selection was one limitation of this study. Nursing educators who are also international students made the criteria for participant narrow. However, they are more likely to describe their countries' situations accurately because the nursing educator studying in other countries can explain both nursing education and nursing activity in the clinical setting in their home country with wide view comparing with other countries. The other limitation was that the number of participants from each ASEAN country was limited. This was also caused by participant selection. The participants who meet the study requirements could also be recruited from universities in other countries such as the United States of America, Australia or Japan, although they participated only in Thailand.

| CON CLUS IONS
Since 2006, laws, acts and regulations regarding nursing and nursing education systems in the ASEAN countries have improved dramatically. However, nursing activities in clinical settings have improved at a slower pace. Nursing educators have not perceived AMoNS' contribution towards nurse migration despite a decade of lapse. This relevant that the quality of nursing after concluding basic regulation regarding nursing and improving nursing education results in nurse migration. And the study indicates its process is in progress.
Once the quality of nursing in the ASEAN countries improves in the future due to AMoNS, the strong demand from other countries experiencing a rising need for caregivers for the elderly may accelerate nurse migration. Several aspects of nurse migration should be considered for the further improvement of nursing quality. Additionally, discussions among policymakers and nurse leaders on new nurse migration trends and a general willingness of nurses from ASEAN countries to work as caregivers or "care workers" are essential.

ACK N OWLED G EM ENTS
We wish to acknowledge the ASEAN nurses who acted as informants, without whose participation this study would have been impossible.

CO N FLI C T O F I NTE R E S T
No conflict of interests has been declared by the authors.

AUTH O R S' CO NTR I B UTI O N
KS and KN conceived the study design and carried out data collection with a substantial contribution from PB. KS and KN performed the analysis and drafted the manuscript, and PB con-