1 Transnational Management of Globalised Workers

Nurses Beyond Human Resources

Introduction

The recruitment and placement of nurse labour from economically poor countries to more affluent countries are not new phenomena. Private nursing schools in the Philippines have been training a large number of nurses for the economically rich labour markets, particularly the United States, since the 1950s (see Choy, 2003). The current patterns of transnational health-labour migration from poor to more affluent countries represent a new phenomenon, however. Even though large numbers of third-world nurses migrated transnationally before the 1990s, they moved along established migration pathways that existed between countries with long-term historical ties and legacies of imperialism and colonialism. Traditional destinations for nurses from third-world countries included the United States, Canada, Australia, New Zealand, France, Germany, and the United Kingdom, all of which benefited from their ties to specific ‘donor’ countries (Brush et al., 2004).

Since the 1980s, however, newly affluent destination countries and poor donor countries have emerged, with different trajectories explaining their entry into the global health care labour market. In some new destinations, countries’ increasing demand for migrant nurses results from rising affluence; in others, structural labour shortages related to the diversification of women’s employment and demographic developments such as an ageing population serve as an explanation (for instance in Saudi Arabia, Southern Europe, and Ireland; Yeates, 2009). In other new country destinations, changes in the organisation of welfare services provide a central explanation for the rising interest in recruiting nurses transnationally (Dahl and Eriksen, 2005; Dahl, 2012).

This book explores emerging human resource practices in a Nordic welfare state, internationally renowned for universal health and social care as well as gender equality. Traditionally, the affluent Nordic countries recruited nurses mainly within the Nordic region, where cultural ties are comparatively close and all of the countries have extensive welfare states (Wrede et al., 2008; Isaksen, 2010). In the Nordic context, the new practice of managing a labour market through transnational recruitment and placing activities is related to welfare state reforms aimed at increasing labour flexibility (Wrede, 2010; Näre and Wrede, 2013). This book examines how nursing work is transnationally managed as a resource through interactions of representatives, both private and public, working to acquire quantities of predetermined ‘human resources’. This reflects a broader, historical management pattern of the nursing occupation.

To illustrate this phenomenon, the book describes the emerging human resource management practices of nurse work in Finland by private and public representatives of nurses from the Philippines. The analysis identifies private and public representatives that are managing the transnationalisation of nurse labour in terms of which representatives and organisations are asserting authority over how nurse labour is transnationally produced and relocated to Finland.

A central argument of this book is that even though the nursing labour market remains anchored in the Finnish welfare state, the emerging recruitment and placement practices globalise the demands associated with nursing work with the aim of increasing labour flexibility. For the private actors, imported nurses are a source of making and saving money. For that purpose, they compete on global markets for suitable nurses and seek to manage their human resources for their clients. The book further argues that the process of managing nurses as marketable ‘products’ for possible clients reproduces not only traditional social hierarchies within nursing at the organisational level, but also within national and transnational levels, impacting the lives of both migrant and domestic nurses in tangible ways (wages, job security, occupational mobility, work/family balance). Historically, nurse work and its workforce have been segregated along gendered, racialised, and classed hierarchies. The social categories constituted around gender, race, and class have essentially designated certain groups of workers into specific divisions of labour within the health care market (Apesoa-Varano and Varano, 2004; Chang, 2000).

Transnational Human Resource Management of Nurse Labour

Nursing, as an occupation, has increased in demand over the last decade and recruitment by organisations in developed countries from less developed countries has intensified. Many scholars, policymakers, and human resource (HR) practitioners argue that this increase in demand is due to ‘push’ and ‘pull’ factors such as better pay and working conditions in recipient countries than sending countries (push) and changing demographics worldwide that place strain on health care systems due to an ageing population (pull).

However, the scope and magnitude of the current process of migration has created a ‘carousel’ of international nurse mobility (Kingma, 2006), causing the dichotomous nature of ‘push’ and ‘pull’ to be limited in its explanation. What was once a one-way exchange among a number of developed and developing countries has become a more complicated and circuitous stream of nurses flowing in new directions and patterns (Brush, 2008). As such, greater competition and demand for these nurse migrants among recruiting countries has created a market demand that is translated into big business (Brush et al., 2004) and encompasses not only micro explanations of push/pull but also a macro context of trade and uneven development.

Demands for nursing from areas such as the Middle East (Saudi Arabia, Kuwait, Libya, Iran, Bahrain, and Iraq), Asia (Japan), the UK, North America (Canada and the United States), and Australia have amplified the importation and exportation process of these skilled workers (Brush and Vaspuram, 2006; Buchan et al., 2003). In response, countries such as the Philippines and India are producing nurses in greater numbers than required to satisfy domestic demand to send abroad (Choy, 2003; George, 2005). Simultaneously, countries such as China and South Korea are also following the Philippines and India as an example to export their own human resources (George, 2005; Percot, 2006). In addition, other professionals such as doctors and lawyers in the Philippines are being driven into the nursing profession in order to be exported abroad (Galvez-Tan et al., 2004).

Although there is an increase in demand for active recruitment of nurses in all countries worldwide, in many countries, fewer people are being attracted to the health care profession domestically. For example, while nursing is an occupation requiring advanced education and skill building, it continually struggles to identify its worth among more traditionally male-dominated health care fields such as medicine, dentistry, and public health in tangible ways: salary, prestige, and work conditions (Apesoa-Varano and Varano, 2004; Melchior, 2004). Subsequently, in both developed and developing countries, careers in health care are becoming less attractive unless it is a means to migrate (Connell, 2008: 24). With this in mind, however, research has shown that migrant workers are unable to use all their existing skills and migration has largely been associated with deskilling (Ribeiro, 2008; Kingma, 2006). In addition, although many nurses are able to transfer their qualifications across borders, they generally do not advance in their careers and experience downward mobility in terms of occupational seniority and overall financial status (Ho, 2008; McNeil-Walsh, 2008). Furthermore, as pointed out by Ribeiro’s study (2008), the institutional conditions and regulatory mechanisms of the nursing profession creates both female migratory tracks towards low-status professional segments and new intra-professional divisions alongside the status of citizenship and the place of graduation for migrant workers.

In 1995, Davies notes that nursing is highly gendered, and management—as well as the nursing work itself—requires the re-examination of nursing as an occupation in which gendered processes and relations are re-enacted on a daily basis in organisations and power dynamics. Davies also argues that, through specific management practices, nursing has been correlated with ‘disposable labour’. Subsequently, nursing labour and its human resources are flexible, complaint, replaceable, and, in the end, disposable.

These circuitous and transnational patterns of nurse migration and the transfer of care from one health care system to another—which are embedded in gendered and racial social divisions—denotes the importance of understanding further the management and organisation of migrating nurses.

Within the discipline of international human resource management (IHRM), the conceptualisation of transnational has been used to explain corporate HR systems in terms of practices and strategic processes (Festing and Eidems, 2011: 162), but the actual term ‘international’ has not been subjected to analytical criticism or replaced with a deeper understanding of what transnational means. The discipline of IHRM, within management and organisation studies, continues to view the processes and practices of managing people across borders in terms of a duality between centralisation (or global integration) versus decentralisation (or local responsiveness) or ‘international’ as in ‘between nation-states’ (Ståhl et al., 2012). This analytical understanding of the geographical (or locational) management of human resources, I argue, has narrowed the empirical focus within IHRM to multinational corporations (MNCs) by focusing solely on headquarters and subsidiaries as well as expatriates, specifically from the West. As raised by management and organisation scholars, ‘transnational’ as a concept is critical to the function of national borders, but also the concept of ‘international’ encapsulates the organisation and management of migrating people, either paid or unpaid workers, or the movement of people for various other reasons (Hearn et al., 2008). Hearn conceptualises ‘transnational’ as the nation and its borders being affirmed and deconstructed simultaneously (2004: 278). More specifically, Hearn defines ‘trans’ as

‘Trans’ and its subsequent associations such as transmigration, trans-organisation, and transcommunities stress the shift from a monolithic, centralised conceptualisation of management and the operations of organisation and management. As a result, transnational organisation, management and processes can be understood in the context of the global, political economy, and its associated social divisions and inequalities around class, gender, ethnicitisation/racialisation, etc. (Locke Swarr and Nagar, 2010; Hearn, 2004: 285; Cleland Silva, 2010: 106).

In this book, I strive to reconceptualise IHRM as a discipline to transnational human resource management (THRM). This reconceptualisation, I argue, broadens not only the theorisation beyond the national borders and the enterprise, but provides a space for health care sectors and human services in terms of empirical exploration into the management of people in a transnational context. Henry Mintzberg recently wrote that he ‘can think of no other field that is more global in its professional practices yet more parochial in its administrative ones than health care’ (2017: 6). I would argue that the need for nursing is a global demand, and yet, the management of the occupation is systematically practiced within the unequal notions of gender and ethnicity, which are both, simultaneously, localised and globalised.

In the following chapters, this book situates a study that focuses on how, in the years 2007 to 2010, five groups of nurses from the Philippines were recruited and transnationally managed and organised to live and work in Finland for both private elderly care facilities and surgical wards in Finnish municipal hospitals. Through the case, the work is critical of IHRM as a discipline and practice and discursively analyses structural and societal issues of control and compliance of the historically gendered and racialised occupation of nursing. Furthermore, the transnational processes and movement of human capital from the Philippines to Finland is discussed in terms of (re)producing the managerial practices of nurse work, which create barriers to equality in the workplace but also construct life patterns that conflict with the situated life patterns of the nurses.

Aim of the Book

I argue in this book that to understand transnational management of nurses, we need to explore organisations and representatives whose work is to manage the nurses within their associated ‘social worlds’ (Strauss, 1978, 1979, 1982a, 1982b). Social worlds are structurally situated, interactive units of analysis that consist of representatives making collective meaning of and acting from at least one primary activity (e.g. management of nurses). Social worlds are structured in society so much so that, ‘we can bet with relative safety[,] will remain basically “in place” and predictable over some time’ (Clarke, 1991: 129). The difference between social worlds, therefore, is the degree of structuration. In other words, the social world’s ‘staying power’ (see Giddens (1979) on structuration).

Social worlds interact in an arena. An arena is ‘a field of action and interaction among a potentially wide variety of collective entities. It is a meso/macro level, voluntaristically oriented, collective-action approach’ (Clarke, 1991: 128). Social worlds function in a field of action through the representatives negotiating, maintaining boundaries, and gaining social legitimisation of the social world itself through the representatives’ work practices and discourses. An arena of a field of study can be metaphorically perceived as a ‘battle field’ (Clarke, 1991) of competing commitments and actions that are believed to be meaningful to representatives of the associated social world. As such, social world/arena theory ‘aims at capturing, describing, and thus rendering susceptible to analysis the multiple simultaneous organized actions of individuals, groups of various sorts, and formal organizations’ (Clarke, 1991: 131).

To develop this understanding of social interactions and associated social worlds, the book uses mapping and maps suggested in the method of situational analysis (Clarke, 2005). Through the analysis of interviews, the book creates and illustrates maps of social worlds in which representatives and organisations transnationally manage nurses through practices and discourses. The maps are considered products of the analysis of spatial representation, and mapping is considered a byproduct of storytelling and the retelling of a journey made. In this case, the story is about the transnational management of nurses framed by the question ‘who cares about the recruitment and placement of Filipino nurses into Finnish institutions and what do they want to do about it?’ Through this situated question, the representatives and the discourses are discussed around the expected work commitments of the identified social worlds in the arena or battle field.

The managerial practices constituting the human resource management of foreign nurses in Finland did not emerge in a vacuum. In the era of economic globalisation, the HRM practices of any country are created and implemented in a wider socio-economic context of trade and development. For Finnish companies, this involves, in addition to influences from countries with a history of recruiting and placing foreign nurses and neighbouring countries, institutional input from international organisations and the European Union.

The Structure of the Book

This book is divided into three parts to discuss transnational management of nurses and moving beyond international human resource management: (1) framing, (2) situating, and (3) a situation.

The first part entitled ‘Framing’ starts with an overview on the transnationalisation of care and nurse labour market as conceptualised through macro, meso, and micro understandings of the circuits and processes of migrants moving for work in the health care industry or private and public actors and organisations producing, recruiting, and relocating nurse labour transnationally. Empirical documentation of the nursing occupation through historical and organisational analyses reveals gendered, racialised, and classed hierarchies that create barriers to equality for the nurses in tangible ways.

Through the theoretical framework of transnational feminism in Chapter 3, I critique international human resource management (IHRM) as a discipline and practice. Using the transnational feminist lens both theoretically and empirically signals attention to uneven and privileging circuits of nonhuman and human capital elements such as financial currency and human resources (or people’s labour) and problematises the concept of ‘international’. The concept ‘international’ implies nation-states as being fixed and sovereign entities with boundaries that can include and exclude political, economic, and social elements, taking for granted that these boundaries are established through a system of inequality and exploitation. Furthermore, Western and/or Eurocentric discourses of entitlement and the superiority of one country over others institutionally creates hierarchies of people and their labour in material forms (for instance, wages, where people live, whether or not family members are separated geographically). The term ‘international’ revolves around cultural differences or, in some instances, a nationalistic discourse of ‘us versus them’, allowing actors in various networks to legitimise uneven circuits of labour and capital based on socially constructed ideas of particular nationalities and cultures.

The transnational feminist lens is considered critical to IHRM as a discipline and practice as I argue that the term ‘international HRM’ should be reconceptualised to ‘transnational HRM’ to not only reflect the current political economy, but also to move ‘beyond the enterprise’ or MNCs of particular sectors. This means considering other sectors that manage human capital across borders such as nurses. This broadens the scope of research but also questions taken-for-granted issues of race and gender in the practice and theorisation of IHRM in management and organisational studies.

The second part of this book is entitled ‘Situating’. To examine the transnational management of nurses, in Chapter 4, I discuss the methodology of situational analysis: a grounded analysis that navigates the data with the use of maps. The ‘situational maps’ (Clarke, 2005), constructed by the researcher, revolve around the central work activity of recruitment and placement of nurses. Various ‘social worlds’ and their representatives related to the work activity emerge into the ‘arena’ to claim authority, and ‘produce’ human resources of nurses.

In Chapter 5, I define discourse(s) and situational analysis and explain how I use these methods of analysis. The goal of these methods is to situate the actors, organisations, and institutions in their respective social worlds and discuss various discursive positions that emerge in the produced talk and text collected. In this way, the unit of analysis is the organisational or meso level and not the individuals.

In the final part, ‘A Situation’, I illustrate transnational management of nurses through a situated story about the recruitment and placement of Filipino registered nurses into Finnish private and public health care organisations. Focusing on the transnational management of 75 Filipino nurses recruited and placed in Finland from 2007 to 2010 (the first recruitment of non-European nurses by businesses), I discuss which representatives are claiming authority in the recruitment and placement practices of Filipino nurses in Finland and which social worlds are associated with the representatives. I aim to illustrate the emergence of these representatives and their respective social worlds and arenas through social world maps, and I analyse the various discursive resources used by the representatives to gain social legitimation. In Chapter 7, I look at the discursive positions of the dominating representatives in the recruitment and placement of Filipino nurses and at the structuring and material implications of these discursive positions.