Nurse Migration in Australia, Germany, and the UK: A Rapid Evidence Assessment of Empirical Research Involving Migrant Nurses

Forecasts predict a growing shortage of skilled nursing staff in countries worldwide. Nurse migration is already a common strategy used to address nursing workforce needs. Germany, the UK, and Australia are reviewed here as examples of destination countries for nurse migrants. Agreements exist between countries to facilitate nurse migration; however, it is not evident how nurse migrants have contributed to data on which these arrangements are based. We examined existing primary research on nurse migration, including educational needs and initiatives to support policymakers’, stakeholders’, and health professions educators’ decisions on measures for ethical and sustainable nurse migration. We conducted a rapid evidence assessment to review available empirical research data which involved, was developed with, or considered migrant nurses to address the research question: what are the findings of research that directly involves migrant nurses in producing primary research data? A total of 56 papers were included. Four main themes were identified in this research data: Research does not clearly define what is meant by the term migrant nurses; discrimination is often reported by migrant nurses; language and communication competencies are important; and structured integration programs are highly valued by migrant nurses and destination healthcare employers. Migrant nurses continue to experience discrimination and reduced career opportunities and therefore should be included in research about them to better inform policy. Structured integration programs can improve the experience of migrant nurses by providing language support (if necessary), a country-specific bridging program and help with organisational hurdles. Not only researching migrant nurses but making them active partners in research is of great importance for successful, ethical, and sustainable migration policies. A broader evidence base, especially with regard to the views and experiences of migrant nurses and their educational support needs, should be promoted to make future immigration policy more needs-based, sustainable and ethically acceptable.


Introduction
Globally, it is increasingly difficult for healthcare systems to recruit sufficient qualified nurses to meet their growing healthcare needs. The gaps in nursing workforces can be broadly attributed to two categories: factors that decrease the number of nurses in the workforce and factors that increase the demand for nurses. One of the factors adversely impacting replacement needs of the nursing workforce is the retirement of qualified nurses. This rate is predicted to increase over the next decade (World Health Organisation, 2020b). In addition, many nurses leave the profession in the context of the economisation of healthcare as demands for more productivity with fewer incentives leave them physically and mentally exhausted (Kordes et al., 2020). The additional need for qualified nurses in healthcare systems is largely due to the growing needs of ageing and chronically ill populations (OECD, 2020;World Health Organisation, 2020a).
High-income countries often look to international nurse recruitment to address their domestic nursing shortages (WHO, 2020b). These countries attempt to create mutually beneficial economic and political arrangements with lowerincome countries to encourage nurses to migrate from one country to another (Connell & Brown, 2004). In some cases, these bilateral labour agreements (BLAs) aim to address labour rights, mutual recognition of qualifications and integration into destination countries (van de Pas & Mans, 2018). BLAs often contain feedback mechanisms to report comprehensively on the nurse migration process; however, in most cases, these are not well enacted (van de Pas & Mans, 2018). The formation of policy and the experiences of migrant nurses should be feedback to each other. For example, the BLA between Germany and the Philippines includes robust protections and involvement for migrant nurses; yet these protections have still not been implemented despite being ratified in 2015. While there are good intentions to include stakeholders in policy development and migration strategies, lack of involvement of migrant nurses and insufficient reporting mechanisms means there is little knowledge about nurses' experiences of the migration process (Kordes et al., 2020;van de Pas & Mans, 2018).
We approach this area of research and policy as an interdisciplinary group of researchers with a public health, nursing, education and communication science background from Australia, Germany, and the UK. We are working collaboratively on a project focusing on the educational aspects of nurse migration in a global health context. In this context it should be acknowledged that the political landscape of the countries of interest here is changing significantly with regard to nurse migration policy, e.g., with the UK leaving the European Union and new staffing and nurse staffing laws in Germany and Australia. It is not transparent what role migrating nurses themselves play in the policy development process and to what extent their perspectives are taken into account in policy decisions. It is also unclear what research data on nurse migration that includes migrant nurses underpins these decisions. We have opted for a Rapid Evidence Assessment to provide an opportune overview of the situation.

Aim
The aim of this research is to explore how migrant nurses are represented in published academic literature on this topic. We aim to collate, analyse, and assess this data to identify any gaps in research and to further support policymakers, stakeholders, and health professions educators in these three countries and internationally to make decisions that support ethical and sustainable nurse migration. This research is conducted as a rapid evidence assessment (REA), as described by Grant and Booth (2009), of academic literature on nurse migration in Australia, Germany, and the UK. The specific focus of this REA is empirical research that actively involves nurses who have migrated to one of these three countries. An REA was chosen to situate the available primary research in the social and political contexts of those countries.

Background
Based on WHO estimations, in 2018 there was a global deficit of 5.9 million qualified nurses (WHO, 2020a). Given the differences between countries, nurses are not further categorised in this report, however, globally professionalised nurses are around 69% of the workforce, associate professionalised nurses around 22% and around 9% of nurses are not classified either way (see also Appendix A). Forecasts predict the deficit of nursing staff to continue to grow over the next decade, which also affects the countries under review here (Marćet al., 2019). By 2030, an additional 520,000 full-time nursing positions will be required in Germany alone to care for the ageing population (WHO, 2020a). This prediction is echoed in the UK and Australia in a manner proportional to their demographics (Buchan et al., 2019). Further characterisation of these global trends using OECD data is available in Appendix A.
One response to these nursing shortages is workforce migration. Globally, one in eight qualified nurses works in a different country than where they were educated as a nurse (WHO, 2020a). However, nurse migration creates a complex system as it can both contribute to nursing shortages in countries of origin and address them in destination countries. The direction of nurse migration is often influenced by nurses seeking better wages and working conditions (Squires & Amico, 2014). Economies of low-and middle-income countries often rely on remittances from international nurse migration (Connell & Brown, 2004;van de Pas & Mans, 2018). Countries such as Australia (Aiken et al., 2004), Germany (Kordes et al., 2020) and the UK (Buchan et al., 2019) typically organise their economic and skilled migration policies around these labour markets.
Until recently, Germany had not looked to migration as a possible solution for recruiting qualified nursing staff (Kordes et al., 2020). In addition to a general change in immigration policy due to demographic and economic circumstances, some authors argue that this situation changed with the introduction of minimum staffing levels in hospitals and in long-term care institutions in Germany. This created a new context for nurse staffing in Germany and more opportunities for employers to look internationally for qualified nurses (Zander-Jentsch & Busse, 2018). Kordes et al. (2020) identified four key areas in understanding nurse migration in Germany: 1) the legitimisation of migration as a solution to nurse staffing shortages; 2) the categorisation of migrants by their background and linguistic abilities; 3) the delegation of international recruitment to third-party private agencies; and 4) the emergent technologies of state and legislative processes that guide migration. Levels of complexity are also added to the context of German nurse migration when negotiating international nurse migration between priorities for the European Union and Germany as an individual member state.
In contrast, the UK has a long-standing history of health workforce immigration. The UK's National Health Service (NHS) has been employing overseas healthcare professionals, including qualified nurses, since it was established in 1948. In the early years of the NHS, both trained and trainee nurses, particularly from Ireland and Caribbean countries, were targeted for recruitment (Winkelmann-Gleed & Hakesley-Brown, 2006). However, patterns of overseas nurse migration to the UK have fluctuated over time. The variability in the total number of overseas nurses entering the UK over the years depends primarily on how many nurses are needed and how many nursing jobs are available in the UK (Buchan & Seccombe, 2013). The existing demand for nurses and the impact of the UK's exit from the European Union are likely to continue to make nurse migration an area of interest for the UK.
Similarly, Australia has a long migration history of nurse migration for many decades to address nursing shortages and that the source countries for qualified nurses have varied over time. The Australian census analysis, published by WHO in 2014 reports that the main sources of nurses migrating to Australia between 2006-2011 were India (3,697), Philippines (3704), followed by the UK (2,885), China (1,266), and North Africa/Middle East (946) (Hawthorne, 2014). This general source country trend remains accurate for the period since, with India and the Philippines by far the dominant sources.
The increasing diversity of source countries of nurse migrants means that the way in which nurses are educated is also more varied, which has significance for the assimilation of nurses into health systems in destination countries (Hawthorne, 2005). Nevertheless, to meet the increased demand for qualified nurses, the state has recently intensified its activities in the area of international recruitment. The Australian National Disability Insurance Scheme (NDIS) of 2013, which was fully implanted in 2020 (AHPRA, 2017), has increased the country's need for qualified nurses.
International migration of nurses affects not only the individuals who migrate but also impacts effective service provision, health policies, workforce planning, training and education, and social and economic development in both the destination and source countries. Therefore, nurse migration must become an integral consideration for various policy fields from development to labour markets and health and social to education policies (Buchan & Seccombe, 2013). In 2010, the World Health Assembly adopted the first WHO Code of Practice on the International Recruitment of Healthcare Personnel. The associated strategic development goals make it clear that migration should be managed in an ethical way and benefit both the destination countries and countries of origin (WHO, 2010). This code of practice also encourages policymakers in higher-income countries to focus on domestic education, further education, and social integration of migrant nurses. These initiatives need a coherent and sustainable evidence base that is supported by research and includes the perspectives of nurses with a migrant background (van de Pas & Mans, 2018).

Methodology
We explored the research question: How do migrant nurses contribute to primary research data? Although there is a large body of statistics, secondary data, and policy statements on nurses' migration, it is not clear what the perspectives and experiences of migrant nurses are and how these are represented in policy. The research aimed to identify common themes emerging from findings of empirical research literature regarding the views and experiences of nurses who migrated to Australia, Germany, and the UK, which should be considered in the design of migration policies. These countries were selected because they represent high-income countries with a strong interest in nurse migration but nevertheless rely on different approaches. In this research, which was conducted in July 2020 and updated in September 2021, we intended to capture a broad overview of the available literature on this topic.

Research Method
Initial Scoping. searches of databases and online search engines were completed using the search terms nurs* OR pfleg* [translation: nursing] OR altenpfleg* [translation: geriatric nurse] OR krankenschwester OR krankenpfleg* [translation: nurse] AND migra* OR ausland OR ausländ* [translation: foreign country] OR oversea* OR foreign OR international* in combination with the three countries (Australia OR Germany OR United Kingdom OR UK).
Context. International economic databases (e.g., Eurostat and OECD) were assessed for contextual relevance.
Research Question Development. How migrant nurses are represented in participation, design or co-design in primary research was unclear in the background information, scoping review, and contextual data.
Method Selection. A Rapid Evidence Assessment (REA) following the model offered by Haby et al. (2016) fits appropriately the breadth of the research question, the resources, and the timeframe available.
Types of Data. Empirical research studies were sought, with priority given to sources with robust methodologies that closely adhere to the CONSORT (Antes, 2010) reporting guidelines for critically appraising quantitative research articles and published in either English or German. Data were also sourced from grey literature and data published by governmental organisations and used as signposts to potential primary research data; however, these data were not included in extraction. All data included satisfied the standard for reporting qualitative research or CONSORT reporting guidelines and the full text be available.
Types of Participants. Sources must produce empirical research that involves migrant nurses in the research process as participants or the research design examines the role of migrant nurses in Australia, Germany, and the UK. We consider nurse migrants and nurse migration as nurses working in a country different from where they were educated or in a country to which they moved to undertake nurse education and subsequently work as a nurse (van de Pas & Mans, 2018).
Types of Articles/Interventions. Studies that examine nurse migrants as participants, the role of migrant nurses or migrant nurses as co-designers and used peer-reviewed primary research methodologies.
Types of Comparisons and Outcome Measures. How migrant nurses are considered or represented in empirical research in Australia, Germany, and the UK.
Search Strategy for Identification of Studies. A comprehensive search of six databases (CINAHL, the Cochrane Library, EconLit, EMBASE, Health Systems Evidence and PubMed (MEDLINE) and two websites (Google and Google Scholar) were conducted including a reference search.
Grey Literature and Manual Search. Google, Google Scholar, CINAHL and PubMed (MEDLINE) include grey, unpublished and conference materials. These were included in the review to look for signposting to research not identified elsewhere.
Search Strategy. Searches of full texts were conducted using the keywords in the PerSPECTiF scheme (Booth et al., 2019): These keywords were selected in English and German to represent terms that may relate to nurses and nurse migrants in the three countries. No time limit was applied to the publication of the articles.
Domain of PerSPECTiF Scheme and Search Terms. nurs* OR pfleg* OR altenpfleg* OR krankenschwester OR krankenpfleg* OR international* AND migra* OR ausland OR ausländ* OR oversea* OR foreign AND Australia OR Germany OR Deutschland OR UK OR United Kingdom. (Table 1) Screening and Selection of Data. One reviewer from the UK (JS) conducted the initial search screening according to the selection criteria. The reviewer had a low threshold for including potential papers (Haby et al., 2016) that could later be screened out. The full texts of sources initially selected for inclusion were then retrieved and screened again with the inclusion criteria. A second reviewer from Germany (DH) screened the excluded papers to identify any sources that may be relevant and should have been included. Disagreements were resolved by a discussion between the reviewers. Data Extraction. Search results from each database were downloaded into Endnote referencing software. Resources that met the inclusion criteria were extracted for full text ( Figure 1).
Assessment of Methodological Quality. Only texts in English and German were included for analysis based on the countries included in the study and the language skills of the researchers. Quality assessment of all the texts used a quality assessment matrix adapted from CONSORT and Standards for Reporting Qualitative Research guidelines, which included a quality and bias assessment of literature.
Data Analysis. The adapted quality assessment framework was synthesised into a narrative report. This approach allows other data available to be mapped in the assessment of available evidence. Data analysis followed an inductive approach and aimed at, firstly, mapping the terrain of primary research involving migrant nurses and secondly, a qualitative description of the identified patterns (Gibbs, 2018). Data analysis followed generic qualitative data analysis processes by the four authors starting to independently re-read included articles, writing notes on insights and ideas, developing descriptive codes, reflecting on codes, developing categories, and eventually developing themes (Flick, 2018;Gibbs, 2018). This process eventually enabled the authors to develop the four themes as discussed below.
Findings 56 research studies were found that met the defined selection criteria (N = 56). Empirical research data for the experience and views of migrant nurses exists in greater numbers in the Australian (n = 24) and British (n = 27) contexts than in published literature from Germany (n = 5). Qualitative research design is the most common approach in the published primary research. The number of participants varied across papers from 2 to 816. A summary data extraction table is presented in Appendix B. Table 2 below summarises the study designs of research included in this review. OECD data which further contextualise this body of literature are available in Appendix A.

Data Synthesis
The results of the data are summarised by four themes: (1) how migrant nurses are described in the literature; (2) language background and language competence; (3) discrimination; and (4) integration and structured educational programmes.
Most of the literature included in this review using these definitions and names do not include people who may have migrated to Australia, Germany or the UK and then been educated as a qualified nurse. This is with the exception of one Australian study (Salamonson et al., 2007) that researched the experiences of nursing students to assess attitudes towards acceptance and awareness of nursing undergraduates from culturally diverse backgrounds.

Language Background and Language Competence
Language proficiency in the first language of the destination country is required for nurses to practice. All research papers retrieved that were conducted in Germany acknowledge that the participants do not speak German as a first language. This is in contrast to the UK and Australian contexts, where the native language of the participants or their fluency in English is reported less often (Omeri & Atkins, 2002;Philip et al., 2019;Salamonson et al., 2007;Walters, 2008). However, this is noteworthy as all studies highlight communication proficiency as an important aspect of nurse migration.
Although 63% of nurses migrating to Australia come from countries where English is the first language (OECD, 2020 see Appendix A), this was acknowledged in only four research studies in the design or discussion (Crawford et al., 2016;Omeri & Atkins, 2002;Tie et al., 2019;Vafeas & Hendricks, 2018). One Australian study suggests that cultural assimilation into clinical practice can be difficult for nurses who speak English as their first language but who are not from this country . Differences in work cultures and expectations are cited as the rationale. Nevertheless, multiple other researchers reported that increased fluency in the language of the receiving country is associated with better assimilation and experiences for nurses and the health systems in which they work (Brunero et al., 2008;Kumpf et al., 2016;Sedgwick & Garner, 2017).

Discrimination
Discriminatory practices were reported in the research data from all three countries, with similar experiences reported across the three countries. For example, migrant nurses reported feeling vulnerable (Crawford et al., 2016) in their new workplaces through mechanisms of alienation (Omeri & Atkins, 2002) and exclusion (Hardill & Macdonald, 2010;Kumpf et al., 2016;Tie et al., 2019).
Migrant nurses can feel alienated from their new teams, which is mediated through feelings of fear or lack of belonging (Walters, 2008). In the literature reviewed, these feelings of disempowerment are primarily attributed to insufficient language skills (Holmes & Grech, 2015;Kumpf et al., 2016;Stuart, 2012). The added pressures of learning and mastering a new language while simultaneously learning a new system can cause stress for nurse migrants (Schilgen et al., 2019). The evidence also suggests that some migrant nurses may experience discrimination from patients, other nurses and from service users (Alexis & Vydelingum, 2009;Lauxen et al., 2019).
Other stressors for nurse migrants can sometimes be due to structural and legislative restrictions in destination countries. This is recorded across data from Australia (Brunero et al., 2008), Germany (Schilgen et al., 2020) and the UK (Stuart, 2012). Migrant workers sometimes perceive training courses for skills and development as disproportionately difficult to access due to a perceived inequity because of their migration background (Kumpf et al., 2016). In addition, some national or state institutions may not recognise nursing qualifications achieved outside of the destination country (Walters, 2008). This can mean that migrants must work in a different, and often less respected position in the destination country. For example, migrant healthcare workers who have trained as a nurse outside of the UK may not be able to have their qualification recognised without further study and, therefore, choose to work as a healthcare assistant. In the UK, these jobs are often in community and long-term care settings (Stuart, 2012), which offer lower wages and status than other healthcare roles. Nurses report that their transferable skills are undervalued in these settings, leaving them frustrated and disempowered (Kumpf et al., 2016).
The underlying causes for implicit, explicit, and structural discrimination are not fully explored in the body of research included in this review; however, the multiple sources suggest they are complex and exist in multiplicities of contradictions between their labour, languages, and places of work (e.g. Hardill & Macdonald, 2010;Kumpf et al., 2016;Tie et al., 2019). There is also not yet an analysis of the different approaches to combating discrimination in the destination countries. One source recommends that there is a relation between the experiences of the migrant nurses and investments in social and cultural integration programmes (Aggar et al., 2020).

Integration and Structured Educational Programmes
Based on the studies reviewed here, the most useful features of local structured integration programmes are those that focus on communication, cultural synthesis and clinical integration (Aggar et al., 2020;Sedgwick & Garner, 2017). These programmes are also described as engaging multiple stakeholders across several sectors, e. g. local hospitals, nurse regulators, universities, and politicians. Crawford et al. (2016) suggests some content for such local integration programmes, including cultural awareness and clinical communication, and report staff integration and communication as essential for patient safety. Structured integration programmes for migrating nurses are reported in the literature from the UK and Australia, but none from Germany. Hawthorne (2005) describes the significant investment in bridging programmes in Australia and a health policy shift since 1980 to provide these programmes for international nurses. In 2019, a 'bridging programme' for Overseas Qualified Nurses was established by a local higher education institution in Australia (Aggar et al., 2020), but there is little evaluation of the structure, goals, or content of this integration programme beyond their participants' reports of usefulness. In the UK, a study also reported the importance of bridging programmes for migrant nurses to improve integration into health systems (Stubbs, 2017). Despite the frequent discussion of the importance of bridging programmes, little empirical research regarding these bridging programmes involving migrant nurses was found during this review.
First, there are specific educational needs of migrant nurses in a new clinical context. The needs of these nurses are different from those of domestically educated nurses (Aggar et al., 2020;Brunero et al., 2008) because they are competent and registered nurses in the country where they were educated. This positions them differently pedagogically from novice nurses, or nurses from the destination country returning to practice (Crawford et al., 2016) because they have a level of skill and expertise that they wish to develop in a different cultural context. Interviews with nurse educators responsible for teaching recent nurse migrants to Australia (Cecchin, 1998) reported that the educators did not feel prepared enough and that the teaching cultures they experienced with this group of nurses were very different to how they usually practice because they have clinical experience as qualified nurses in their countries of origin. The specific learning needs for migrant nurses is reported elsewhere as others call for specific educational frameworks for educators of overseas nurses (Allan & Westwood, 2016) and for distinct syllabi for such integration programmes (Aggar et al., 2020;Crawford et al., 2016).
Second, this data suggests that structured integration programmes improve the health and well-being of nurses, which in turn contributes to better recruitment and retention (Ohr et al., 2016). These programmes increase feelings of wellbeing and belonging alongside the camaraderie and support of colleagues and new friends ). An increased perception of health and well-being enhances success rates and improves nurses' experience and integration within an unfamiliar healthcare system. Feelings of discrimination can often be reduced or moderated by supportive colleagues (Schilgen et al., 2020) or by the development of strong friendships in destination countries (Vafeas & Hendricks, 2018). All studies report that nurses perceive the extent to which they are able to integrate as fundamental to their health and well-being. This accompanies multiple findings in the UK and Australia that structured integration programmes are essential to support positive outcomes from nurse migration (Aggar et al., 2020;Al-Hamdan et al., 2015).

Discussion
Australia and the UK have longer histories of nurse migration than Germany, and they have far more established structures for conducting research on this issue in which migrant nurses are involved as active partners. However, even in these countries, much of the available peer-reviewed data comes from smaller qualitative studies with limited scope. There are more empirical research data for nurse migration available from Australia and the UK than Germany. While Australia and the UK have more published data available, the themes produced by all three countries are consistent: (1) how migrant nurses are described in the identified literature, (2) discrimination, (3) the importance placed on communication skills, and (4) the value of structured integration education programmes. It is not clear how these findings are used to support nurse migration policies and initiatives. BLAs such as the one discussed earlier between Germany and the Philippines (van de Pas & Mans, 2018) have mechanism built into them to include migrant nurses in the processes, however, are reportedly not well enacted. These findings suggest that these feedback mechanisms should be strengthened to improve the experiences of migrant nurses. These lessons can be incorporated in future discussions of policy, in a global context, as nurse migration is an international issue. Discrimination is the most prominent theme throughout the research included in this review; therefore, there is an ethical imperative to report this finding to the broadest possible audience.
The Australian literature included in this review appears to over-represent migrant nurses in research who do not speak English as their first language, despite 64% of OQN's being from countries with English as the first language (OECD, 2020). This representation of OQN's language ability may be due to changing trends in source and destinations countries of migrant nurses. Studies calling for migrant nurse participants may be unclear as to who is the target participant group. Nevertheless, this finding raises questions of why this is not addressed more directly.
Comparisons of nurse migrants and their experiences should consider that the terminology used to describe 'nurse migrants' varies in different international contexts, which has consequences for the way the topic is discussed. Australia and the UK use terminology that is sensitive to the different educational backgrounds of nurse migrants (like OQN, IQN) or to aspects that can be addressed in integration programmes (culture, language). In contrast, Germany uses terminology that tends to derive from citizenship law and does not take educational aspects into account. Furthermore, the different titles of nurses or caregivers may create inaccurate comparisons. The terms, 'nurse' 'registered nurse' and 'migrant nurse' have different meanings across the three countries discussed. These differences have implications for future research when drawing upon an international research base for policy and project design and must be considered to ensure appropriate comparisons are made.
In all three countries, there is a gap in empirical research when it comes to sufficiently considering the perspectives and experiences of migrant nurses in planning, conducting, and publishing on this topic. This gap in knowledge is made more relevant by each country's identification of nurse migration as a potential solution for increasing nurse shortages. Despite the established WHO ethical principles for an international approach to managed nurse migration, nurse migrants have not been considered in this policy process through research and suggests the need for a more participatory approach when dealing with nurse migration.
A point emphasised is the contrast between the available primary and secondary data. This difference is characterised by fewer quantitative empirical research studies being available that actively include migrant nurses. Many of the articles included in this review sre qualitative studies, that explore the lived experience of migrant nurses. The perspectives reported in these studies often describe ongoing discriminatory practices or exclusion. Examples of discrimination exist in each country for example Boese et al. (2013), reporting that migrant nurses are excluded from career progression pathways, Stuart (2012), reporting that migrant nurses often work as lower paid healthcare assistants, and Schiligen et al. (2019) reporting that migrant nurses experience more distress in their roles. These findings correspond to the theme of discrimination throughout the relevant literature. Despite the inclusion of the lived experience of some migrant nurses in the articles reviewed, this does not appear to translate into better experiences for migrant nurses. Future research that includes nurses with a migration background in the production of empirical data would address this gap in knowledge.
Structured integration educational programmes are highly valued by all stakeholders: therefore, it is all the more remarkable how infrequently they are addressed, scientifically substantiated and empirically investigated. Where such programmes are provided, they are reported to improve nurses' health and well-being, retention, and patient safety. These programmes have specific requirements that differ from other educational initiatives and should be planned to meet the needs of those for whom they are provided. The two types of bridging courses are pre-registration courses or employment integration courses, each with specific pedagogical requirements but common themes of language and cultural integration. In Australia and the UK, the focus since the mid 1980s has been on pre-registration courses, with a language and clinical adaptation focus. The German governments Triple Win project is an employment integration programme for migrant nurses. This program offers support for nurses who migrate to Germany. The programme offers language support in nurses' origin countries and professional orientation to nursing in Germany. The programme has resulted in 2,700 nurses being employed in Germany since 2013 but it is not transparent how nurse migrants are considered in this initiative (Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, 2021).
Among others, integration programmes should focus on the systematic development of language and communication skills for everyday and workplace situations. The ability to freely communicate in the first language of a destination country is given high value across all contexts by nurse migrants, healthcare representatives and service users. There is evidence for better outcomes for migrant nurses, patients and employers if language and communication support is integrated into educational programmes (Aggar et al., 2020;Holmes & Grech, 2015); therefore, policies should be guided by this evidence.
Successful integration schemes are typically multi-sector, with multiple stakeholders, e. g. local nurse managers, nurse educators, healthcare managers and representatives of educational institutions. This suggests that these programmes should have a strong focus on local institutional integration. Most importantly, including nurses with a migration background in the production of these programs and of empirical data, could address these issues.
The inclusion of nurses' perspectives can be achieved directly by asking migrant nurses or, if that is not possible, by using relevant inclusive research. A broader evidence base, especially with regard to the views and experiences of migrant nurses and their educational support needs, should be promoted to make future immigration policy more needs-based, sustainable and ethically acceptable.

Limitations
The REA methodology chosen for this work is not as comprehensive as a longer systematic review. However, the REA approach is a clear and transparent one that has helped to ensure that recognised standards of data production have been met.
Essentially, there would have been four ways to expand the findings presented here. First, the search criteria could have been expanded to include secondary research data and grey literature, including health policy documents and other data from government agencies. However, such data is extensive and would have required a different form of analysis, thus exceeding the scope of this project. It was decided, therefore, to include only empirical research actively involving migrant nurse in order to meet the demand for evidencebased migration policy measures in this area. In addition, further reviewers could have examined all extracted articles and not only those articles selected for inclusion in the final dataset. However, this process would possibly have led to further exclusion from the already small number of primary research articles.
Second, the research examined in this review does not provide in-depth information on the education and integration programmes, such as the breadth of the curriculum, the assessment procedures used, whether they give the participating nurse a transferable qualification such as a diploma or degree, or who is responsible for organising and commissioning the courses. This level of detail can be found in the literature outside the scope of this paper and may provide future research opportunities.
Third, the search strategy returned a small number of papers (n = 2) in the German context that were not available in the full text. The title was suggestive that these may be relevant to this review, however, further screening was not possible since these papers were over 19 years old.
Fourth, this review includes grey literature to understand the context of nurse migration, however, did not analyse this data in-depth. A vast amount of grey literature available from sources such as WHO, OECD and the International Monetary Fund yet much of this is not peer-reviewed and therefore did not meet the inclusion criteria. A broad overview of nurse migration by country was included in Appendix A to provide a brief statistical overview of nurse migration to further contextualise the discussions of articles included in this review. This paper was prepared at the beginning of the COVID-19 pandemic and does not address resulting changes in global mobility. This emerging context will undoubtedly impact migration in ways that are not yet clear. The reduction in international travel will raise questions about countries' reliance on nurse migration.

Conclusion and Implications for Nursing Policy and Research
The findings of this paper suggest that healthcare research on nurse migration should be more inclusive of migrant nurses' perspectives and experiences and incorporate these perspectives into policy and processes of nurse migration. Existing research has included the perspectives, knowledge, and experiences of migrant nurses in research, however, an opportunity exists to address the scale of this involvement to reflect the size of the deficits in nursing staff and the efforts of migrant nurses. There is also a clear opportunity to conduct larger research projects with migrant nurses beyond the relatively small studies found in this review; however, further research would require financial and structural initiatives by those invested in the process. We recommend further studies on the factors related to discrimination of migrant nurses. This research should look more comprehensively at the factors relating to discrimination and how research with and by migrant nurses can integrate into policy and practice.
We approached this project as researchers with a background in public health, nursing, education, and communication studies, but without a migration background ourselves. However, we wanted to understand and support the processes of nurse migration and create research based local policies that guide this process. The data suggests that such research should be integrated into national nurse recruitment strategies. Patient and Public Involvement (PPI) is an essential component of research practice therefore and should also be enacted in empirical research that supports policies around nurse migration. All research and policies should consider the ethical principles for nurse migration outlined by the WHO (2010WHO ( , 2020a. Such integration is ethically mandated and is more successful for nurses and health systems socially and economically. The available research suggests that further development of migration strategies such as educational transition programmes, that consider or franchise migrant nurses, are urgently required. Further research could also examine these countries' migration policy to determine if evidence exists to support that migrant nurses' views and experiences were considered in policy design and identify how these policies are interpreted and executed in practice.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
OECD data provide a sound basis for identifying some of the general differences and similarities between Australia, Germany, and the UK, and in particular for highlighting aspects relevant to nurse migration.
OECD data demonstrates close similarities in life expectancy and per capita healthcare expenditure in these three countries (OECD, 2020). What is striking, though, is the difference in the ratio of nurses to care personnel in these data. The UK reports a much higher ratio of care personnel to nurses than Germany and this value is not reported for Australia. This phenomenon may be explained by a different understanding of who is described and categorised as 'Qualified Nurse' and who as 'Care Personnel' in the respective statistics. Lauxen et al. (2019) discusses that the definition of nursing by a professional title may not be the same in every country and may be protected in law in different ways. In Germany, for example, there are three different professional titles for nurses that are mainly educated in a traditional hospital-based vocational training system: Adult Nurse (Gesundheits-und Krankenpfleger*in), Paediatric Nurse (Gesundheits-und Kinderkrankenpfleger*in) and Care of the Older Person Nurse (Altenpfleger*in). However, none of them are registered by a professional body in Germany and only two meet the formal requirements of the European Union (EU) Directive for registered nurses in Europe. Due to different qualification standards, the title 'Altenpfleger*in' is not automatically recognised as a Qualified Nurse in other EU countries, which is why this professional group might be classified as 'Care Personnel' in other countries. In most other European countries, qualified nurses are graduated and registered, whereas care personnel undergo less demanding training. Such differentiation and educational aspects are important for the discourse on nurse migration, which is why they must be taken into account when comparing international statistics and research data.
Australia, Germany, and the UK have migrant nurses in their workforces, and these individuals are often recorded by country of origin (see Appendix A). These data show characteristics for the respective countries that should be considered when assessing the information available on nurse migration in research. First, the category of 'migrant' nurse is heterogeneous, but more so in Germany and the UK than Australia. The reported number of countries of origin or different nationalities varies widely: 12 in Australia, 16 in Germany and 129 in the UK (OECD, 2020, see Table 3 in Appendix A). These differences may be caused by the method of recording or level of detail of information recorded for migrant nurses in their destination countries. They may also demonstrate levels of diversity in migrant nursing workforces. As of 2017, 53.2% of overseas educated nurses working in Australia are from the UK. Sixty-four percent of recorded nurse migration to Australia is from countries where English is spoken as a first language by the majority of the population. Other countries, such as Germany, therefore, have a completely different starting situation due to the language barrier. This feature should be considered when discussing this cohort of research. Second, the number of migrant nurses recorded as 'Others not recorded' is larger in Germany (29.8%) and the UK (26.7%) than in Australia (5.9%). Given the large amount of missing information and the broad characteristics of these data, further analysis may require additional research.

Mixed
Australia Without a hospital based orientation program participants were more likely to experience failure to 'fit in'. This led to maladaptive behaviours where they did not actively seek, support or question practice through fear of drawing increased attention to themselves. Hospital orientation programs need to be developed as to the specific learning (continued) Appendix B.

Mixed
Germany The results indicate that the potential of nursing immigration for securing skilled workers has increased, especially in health and nursing or in the hospital sector. In contrast, the potential still appears low in nursing for the elderly and children.

Vietnamese nurses working in Germany
Semi-structured interviews Germany Professional, cultural and linguistic support are useful for successful migration. Schilgen et al. (2020) The Extent of Psychosocial Distress among 249 and 287 The Extent of Psychosocial Quantitative Germany There was no significant difference in the extent of (continued)