The lives of Malawian Nurses: The stories behind the statistics

Abstract

Malawi faces a critical shortage of nurses. Challenging working conditions and poor remuneration have led many nurses to seek employment overseas. The study uses qualitative biographical methods to describe the experiences of migrant Malawian nurses and compares them with the experiences of nurses who remain in Malawi. Choices made about pursuing a nursing career in Malawi, and decisions to migrate, are complex and heavily entwined with nurses’ personal circumstances. In addition, although nurses in Malawi perceive that conditions in the UK are difficult, many still aspire to migrate themselves.

Background

The current attrition of nurses has reached critical proportions in Malawi. Latest Ministry of Health figures (2008) show a 77% vacancy rate for nurses in the government health service. The restricted capacity of training colleges has limited the number of nurses to begin with, but more recently poor remuneration and excessively challenging conditions have led many nurses to seek alternative employment within Malawi and abroad. Between 2000 and 2008 Malawi lost a significant proportion of its most experienced nurses to overseas countries (mainly to the UK), leaving a pool of nurses grossly insufficient to deal with the country’s burgeoning health needs (Nurses and Midwives Council of Malawi 2008).

The conditions faced by nurses in Malawi - and the motivations for them to leave - have been well described by researchers (Mangham 2007; Palmer 2006). However, despite widespread migration, little is known about the experiences of migrant nurses. This study endeavours to fill this knowledge gap by focusing on the lives of Malawian nurses working in the UK and in Malawi. The results will improve understanding of their personal circumstances, obligations, and motivations. In addition, they will inform strategies to address the human resource crisis in Malawi through recommendations about worker incentives and retention.

Aims

To describe the experiences of Malawian nurses working in the UK, and compare them with the experiences of nurses who have chosen to remain in Malawi; and to examine how their experiences fit into the broader context of the decisions they make about their lives. Of particular interest are their reasons for deciding to train as nurses, the factors that influenced their decision to either migrate or remain in Malawi, and their experiences of day-to-day work.

Methods

The study uses qualitative biographical methods to describe the experiences of 40 Malawian-born nurses, 20 of whom remain in Malawi and 20 who have migrated to the UK. The idea is to develop biographical narratives following a timeline of key life events. Analysis combines a thematic approach with the literary narrative technique used in the biographical method (Muller 1999; Riessman 2001 cited in Robb et al 2007).

Results

The current nursing situation in Malawi is complex, and has been shaped by many key events, including population increases (leading to increased nurse-to-patient ratios), the proliferation of non-government organisations (NGOs), and the advent of democracy (with its many attendant economic and societal changes). These changes have been accompanied by a palpable shift in the motivations to become a nurse in Malawi. Nurses who graduated before 2000 gave reasons such as their admiration for nurses, pride in having a nurse in the family, and wanting to care for Malawians. However, more recent graduates appear to be less concerned with ‘doing good’ and more concerned with obtaining qualifications. Competition for higher education is extremely high, and they perceived nursing to be a marketable career that could lead to opportunities for employment with higher-paying NGOs, or even abroad.

Some nurses argued that this motivational shift has led to a decline in the quality of health care. Nurses who remain in Malawi report feelings of frustration, not only because of a lack of commitment and discipline in younger colleagues, but also because of the desperate lack of resources, high workload and low salaries that do not meet the basic costs of living. Although many nurses still remain in Malawi, most report that they had at some point intended to emigrate. Despite their efforts to leave they had stayed either because their plans had fallen through or because of family responsibilities. These nurses evinced no resentment of their colleagues who left Malawi to seek greener pastures.

The reasons behind migration to the UK are complex, but the role of high salaries is undeniable. Other reasons relate to personal circumstances, such as pressure from family members to earn more money, or the necessity to accompany a spouse. Once in the UK, although nurses were pleased with improvements in lifestyle, they also reported significant difficulties, in particular with communication, non-recognition of qualifications, and pressure from families to send money back home.

In recent years, Malawi has seen a significant decline in the number of nurses migrating to the UK. This is not due to a reduction in intent to migrate, or because of recent initiatives to improve working conditions, but because of tighter migration regulations. New restrictions have meant that many graduates settle on employment with an NGO in Malawi as the next best option. The desire to seek a better life abroad has not been quenched. To migrate from Malawi is seen as respectable and admirable, and this has significant implications not only for efforts to improve nursing numbers in Malawi, but on the health care system as a whole.