book-34714 (2).pdfhjkkljgfdssawtjiiiiiujj

Georgia State University
ScholarWorks @ Georgia State University
Public Health Theses School of Public Health
5-16-2014
A Proposal for a Series of Studies to Explore the
Phenomenon of the International Migration of
Indonesian Nurses
Nila Kusumawati Elison
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Elison, Nila Kusumawati, "A Proposal for a Series of Studies to Explore the Phenomenon of the International Migration of Indonesian
Nurses." Thesis, Georgia State University, 2014.
http://scholarworks.gsu.edu/iph_theses/323

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Author’s Statement Page
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Health. Such quoting, copying, or publishing must be solely for scholarly purposes and
will not involve potential financial gain. It is understood that any copying from or
publication of this dissertation which involves potential financial gain will not be allowed
without written permission of the author.
Author,

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A Proposal for a Series of Studies to Explore the Phenomenon of the International
Migration of Indonesian Nurses
A Capstone Submitted to the Graduate Faculty
of Georgia State University in Partial Fulfillment
of the
Requirements for the Degree
MASTER OF PUBLIC HEALTH
ATLANTA, GEORGIA

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Table of Contents
ABSTRACT....................................................................................................................... 7
CHAPTER I ...................................................................................................................... 8
INTRODUCTION ............................................................................................................ 8
CHAPTER II................................................................................................................... 13
LITERATURE REVIEW .............................................................................................. 13
Universal Health Coverage ............................................................................................ 13
Universal Health Coverage in Indonesia ...................................................................... 14
Universal Health Coverage and Human Resources for Health.................................. 16
International Nursing Migration................................................................................... 18
Causes of International Nursing Migration ................................................................. 18
Recruitment Agencies..................................................................................................... 19
Impacts of International Nursing Migration................................................................ 20
Return Migration............................................................................................................ 21
International Organizations’ Recommendations......................................................... 22
The Profile of Human Resources for Health in Indonesia and the International..... 25
Migration of Indonesian Nurses .................................................................................... 25
CHAPTER III ................................................................................................................. 29
METHODS AND PROCEDURES................................................................................ 29
Study Populations ........................................................................................................... 29
Inclusion and Exclusion Criteria................................................................................... 29
Sampling Methods .......................................................................................................... 31
Institutional Research Committee (IRB)...................................................................... 32

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Recruitment Methods, Informed Consents, and Data Collection Methods .............. 32
The Research Instruments ............................................................................................. 36
Validity and Reliability of the Research Instruments ................................................. 38
Data Analyses .................................................................................................................. 41
Data Management........................................................................................................... 43
Timeline ........................................................................................................................... 44
CHAPTER IV ................................................................................................................. 45
POTENTIAL IMPACTS OF THE STUDIES ............................................................. 45
REFERENCES................................................................................................................ 50
APPENDIX A: Informed Consent Form for the Indonesian Embassy Overseas..... 54
APPENDIX B: Informed Consent Form for Returning Nurses................................. 56
APPENDIX C: Informed Consent Form for Recruitment Agencies......................... 58
APPENDIX D: Informed Consent Form for the Board for Development and
Empowerment Human Resources for Health Ministry of Health of Indonesia........ 60
APPENDIX E: Informed Consent Form for the National Protection Board for
Indonesian Overseas Workers....................................................................................... 62
APPENDIX F: Informed Consent Form for the Central Board of the Indonesian
National Nurses Associations Jakarta........................................................................... 64
APPENDIX G: Informed Consent Form for the Branches of the Indonesian
National Nurses Associations Overseas ........................................................................ 66
APPENDIX H: Topic Guide on the Return Migration Experiences of the Returning
Nurses............................................................................................................................... 68
APPENDIX I: Topic Guide on Recruitment Agencies................................................ 70
APPENDIX J: Topic Guide on the International Migration of Indonesian Nurses for
the Board for Development and Empowerment Human Resources for Health,
Ministry of Health of Indonesia (BDEHRH)................................................................ 72
APPENDIX K: Topic Guide on the International Migration of Indonesian Nurses
for the National Protection Board for Indonesian Overseas Workers (BNP2TKI) . 74

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APPENDIX L: Topic Guide on the International Migration of Indonesian Nurses
for the Central Board of the Indonesian National Nurses Association (INNA)
Jakarta ............................................................................................................................. 76
APPENDIX M: Topic Guide on the International Migration of Indonesian Nurses
for the Branches of the Indonesian National Nurses Association (INNA) Overseas 78
APPENDIX N: Topic Guide on the International Migration of Indonesian Nurses
for the Indonesian Embassies Overseas........................................................................ 79
APPENDIX O: Survey on Reasons for the International Migration of Indonesian
Nurses in Indonesian ...................................................................................................... 80
APPENDIX P: Survey on Reasons for the International Migration of Indonesian
Nurses in English ............................................................................................................ 85
APPENDIX Q: Research Timeline................................................................................ 91

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ABSTRACT
A Proposal for a Series of Studies to Explore the Phenomenon of the International
Migration of Indonesian Nurses (Under the direction of Rodney Lyn, Ph.D. and Bruce
Perry, M.D., MPH)
On January 1st
, 2014, Indonesia began implementing universal health coverage.
Despite the fact that the density of human resources for health (HRH) is far lower than
the International Labor Organization’s benchmark, the Indonesian government is
ambitiously committed to providing equal, quality, and extended healthcare services to an
estimated population of 257.5 million people by 2019 without putting them in financial
hardship. In addition, the government expects to ensure a minimum of 85% of the health
recipients is satisfied with attained healthcare services. With respect to nurses, the
massive international migration of qualified and motivated Indonesian nurses that has
taken place over the last decade is alleged to be one of the factors responsible for the low
density. However, at this point, very little publicly available information exists that
comprehensively displays the phenomenon. As such, to help stakeholders understand the
phenomenon, mitigate the recurrence of massive international migration of Indonesian
nurses, and make relevant data-driven HRH policies, a proposal for a series of studies to
reveal the phenomenon of the international migration of Indonesian nurses is developed.
An 18-month research project with various sampling methods, research instruments, and
research methods will be conducted to explore four main international nursing migration
issues from multiple study populations. The study populations include migrating and
returning Indonesian nurses, nursing organizations both in Indonesia and in four foreign
countries, local recruitment agencies, two government agencies in Indonesia, and several
Indonesian embassies overseas.
INDEX WORDS: universal health coverage, international nursing migration,
international migration of Indonesian nurses, migrating nurses, returning nurses,
recruitment agencies, Indonesian National Nurses Association, the Indonesian
government

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Chapter I
Introduction
The 2005 World Health and the 2012 United Nations General Assemblies have
been important landmarks in the implementation of universal health coverage (UHC)
(WHO, 2005; WHO 2010; UN, 2012). They encouraged many nations to provide
healthcare services to all their citizens without putting them into financial hardship
(WHO, 2012). Indonesia began transitioning to the UHC on January 1st
, 2014 as
regulated by the 2004 National Social Security System and the 2011 Social Security
Agency (BPJS) laws and guided by “The Road Map Towards National Health Insurance
– INA Medicare 2012-2019”, (RI, 2012). With the expected increase in total health
expenditure of gross domestic product from 2.7% in 2011 to around 4% in 2014, the
Indonesian government is ambitiously committed to covering a projected population of
257.5 million, providing equal medical and non-medical benefit packages, and ensuring a
satisfaction of minimal 85% of BPJS health services recipients by 2019 (RI, 2012;
GHWA & WHO, 2013; Widowati, 2013).
A strong health system manifested by sufficient, competent, motivated and
equitably distributed human resources for health (HRH), including nurses and midwives,
is crucial to achieve UHC (WHO, 2005; WHO, 2010; WHO, 2012; UN, 2012;
GHWA&WHO, 2013; ICN & ICM, 2013). According to the International Labor
Organization (ILO), to be able to provide quality, expanded healthcare services, a country
requires a 34.5 HRH per every 10,000 people (GHWA & WHO, 2013). The data revealed
that in 2012 the density of physicians, nurses, and midwives in Indonesia was only 20.6
per every 10,000 people (cited by Padilha et al., 2013). Even though this number

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increased from 16.1 per every 10,000 people in 2010 (GHWA & WHO, 2013), it was still
far lower than the ILO’s benchmark. With respect to the availability of nurses, the
migration of thousands of the Indonesian nurses overseas is also responsible for this low
density (WHO SEARO, 2010).
The international nursing migration in Indonesia is not a new issue (WHO
SEARO, 2010). Facilitated mainly by local recruiting agencies, the migration, which
began more than a decade ago, made Indonesia one of the major sending countries in
Asia (Hugo and Stahl, 2004; Matsuno, 2009; WHO SEARO, 2010). Economic,
professional and educational, personal, social, and political factors are found to be
primary drivers that motivate nurses to migrate (Dywili, Bonner, O’Brien, 2013). Despite
its potential benefits for both nurses and countries, an international nursing migration that
leads to the loss of qualified nurses in sending countries makes a fragile national health
system weaker, which further hampers the attainment of UHC (ICN, 2004; WHO, 2004;
WHO, 2005; Padilha et al, 2013; Sousa, Scheffler, Nyoni & Boerma, 2013).
While Indonesia is transitioning to UHC, nurses are expected to deal with new
demands and challenges (Padilha et al, 2013). As nursing legislation is not in place, or
when HRH policies are not data driven, which is currently happening, the transition to
UHC negatively impacts nurses’ outcomes, including nursing retention (GHWA &
WHO, 2013). This fact, which is bolstered by some studies, found that a poor nurse work
environment leads to nurse burnout, job dissatisfaction, and intention to leave the job
(Stimpfel, Sloane & Aiken, 2012; Kutney, Wu, Sloane & Aiken, 2013). These
professional issues drive attrition, international migration, and emigration of nurses
(Dywili, Bonner & O'Brien, 2013). Further, they can discourage people to enter the

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nursing profession and threaten the availability, accessibility, acceptability and quality of
future Indonesian nurses.
If the Indonesian government does not accompany an aspiration to achieve UHC
by 2019 with strategic planning of nursing profession, UHC may turn into a push factor
that leads to a recurrence of massive international migration of the Indonesian nurses.
Indeed, by 2035 both developing and developed nations will face around a 12.9 million
shortfall in skilled HRH. The United States of America (the U.S.), Europe, and Australia,
which currently have the highest density of HRH equal or greater than 59.4/10,000
people, are projected to lack 500,000 nurses by 2025, 2,000,000 by 2020, and 109,000 by
2025 consecutively (GWHA and WHO, 2013).
Due to various issues, inter alia, aging HRH and student nurses and faculty
recruitment challenges, countries such as the U.S. are projected to keep recruiting foreign
nurses (Wheeler, Foster & Hepburn, 2013). While there are countries whose international
recruitment of foreign nurses policies are not in place, some others have already had an
international recruitment code of conduct, yet these codes are not legally binding.
Accordingly, these countries will be potential destination countries for both Indonesian
recruitment agencies and nurses.
To prevent or to mitigate the impact of a perpetual international nursing
migration, the WHO (2004) and International Council of Nurses (ICN) (2007) have long
recommended that countries resolve the reasons for international nursing migration,
regulate recruitment agencies, establish collaboration with any institutions, and help
monitor the movement of HRH. They also requested that countries develop a mechanism
to support nurses who want to return to their home countries because of the benefits they

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may bring (WHO, 2004; ICN, 2007). There are numerous studies on international nursing
migration in other countries. However, there is limited information and publicly available
data on the international migration phenomenon of Indonesian nurses including the
implementations of the ICN’s and WHO’s recommendations.
Therefore, a study will be conducted as a contribution to the Indonesian
government that explores overseas placement occurrence as a strategy to improve health
human resources management as stated in the Indonesia Human Resources for Health
Development Plan 2011-2015. The findings are also expected to provide stakeholders
with a complete picture of international migration of the Indonesian nurses needed to
make both evidence-based and relevant HRH policies while the country progresses
toward the attainment of UHC by 2019. Thus, the study will attempt to address the
following issues and questions:
Reasons for International Nursing Migration:
1) What personal, social, professional/educational, economic, and political factors
motivate the Indonesian nurses to work overseas?
2) Which motivating factors strongly drive the Indonesian nurses to work overseas?
Return Migration Experiences:
3) What are the Indonesian nurses’ experiences with return migration?
Recruitment Agencies:
4) How do recruitment agencies work with respect to recruitment and placement
practice, nurses’ movement monitoring, and return migration promotion?

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Actions of the Indonesian Government and Nurses Associations:
5) What information can be learned from the Indonesian government and the nurses
associations about regulating local recruitment agencies, supporting return
migration, and monitoring nurses’ movement?

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Chapter II
Literature Review
Universal Health Coverage
Universal health coverage is defined as a goal to ensure that all people have
access to healthcare services without suffering from financial hardship (WHO, 2010;
WHO 2012). This concept had been long recognized in the 1948 WHO’s constitution and
the 1978 Alma-Ata declaration that acknowledged that health is a human right (WHO,
2010; WHO 2012). However, universal health coverage was out of many countries’
political agenda until the WHO’s 192 member states convened at the 58th
World Health
Assembly in May 2005. In this assembly, a number of member states conveyed their
concerns about health financing, which is fundamental to help protect public from a
financial hardship risk while they are seeking healthcare services. The concerns of these
member states prompted the WHO to adopt the “Sustainable Health Financing and
Universal Coverage and Social Health Insurance” resolution (WHA58.33) (WHO, 2005a;
WHO, 2005b).
Since then, the UHC has become the WHO’s priority agenda. Efforts were put
together to help guide member states either to transition into or progress towards the
UHC. One of the endeavors was by issuing the 2010 World Health report that
comprehensively discussed health system financing for UHC (WHO, 2010c).
UHC gained momentum in December 2012 while the United Nations (UN)
recognized the world’s commitment to UHC and urged the member states’ government to
move towards UHC (UN, 2012a; UN, 2012b). Encouraged by the UN’s support, the

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WHO and World Bank then convened a ministerial meeting in February 2013 to start
exploring the best way for countries to progress toward UHC. The finance and health
ministries from 27 countries attended this summon. It included some delegates from
Indonesia (WHO, 2013).
Universal Health Coverage in Indonesia
Worth noting as well, the aspiration to provide quality and expanded healthcare
services for all population in Indonesia had been initiated in 2004. This goal was
manifested by the enactment of law on the National Social Security System No. 40/2004,
which mandated the country establish the National Social Protection System (Sistem
Jaminan Sosial Nasional (SSJN)) (Widowati, 2013). Due to lack of political commitment
and some challenges, the implementation of the law did not progress as expected.
Four years later the notion of UHC resurfaced in the nation. Another act titled the
Social Security Act was enacted in 2008, and National Social Security Council was also
established. However, it was in 2009, when a presidential election campaign was being
held, that the law attracted the attention of politicians (Widowati, 2013).
A year later health financing and health insurance issues accompanied the
country’s aspiration to transition into UHC. Disputes between national parliament and
central government occupied political situation. On one side, national parliament that
drafted the bill of National Security Agency (Badan Penyelenggara Jaminan Social
(BPJS)) insisted on merging four state insurance companies into one non-profit social
protection agency. On the other side, the central government, especially the Ministry of
State Owned Enterprises, stood firm on the idea of keeping those four insurance
companies as profit oriented entities. With some mutual solutions, finally, BPJS and the

15

central government agreed to enact the BPJS bill that became the law No. 24/2011 in
2011 (Widowati, 2013).
The law officially ordered the country to establish two national agencies: BPJS I
and II. While BPJS I has to handle health insurance, BPJS II must focus on employment
benefits that include injury, retirement, pension and death. Also, the law mandated that
by 2029 the state-owned insurance companies (Jamkesmas, government-financed health
insurance programme for the poor and near-poor; other health insurance programs, such
as Askes, Jamsostek; and some local health insurance schemes (Jamkesda)) would hand
over their beneficiaries to both BPJS I and II. PT Askes, previously a profit health
insurance programs for Indonesian civil servant, was then altered into BPJS I, a non-
profit agency that will manage national social health insurance programs (Widowati,
2013).
To guide the country to transition into UHC on January 1st
, 2014, the Ministry of
Health supported by other ministries and national and international relevant stakeholders
designed “A road map to National Health Insurance-INA Medicare 2012-2019 (Peta
Jalan Menuju Jaminan Kesehatan Nasional 2012-2019) (RI, 2012)”. With this road map
in place, Indonesia is committed to progressing toward the attainment of UHC by 2019.
To be able to measure the achievement, the roadmap highlighted two stages with 16
targets (RI, 2012).
Stage one, set up for January 2014, has eight targets. Those targets are: 1)
necessary implementing regulations are in place, 2) BPJS is operated in January 1, 2012
as per Law No. 24/2011, 3) minimal 121.6 million people are covered by BPJS I, 4)
medical benefits are equal for all populations, though there are some differences in non-

16

medical benefits, 5) action plan for health facilities development is in place and will be
gradually implemented, 6) at least 75% of beneficiaries are satisfied with health services
of the BPJS, 7) at least 75% of health facilities are contented with the BPJS service, and
8) BPJS financial management is transparent, efficient and accountable (RI, 2012).
The second stage is established for 2019. This stage also has eight targets. They
are: 1) people fully trust BPJS, 2) all populations, projected to be 257.5 million, are
covered by BPJS, 3) both medical and non-medical health services are equal for all
participants, 4) health facilities are equally distributed, 5) laws and regulations are
adjusted according to situation and condition, 6) a minimum of 85% of the participants
are contested with services provided by both health facilities and health services of the
BPJS, 7) at least 80% of health facilities are satisfied with BPJS’ services, 8) the BPJS
financial management is fully transparent, efficient and accountable (RI, 2012).
Universal Health Coverage and Human Resources for Health
To successfully achieve those 16 UHC’s established targets, a functional health
system is essential. In order for a health system to function, human resources for health
(HRH), which is one of building blocks of a health system, are critical (GHWA&WHO,
2013b; WHO, 2013a). Padilha, et al (2013) asserted that a country will not attain UHC
without HRH, and lack of HRH hampers the attainment of UHC. Not only do HRH have
to be well trained, competent and motivated, but they also have to be adequate in
numbers (WHO, 2005; WHO, 2010; WHO, 2012; UN, 2012).
In addition, HRH need to fulfill four dimensions that are congruent with the
dimensions of effective health services as established in the 2012 International Labor
Organization’s (ILO) Social Protection Floors. These dimensions are availability,

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accessibility, acceptability and quality (Adlung, 2013; GHWA&WHO, 2013). First,
availability means the adequate supply and demand of competent HRH. To help countries
estimate HRH requirement while providing expanded healthcare services to people, the
ILO establishes a staff access deficit indicator. The benchmark is 34.5 physicians, nurses
and midwives per every 10,000 people. Second, accessibility refers to available HRH that
are equitably accessible to all people. More precisely, accessibility means population in
rural and remote areas seeking healthcare services can access HRH as equal as those in
urban areas. Third, acceptability refers to HRH whose characteristics meet the
expectations of people seeking healthcare services. Having cultural competence and
sensitivity and having attitude and behavior that build trust are some of these
characteristics. Lastly, quality is a package of HRH’s behavior, knowledge, competency
and skill that is in congruent with professional norms (GHWA&WHO, 2013).
Of all dimensions of HRH, availability is the basis for the other dimensions.
However, in many developing countries, the availability of HRH is low, and this
availability issue hinders countries to either transition to or progress toward UHC (Sousa,
et al, 2013). To solve this global issue, a country’s global HRH crisis was mapped out by
using an HRH benchmark, a 22.8 HRH per every 10,000 people, set up by the Joint
Learning Initiative from 2002 to 2004. In 2006, the WHO further developed the
benchmark. This benchmark showed that in 2013 around 83 countries experienced low
HRH density and low service coverage (GHWA & WHO, 2013).
Additionally, to resolve access deficits in the coverage of population when
healthcare services are being expanded, the ILO developed a benchmark. The benchmark
entitled a staff access deficit indicator (SAD), sets a higher HRH threshold than that of

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the WHO’s. The SAD’s threshold is 34.5 physicians, nurses, and midwives per every
10,000 people. The ILO’s benchmark revealed that approximately 100 countries fell
below the threshold (GHWA&WHO, 2013). Based on the WHO’s and ILO’s benchmark,
it is clear that Indonesia has low HRH density and healthcare services coverage.
International Nursing Migration
Of several factors that result in HRH availability issue, international migration is
the most central and has grabbed global attention. The International Organization of
Migration (IOM) defines migration as “a process of moving, either across an
international border, or within state” (IOM, 2004). Migration can take place among
developing countries, among developed countries, and from developing to developed
countries (Dywili et al, 2013).
Migration cannot be prevented. It is, in fact, one of the human being’s rights that
are guaranteed in the article 13 of the universal declaration of human rights (UN, 1948).
With respect to nursing migration, the International Council of Nurses (ICN), the
federation of over 130 national nurses associations, has recognized the right of nurses to
migrate regardless of their reasons. The ICN endorses this nurses’ right on “the Nurse
Retention and Migration” position statement (ICN, 2007).
Causes of International Nursing Migration
While nursing shortage in many developed countries (receiving countries) is the
leading cause of international nursing recruitment, fragile health system in developing
nations (sending countries) is the main reason for international nursing migration (ICN,
2007). Many studied revealed that the existences of push and pull factors are the main
drivers of international nursing migration. Pull factors refer to lucrative conditions in

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foreign countries that attract nurses to migrate and work overseas. Push factors, on the
flipped side, are conditions in home country that push nurses to leave (Kline, 2003).
Both push and pull factors primarily can be economic, social,
professional/educational, personal, and political reasons (Dywili et al, 2013). Economic
factor delineates money, politic factor relates to government decisions or power, and
professional/educational factor is associated with the job as a nurse. Additionally,
personal factor is correlated to preference or choice and social factor relates to family and
society. While both push and pull factors drive nurses overseas, they offer valuable
opportunities for both public and private sectors, such as recruitment agencies, to run and
develop huge profit-making business (Kingma, 2008).
Recruitment Agencies
According to the WHO (2003), recruitment agencies have played a fundamental
role in the occurrence of international nursing recruitment and migration. On one side,
they have diminished the problems of hospitals that are suffering from massive nursing
shortage by recruiting foreign nurses. On the other side, recruitment agencies have helped
nurses who want to work to foreign countries regardless of those nurses’ reasons by
sending them overseas.
Realizing their important position, not a few recruitment agencies perform an
unethical recruitment and placement practice. This unethical practice frequently happens
to nurses who have a serious aspiration to work overseas but have to rely on the services
of recruitment agencies. Some of unethical practices that recruitment agencies do are
failing to provide nurses with clear information, giving fake promises and treating nurses
with a deportation. Worth knowing, even though recruitment agencies charge a hospital

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either a standard fee or an hourly basis fee for international recruitment services they
provide, many recruitment agencies also charge nurses with a big amount of money.
Nurses have to struggle to get money to pay a recruitment agency but will never get their
money back when recruitment agencies fail to send them overseas. Unfortunately, nurses’
strong desire to work overseas has put most of them in a lower bargaining position
(Gostin, 2008).
Impacts of International Nursing Migration
International nursing migration poses both positive and negative repercussions.
Even though it gives nurses more advantages than drawbacks, the migration brings
positive and negative to a country. Negatively, the migration causes nursing shortage or
brain drain, which is defined as the loss of motivated, highly educated, and trained nurses
(WHO, 2010). As HRH is one of the health system’s building blocks, the loss of
competent nurses makes the national’s health system weaker (WHO, 2004; Gostin, 2008;
Matsuno, 2009). Further, a weak health system impedes the achievement of international
targets, such as the Millennium Development Goal or universal health coverage (WHO,
2006).
On the flipped side, international nursing migration poses positive impacts
(WHO, 2010). While nurses are working overseas, they are sending money, remittance,
to their home country. Money they send will not only improve the prosperity of their
family members, but also increase country’s economic development. When nurses return
to their home country, the country benefits from nurses’ new and advanced skills,
knowledge, and experience (ICN, 2007). Further, quality healthcare services returning

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nurses deliver to people help strengthen countries’ health system (ICNM, 2008; WHO,
2010).
Return Migration
A return migration is “the process of a person returning to his/her country of
origin or habitual residence…” (Cited by ICNM, 2008). According to King (2000) as
cited by ICNM in 2008, there are several factors that cause return migration. They are
economic, social, family/life cycle, and political factors. One common example of
economic factor is a contract termination. While the issues of integration difficulty in
foreign countries and homesickness are examples of social factor, retirement, children’s
education, and marriage become family/life cycle factors that influence nurses to return
home. Additionally, the example of political factor is the end of governments’ agreement
on sending and receiving workforce.
If managed well, return migration can benefit a country. As such, as
recommended by the ICN (2007) and the WHO (2010), a country should establish a
mechanism that supports nurses to return home. A country also should prepare the return
process of migrating nurses and help returning nurses ease challenges they may face.
Some of the challenges the returning nurses often experience are difficulty to readjust to
the home country due to unwelcome attitudes of coworkers and limited resources to
apply new skills and experience (ICNM, 2008). Failure to resolve these difficulties may
encourage nurses to re-migrate, discourage other nurses to return to home country and
motivate many nurses to emigrate.

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International Organizations’ Recommendations
International migration of HRH, mainly nurses’ migration, is not only the concern
of many nations, but also of international health organizations, such as the WHO and the
ICN. These organizations have performed a great number of efforts to mitigate the
impacts of international migration. Some of those endeavors were the adoption of the
international migration-related resolutions, codes of practice, world health reports, and
position statements.
The first resolution on HRH’s international migration the WHO adopted was the
World Health Assembly (WHA) 57.19 in 2004 entitled the “International Migration of
Health Personnel: a Challenge for Health Systems In Developing Countries.” The
resolution appealed to member states to establish strategies to mitigate the negative
impacts of international migration of HRH and to develop effective policies. The
resolution also urged member states to support a G-to-G agreement with receiving
countries to regulate international migration (WHO, 2004).
A year later, the WHO adopted the resolution on “the International Migration of
Health Personnel.” The resolution asked the WHO’s Director General to establish
programs for HRH development. The adoption of this resolution took place at the same
WHA as the adoption of the resolution on “Sustainable Health Financing and Universal
Coverage and Social Health Insurance” (WHO, 2005b).
In 2010, the prevailing international migration of HRH drew many countries’
attention. Accordingly, on May 21, around 193 member states of the WHO assembled to
find a solution for regulating HRH’s international migration practices. These countries
agreed to adopt “the WHO Code of Practice on the International Recruitment of Health

23

Personnel.” The code requested that the member states’ national government establish a
national authority to implement the code and periodically report the international
migration practices. Concerning recruitment agencies, the code recommended that the
WHO’s member countries use only agencies that abode by ethical recruitment principles.
Since the code was adopted, the national authorities have been established in many
countries.
In addition, the code called for stakeholders who were concerned about HRH
international recruitment and migration to help gather evidence-based data to be shared
worldwide through the WHO secretariat. The data will be used to help countries put
forward effective national actions on alleviating the negative impacts of HRH’s inflow
and outflow. Moreover, the evidence will help invigorate global cooperation to regulate
international recruitment and migration and strengthen national and global health system
(WHO, 2011a).
To be committed to strengthening health systems, in the sixty-fourth WHA, the
WHO adopted five resolutions. Of those resolutions, two were related with HRH. They
included the WHA 64.6 (2011) on “Health Workforce Strengthening” and the WHA 64.7
(2011) on “Strengthening Nursing and Midwifery.” Additionally, with respect to UHC,
the WHO adopted the resolution on “sustainable Health Financing Structures and
Universal Health Coverage of Health Care and Services” (WHO, 2011b).
Similarly, to regulate international nursing migration, the ICN, the federation of
more than 130 National Nurses Associations in the world, issued two position statements.
Those position statements were “Ethical Nurse Recruitment” and “Nurse Retention and
Migration.” They recommended that the ICN’s country members mitigate the impacts of

24

international nursing migration by resolving the reasons for migration and strengthening
nursing profession. The ICN also requested that the countries regulate the recruitment
agencies, monitor the movement of nurses, and corroborate the return migration of
nurses.
To protect nurses from exploitation and other international recruitment practice’s
harms, the ICN asked for its country members to regulate recruitment process and
establish a disciplinary mechanism for recruitment agencies that violate ethical
recruitment. To track the nurses’ movement, the ICN suggested that the countries
collaborate with relevant organizations and institutions. Furthermore, the ICN highlights
principles of nurses’ rights that have to be fulfilled when the nurses are sent overseas.
Some of those principles include full employment access, movement and discrimination
freedom, consistent working contract, equal remuneration, and safe work environment
(ICN, 2007).
Lastly, these organizations also encouraged the development of international
nursing migration-related codes of practice. Some of the receiving nations that
established the code of practice were Commonwealth countries, the U.K, and U.S. The
Commonwealth countries established its “Commonwealth Code of Practice for the
International Recruitment of Health Workers” in 2003. The code stated that the
commonwealth countries were not allowed to recruit foreign nurses from countries that
were suffering from nursing shortage (The Commonwealth, 2003). Similarly, in 2004 the
U.K developed the “Code of Practice for International Recruitment of Healthcare
Professionals.” This code mandated any entity not to recruit foreign nurses from
developing countries (DH-UK, 2004; Matsuno, 2009). Likewise, in 2008, the American

25

Nurses Association developed the “Code of Conduct for the Ethical Recruitment of
Foreign Educated Nurses to the United States” (ANA, 2008). The code regulated the
recruitment of international nurses who were interested in working in the U.S.
The Profile of Human Resources for Health in Indonesia and the International
Migration of Indonesian Nurses
From a global perspective, as reported by the WHO, in November 2010,
Indonesia was one of 57 countries that suffered from a critical HRH shortage with the
density of only 16.1 physicians, nurses, and midwives per every 10,000 people (WHO,
2010a). Even though the HRH density showed an increase to 20.6 HRH per every 10,000
people in 2012 (cited by Padilha et al., 2013), Indonesia still fell into the group of
countries with a low HRH density and service coverage (GWHA & WHO, 2013). As
reported by the Ministry of Health of Indonesia to the WHO, in 2012 Indonesia had 13.83
nurses and midwives per every 10,000 people and around 2.04 physicians per every
10,000 people. In 2013 Indonesia was one of 83 countries that had skilled HRH lower
than 22.8 per every 10,000 people, and coverage of births attended by skilled birth
attendants was less than 80% (GWHA & WHO, 2013).
According to the former president of the Indonesian National Nurses Association,
the mismanagement of nurses’ recruitment and placement nationally was one of the
reasons that cause the low numbers of nurses in Indonesia. In addition, the attrition of
nurses as they both were not employed and chose to work in another sector was also
responsible for the lack of the Indonesian nurses (Senior, 2010). In 2010, the WHO South
East Asia Region (WHO SEARO) added that another reason that causes the nursing
shortage was the international migration of Indonesian nurses.

26

As of now, there is no study that has been conducted to prove the relationship
between the international migration of Indonesian nurses and the prevailing nursing
shortage. However, in its report, the WHO SEARO disclosed that up to 2009,
approximately 2,829 qualified Indonesian nurses migrated overseas, such as to the United
States of America, Asia, the Middle East, and European countries (WHO SEARO, 2010).
The inconsistency of the number of the Indonesian nurses who migrated overseas was
found when Anggriani (2011) reported that around 9,705 had migrated overseas from
1989 to 2010.
Similar to other sending countries, the international migration of Indonesian
nurses was primarily facilitated by a recruitment agency through either private-to-private
(P-to-P) or private-to-government (P-to-G) nurses placement program agreements. The P-
to-P program agreement is an arrangement between an Indonesian’s recruitment agency
and either a foreign recruiting agency or a foreign private health institution. Conversely,
the P-to-G program is an agreement between an Indonesian recruitment agency and either
the Ministry of Health or the government’s hospital overseas.
However, since the negative impacts of international migration became the center
of the world’s attention, many countries such as U.K have issued a code of practice to
regulate international recruitment practices (The Commonwealth, 2003). Most of those
codes discourage a country from recruiting nurses from the developing countries where
the health system has been already fragile. This recommendation greatly affects local
recruitment agencies in Indonesia. Accordingly, many recruitment agencies lose a
lucrative global labor market. Some of the recruitment agencies even have collapsed as
many developed countries, such as the United Kingdom, have stopped recruiting

27

international nurses, including Indonesian nurses. Regardless of the existence of these
codes of practice, some local recruitment agencies still maintain their business by
targeting countries that do not have a strict regulation on international nurses recruitment.
In addition, the facts that the world is experiencing a shortage of 12.9 million HRH, and
developed countries are heading to an impending nursing shortage (GWHA & WHO,
2013) have encouraged many recruitment agencies to continue to exist.
Besides nurses’ recruitment and placement practices by recruitment agencies, the
Indonesian’s Board for Development and Empowerment Human Resources for Health
also has actively sent Indonesian nurses overseas. Through G-to-G placement program,
the government has sent 1,048 nurses to Japan between 2008 and 2013. This practice is
projected to continue since the head of this agency is committed to taking a chance of
significant demands of skilled and professional workforces offered by the Asia Pacific
region, the Middle East, Europe, and Africa (BNP2TKI, 2011).
Following “The WHO Global Code of Practice on the International Recruitment
of Health Personnel” (the code), Indonesia, a country that recognizes the impacts of the
international nursing migration established a national authority named the Board for
Development and Empowerment Human Resources for Health (BDEHRH) Ministry of
Health of Indonesia in 2010. The BDEHRH is responsible to implement the code and
report HRH international migration information to the WHO on a regular basis. In
addition, supported by the Global Health Workforce Alliance and Deutsche Gesellschaft
für Internationale Zusammenarbeit, the Indonesian government has also developed “The
Indonesia Human Resources for Health Development Plan 2011-2025”. In this HRH

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plan, Indonesia is committed to improving the management of HRH by regulating the
international nursing migration.

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Chapter III
Methods and Procedures
Study Populations
To be able to investigate the phenomenon of the international migration of
Indonesian nurses, the researcher uses multiple study populations. They are: 1) migrating
nurses, 2) returning nurses, 3) recruitment agencies, 4) the Indonesian government and 5)
the Indonesian National Nurses Associations.
Inclusion and Exclusion Criteria
Migrating Nurses
The study defines migrating nurses as the Indonesian nurses who are working overseas in
any nursing fields either part time or full time. Nonetheless, the study will not include
nurses who are Indonesians but receive their initial nursing credentials in any foreign
country. The researcher uses migrating nurses to explore their reasons for taking part in
international migration. Due to the reason that migrating to foreign countries for the first
time is different from that for the second time (Alonso-Garbayo & Maben (2009), the
study will solely focus on the first migration. Lastly, since the reason for leaving the
home country is much influenced by dissatisfaction with the nation’s conditions, the
researcher will ask the nurses only about the reasons that drive them to migrate overseas
for the first time.

30

Returning Nurses
To investigate return migration experiences, the study uses the returning nurses.
Returning nurses are those who have returned to Indonesia from their international
migration and are no longer bound by any working contract overseas.
To investigate recruitment agencies, the study only includes the Indonesian recruitment
agencies based in Indonesia that have experience with recruiting and sending Indonesian
nurses overseas.
The Indonesian Government
To examine the actions of relevant stakeholders on international nursing migration, the
study involves the Indonesian government. The relevant Indonesian government agencies
that are considered to directly relate with the phenomenon of the international migration
of Indonesian nurses are the Board for Development and Empowerment Human
Resources for Health of Ministry of Health of Indonesia (BDEHRH), the National Board
for the Protection of Indonesian Overseas Workers (BNP2TKI), and the Indonesian
embassies in foreign countries where the Indonesian nurses work.
The Indonesian National Nurses Associations (INNAs)
The study will only include the central board of INNA in Jakarta, which heads 34
provincial INNAs. Also, this study involves all branches of the Indonesian National
Nurses Associations established in foreign countries—Japan, Kuwait, Netherlands and
Qatar.

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Sampling Methods
Migrating Nurses
Since there is no accurate information about which foreign countries the Indonesian
nurses migrate to and work in, the study is not able to create a sampling frame for a
probability sampling. Thus, this study will use snowball sampling.
Returning Nurses
Similarly, there are no available data of nurses who have returned to Indonesia.
Therefore, this study will use snowball sampling.
Snowball sampling, which is a type of purposive sampling, is used to persuade local
recruitment agencies in Indonesia to participate in the study.
The study deliberately selects BDEHRH and BNP2TKI because they are the government
agencies that considerably deal with the international migration of the Indonesian nurses.
Thus, an expert sampling, which is part of purposive sampling, is used. However, the
study uses chain referral sampling to identify the Indonesian embassies overseas where
the Indonesian nurses work.
The Indonesian National Nurses Associations
To select the INNAs, the study uses expert sampling. The INNAs included are the
Central Board of INNA and all four branches of INNAs established in Japan,
Netherlands, Kuwait and Qatar.

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Institutional Research Committee (IRB)
The study will seek approval from the IRB at National Institute of Health Research and
Development, Ministry of Health, Indonesia.
Recruitment Methods, Informed Consents, and Data Collection Methods
Migrating Nurses
Once the study gets research approval from the IRB, the researcher will email
potential study participants and the presidents of the branches of INNAs in Japan,
Kuwait, Netherlands, and Qatar. The researcher will notify them that she is going to
conduct the study on the reasons for the international migration of Indonesian nurses. Not
only will the researcher ask whether they are willing to participate in the study, but she
will also ask if they can help identify other potential study participants. If they agree with
these requests, the researcher will send them two follow-up emails. One email embeds
the link of anonymous Internet survey for them to complete and any other is an invitation
email for them to forward to other future study participants.
To acquire as many study participants as possible, the researcher will also post a
survey invitation in Facebook page group of the branches INNAs. Even though not all of
the Indonesian nurses working overseas are members of this social network, many have
joined as members. The identified available Facebook groups are the Indonesian National
Nurses Association in Japan (INNA-PPNI Japan) (Japan), INNA-K PPNI (Kuwait), PPNI
Belanda (Netherlands) and PPNI Perwakilan Qatar (Qatar).
If the researcher receives either email or Facebook message from potential study
participants, the researcher will send them a reply to provide information about the study.
In this email, the link of Internet survey is embedded. For this study population, a tacit

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informed consent will be attained; that is, when study participants click the link for the
Internet survey, they are providing their consent. There is no incentive for this study
population. Data collection will be carried out over four months.
Returning Nurses
Some Indonesian nurses who no longer work overseas and have returned to
Indonesia will be contacted. A minimum of 20 participants is expected to join the study.
Through a phone call, email or Facebook message, they will be notified about research
that will be conducted. The researcher will ask them if they are interested in participating
in the study. If they agree to participate, the researcher will conduct a semi-structured
interview in Indonesian through either phone or face-to-face interview.
Prior to interview, the researcher will have study participants sign an informed
consent form. If the interview is a phone interview, informed consent will be taken via
email prior to the interview (Appendix B). If the interview is a face-to-face interview, the
researcher will attain informed consent when meeting with study participants. The
interview will then be conducted in a comfortable, confidential place. A tape recorder
will be used to record the conversation with the approval of study participants. The
estimated time of interview will not exceed 90 minutes. However, study participants are
free to withdraw at any time during the interview without any penalty. However, only
study participants who complete interview receive an incentive as much as 100,000
rupiah or ten U.S dollars.
Study participants are also asked if they can help the researcher to identify other
Indonesian nurses who no longer work overseas and have returned to Indonesia. Once the
researcher gets a response from those potential candidates, the researcher will explain the

34

study and its purpose. To collect the data, potential study participants will be treated as
the same way as their referees.
The researcher will visit several recruitment agencies she is familiar with to meet
either the director or representative of the agencies. These individuals will be notified that
the researcher will be conducting a study about international migration of the Indonesian
nurses. If they agree to participate in the study, then the researcher will hand in an
informed consent form for them to sign (Appendix C). A semi-structured interview in
Indonesian will then be conducted for not more than 90 minutes. The interview will be
recorded by using a tape recorder with the approval of study participants. However, there
is no incentive allocated for participating recruitment agencies.
To get more recruitment agencies, the researcher will also ask if the recruitment
agencies are willing to help the researcher identify the other local recruitment agencies.
Once the researcher receives an email from potential recruitment agencies showing an
interest to participate in the study, the researcher will then come to the agencies’ offices
to explain the study. If they agree to participate, the researcher will perform the same
treatments as those given to their referees.
Once the researcher can identify the foreign countries in which migrating nurses
work, the researcher will then send an email about ongoing research to the available
Indonesian embassies. This email invites the embassies to participate in the study. If they
agree, they will receive another email where they can find an informed consent form to
sign (Appendix A). Once the researcher receives the signed informed consent form, a

35

semi-structured international phone call interview will be set up. With the approval of
study participants, the interview conducted in Indonesian will be recorded by using a tape
recorder. Interviews will not exceed 90 minutes. There will be no incentive allocated for
this study population.
With respect to BDEHRH and BNP2TKI, the researcher will come to the offices
of these two government agencies. A meeting appointment with representative of these
boards will be set up. The researcher will explain the study and ask if the agency can
participate. If they agree, the researcher will give an informed consent form to sign
(Appendix D and Appendix E).
A semi-structured interview conducted in Indonesian will be recorded by a tape
recorder with the approval of the study participants. The interview will be conducted by
the researcher and will last no more than 90 minutes. There will be no incentive for this
study population.
The Indonesian National Nurses Associations
Once meeting appointment is made, the researcher will come to the Central Board
of INNA in Jakarta to explain the study that is being conducted. The president or
representative will be asked to participate. If they agree, the researcher will ask them to
sign an informed consent form (Appendix F). The researcher will conduct a semi-
structured interview in Indonesian for no more than 90 minutes. The interview will be
recorded by a tape recorder with the approval of the study participant. There will be no
incentive for this study population.
To collect data from the branches of INNAs in Japan, Kuwait, Netherlands and
Qatar, the researcher will send them an email about the study. They will be asked if they

36

are interested in participating. If they agree to participate, they will receive another email
from the researcher. This email will embed an informed consent form (Appendix G). A
semi-structured international phone call interview in Indonesian will be conducted for no
more than one hour. The interview will be recorded by a tape recorder with the approval
of the study participants. Similarly, there will be no incentive for this study population.
The Research Instruments
The study uses two types of research instrument. They are interview topic guide and
questionnaire.
Topic Guides for Interview
The topic guides that have list of key questions are developed for interviewing
returning nurses, recruitment agencies, BDEHRH, BNP2TKI, the central Board of INNA,
the branches of INNAs overseas and the Indonesian embassies overseas (Appendix H, I,
J, K, L, M, N). The topic guide for returning nurses asks participants to provide personal
information before and while working overseas, information about the return and
reintegration processes. The topic guide for recruitment agencies will explore recruitment
agencies’ general information, recruitment and placement practices, nurses’ movement
monitoring, and return migration promotion.
The topic guides for BDEHRH and BNP2TKI will investigate recruitment
agencies’ practice regulations, nurses’ movement monitoring and return migration
support. The topic guide for the Indonesian embassies overseas and the central Board of
INNA will request INNA’s general information, recruitment agencies’ practices
regulations, nurses’ movement monitoring, and return migration support. Whereas, the

37

branches of INNAs overseas will only cover INNA’s general information, nurses’
movement monitoring and return migration support.
Questionnaire for Internet Survey
Internet survey will be conducted for migrating nurses. To keep study
participants’ confidentiality, the questionnaires are designed to be anonymous.
Questionnaire that will be distributed to migrating nurses is written both in Indonesian
(Appendix O). The link of the questionnaire will be embedded in the email.
The questionnaire for migrating nurses has six sections and 36 items. Section one
investigates the Indonesian nurses’ reasons for working overseas. In this section, five of
the biggest driving factors of international nursing migration are enumerated. Those
factors encompass personal, social, professional/education, economic, and political
reasons. Each type of reason is defined briefly to give study participants an idea about the
definition. Under each type of reason, several specific reasons are listed. Personal and
social categories have three specific reasons. Professional/educational category has six
specific reasons, economic category has four specific reasons and political category has
three specific reasons.
Study participants will have to respond to each specific reason listed under each
category by selecting one of six points Likert-type scales. The points on the scale range
from very strong, strong, somewhat strong, somewhat weak, weak and very weak. To
allow study participants to write other reasons they might have, the researcher provided a
space in the second section.
Section three will explore study participant’s information before they migrate and
work overseas. This section consists of nine questions. Those questions are age

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(continuous variable), highest nursing education (categorical variable), and years of
working experience (continuous variable). Also, this section asks about workplace
(categorical variable), last nursing position (categorical variable), type of institution
(dichotomous variable) and location of the workplace (dichotomous variable). In
addition, this section will investigate who facilitated their international migration
(categorical variable). The participants will further be asked if they ever had bad
experiences with any Indonesian recruitment agency (dichotomous variable).
Section four will explore nurses’ current information. This section consists of
seven questions. Those seven questions probe their country of current residency (open-
ended question), gender (dichotomous variable), current nursing education level
(categorical variable), current workplace (categorical variable), current nursing position
(categorical variable), and current citizenship (categorical variable). In addition, this
section asks whether they have a plan to return and work again in Indonesia (categorical
variable).
Validity and Reliability of the Research Instruments
Questionnaire Validity
Before the questionnaire could be drafted, the researcher conducted a focus group.
The focus group consisted of seven Indonesian nurses who no longer work overseas and
have returned to Indonesia. The focus group was held from March 7 to March 11 2014 to
discuss about some hypothetical reasons that drive the Indonesian nurses to migrate
overseas.
To improve questionnaires’ structure validity for migrating nurses, three faculty
members of the School of Public Health at Georgia State University helped review the

39

questionnaire. For this purpose, the researcher used the questionnaire that she wrote in
English (Appendix P). Their feedback was then used to revise the questionnaire. To
enhance questionnaire’s content validity, the researcher will do four steps. These four
steps will involve five Indonesian nurse leaders who have firsthand experiences with
international nursing migration and one professor who used to get involved in the
recruitment agency. In addition, the professor was the former president of the central
Board of INNA Jakarta.
The first step will be carried out by asking for input from two nursing leaders who
have returned to Indonesia from their international migration to Kuwait and Saudi
Arabia. Second, the researcher will contact an Indonesian nursing leader who used to be
the head of the International Nurse Trainer’s organization in Qatar. Third, the drafts of
the questionnaires will be sent to two Indonesian nursing leaders who are currently
studying master and doctoral science of nursing in the Philippines and Canada. These two
nurses also used to work for local recruitment agencies and have experience with
international nursing migration. Lastly, the questionnaires will be sent to the former
president of the Central Board of INNA.
Questionnaires Reliability
To check the reliability of the questionnaire for migrating nurses, the researcher
will complete two steps. First, the researcher will conduct a pilot study through the test-
retest reliability. The researcher will then measure the internal consistency of the
questionnaires.
To do the test-retest reliability, the researcher will use 15 Indonesian nurses who
have returned to Indonesia from their migration. The first step will only involve five

40

nurses. These nurses will receive the questionnaire. They are asked to respond to the
questionnaire and then to give feedback. Their feedback is then used to improve the
questionnaire’s items. After one week, the researcher will test ten other nurses. They will
be asked to do the same. Again, based on their feedback, the researcher will improve the
questionnaire.
To examine questionnaire’s internal consistency, these completed 15 surveys
from 15 nurses will be analyzed. The researcher will use a Cronbach’s Alpha Coefficient
by using the IBM SPSS 21. Negatively worded questions will be reversed. Reliability
statistics, item statistics, inter-item correlation matrix, summary item statistics, item-total
statistics and scale statistics will be reported.
The Cronbach’s alpha value is expected to be greater than .8. The corrected item-
total correlation in the item-total statistics is expected to be more than .3. The
Chronbach’s alpha if item deleted is expected to be less than the Cronbach’s alpha value.
If findings of the reliability test violate the values above, poor items of the questionnaire
will be deleted and/or the number of items will be increased.
Interview Topic Guides Validity / Trustworthiness
To improve topic guides’ trustworthiness, the researcher will complete all
interview topic guides’ content validity. One faculty member of the School of Public
Health at Georgia State University who excels at qualitative study helped the researcher
review the interview topic guides on March 2014. The next step is that the researcher will
use six Indonesian nursing leaders. One of these nurses is the former president of the
Central Board of INNA Jakarta and the remaining five nurses used to work for local

41

recruitment agencies. They are expected to give feedback, and their input will then be
used to improve the interview topic guides.
Interview Topic Guides Reliability
To test the reliability of the topic guides, a pilot interview will be conducted. Four
nursing leaders who previously worked overseas and got involved in a recruitment
agency in Indonesia will be used. The researcher will ask these four nursing leaders to
review the content of the improved interview topic guides. They are also asked to give
input if the key questions listed are relevant and culturally and politically appropriate.
Feedback will then be used to improve the topic guides.
Next, the researcher will do an interview practice with those nursing leaders. The
time will be recorded to identify if the interview runs too short or too long. Less than a
ninety-minute interview will be expected for each interview practice. Finally, the
improvement of interview topic guides will be finalized when these two steps are
completed.
Data Analyses
To answer the research questions, the study uses statistical analyses as described below:
1. Reasons for International Nursing Migration:
a. What personal, social, professional/educational, economic, and political
factors motivate Indonesian nurses to migrate and work overseas?
To answer this question, a quantitative research method is used. A univariate
statistical method, which is statistical descriptive, will be used to report the profile
of the migrating nurses. A multivariate statistical method, which is logistic

42

regression, will be used to predict reasons for international migration of the
Indonesian nurses.
b. Which motivating factors strongly drive the Indonesian nurses to work
overseas?
The researcher will use an analysis factorial ANOVA to answer this question.
2. Return Migration Experiences:
What are the Indonesian nurses’ experiences with return migration?
To answer this question, the transcendental phenomenological approach of
qualitative design is used. The statistical method will provide a profile of the
returning nurses and reveal the returning nurses’ experiences with the return and
reintegration processes.
3. Recruitment Agencies:
How do recruitment agencies work with respect to recruitment and placement
practice, nurses’ movement monitoring, and return migration promotion?
The researcher will use the systematic procedures of the grounded theory approach
of qualitative design to answer this question.
4. Actions of the Indonesian Government and Nurses Associations:
What information can be learned from the Indonesian government and the nurses
associations about regulating local recruitment agencies, supporting return
migration, and monitoring nurses’ movement?
This question will be answered by using the systematic procedures of the grounded
theory approach of qualitative design.

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Data Management
Quantitative Research Method
First, the researcher will develop a codebook for the questionnaire. Both closed
and open-ended data collected from all study participants will be coded. The dataset will
then be imported into IBM SPSS 21. Before statistical analysis can be run, the data will
be screened for errors for each categorical and continuous variable. Individual items that
make up the scale will also be checked. For categorical data, minimum and maximum
values, as well as cases valid numbers and missing cases will be evaluated. For
continuous variables, mean and out-of-range values or outliers will be also tested. If
errors are found, they will be corrected. To double check errors, frequencies will be
reexamined.
Once the data file is free from errors, descriptive statistics will be performed both
for reporting the characteristics of study participants and checking variables for any
assumption violations that will be needed to determine the use of either parametric or
non-parametric statistical analysis. For categorical variables, frequencies will be
examined. For continuous variables, missing data and normality will be assessed.
To carry out a logistic regression, the scales will be recoded. In addition to the
process described above, three points of the Likert scale; very strong, strong, somewhat
strong, will be treated as the reasons that drive nurses to migrate overseas. A “yes” will
be assigned. Meanwhile, the other three Likert scale’s points; very weak, somewhat weak
and weak, are treated as the reasons that do not motivate nurses to work overseas.
Similarly, a “no” will be assigned. Therefore, the value of 1 will be given for “yes” and 0
will be for “no”.

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Additionally, to conduct a factorial ANOVA, each reason for international
nursing migration will be treated as an independent variable. A code will be assigned for
each of these variables. Then, the researcher will calculate the total score of the Likert
scale for each study participant. The total score will be treated as dependent variable.
Qualitative Research Method
Data recorded by a tape recorder will be transcribed to Microsoft Word. However,
before the transcript is analyzed, the researcher will perform a stakeholder check to
ensure the validity of the obtained data. Within 48 hours after interview is conducted, all
study participants will be emailed the researcher’s written interpretation of sensitive or
important data pulled from the interview. However, the transcript study participants will
receive only contains some important information they gave during interview. They are
asked to review any misinterpretation made by the researcher. Once the researcher
receives feedback from each study participant, the transcript will be edited; personal
information such as the study participant’s name will be de-identified; and a thematic
analysis of the data will be performed.
The first step in the thematic analysis is that the transcript will be read several
times for preliminary observation. Second, the researcher will start identifying themes by
looking at the transcript in detail. Third, the researcher will classify the data by
developing a coding scheme. Lastly, the transcript will be imported into NVivo 10,
qualitative research software, for further analysis.
Timeline
All studies planned in this proposal will be conducted from June 2014 to August 2015.
Detail of the timeline is described in the appendix Q.

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Chapter IV
Potential Impacts of the Studies
Findings of the studies have impacts on:
1. Public Health Field
To achieve universal health coverage (UHC), functional health system is
highly crucial. One of six building blocks of health system is human resources for
health (HRH). One of HRH is nursing profession.
By 2019, the Indonesian government is committed to providing healthcare
services to around 257.5 million people, equally providing both medical and non-
medical health services to all participants in all provinces, and ensuring a
minimum of 85% of the participants will be satisfied with services provided by
both health facilities and health services of the BPJS. To achieve these ambitious
targets, nurses are one of HRH who will stand on the front line of healthcare
services provision. Further, nurses will be important part of health professions to
perform ten essential public health services while the country progresses toward
UHC.
The international migration of Indonesian nurses has caused the loss of
motivated and qualified nurses, which further has weakened the Indonesian’s
health system. If this issue is not well managed, the international nursing
migration will keep continuing and can negatively impact the attainment of UHC
by 2019. The country’s inability to achieve UHC means the country’s failure to
protect people from suffering from financial hardship while trying to fulfill their
right to attain healthcare services.

46

As such, the findings of the studies are expected to help the country
comprehensively understand all facets of the phenomenon of the international
migration of Indonesian nurses. With the expected comprehensions, the country
can mitigate the impacts of the issues and manage nursing professions, which are
crucial to support the country to achieve its UHC targets.
2. The Indonesian Government
Since the “WHO Code of Practice on the International Recruitment of
Health Personnel” (the code) was adopted, the Indonesian government established
a national authority named the Board for Development and Empowerment Human
Resources for Health under the Ministry of Health of Indonesia (BDEHRH). The
government mandated that the BDEHRH implement the code and monitor its
implementation. In addition, the BDEHRH must submit a regular national report
to the WHO every three years (WHO, 2011). The national report has to cover the
migration of health personnel, health personnel information systems, human
resource for health data, recruitment and migration laws, regulations, and HRH
policies (WHO, 2011).
The Ministry of Health of the Republic of Indonesia, supported by
International organizations, also developed the Indonesia Human Resources for
Health Development Plan 2011-2015. The plan highlighted the importance of
finding effective strategies for international nursing migration issues. However, in
their 2013 report, the Global Health Workforce Alliance and the WHO disclosed
that Indonesia had limited data on HRH that can help inform government and

47

policy makers in the country to develop appropriate and effective policies. The
policies include the data on international nursing migration.
As such, the researcher expects that findings of the studies will give
several contributions. First, findings will provide the BDEHRH with the holistic
picture of the phenomenon of the international migration of Indonesian nurses. It
includes the reasons for the international migration of Indonesian nurses, the
experience of returning nurses, and the recruitment and placement practices of
recruiting agencies’. Additionally, the data will inform the government what
actions have been carried out by relevant stakeholders in regulating the
international migration of Indonesian nurses. Therefore, the government can
synergize to strengthen national health systems through strengthening both nurses
and nursing profession.
Second, by having a complete picture of the international migration of
Indonesian nurses’ phenomenon, the BDEHRH can have a better comprehension
of the issue. As such, the BDEHRH can comprehensively evaluate actions and
strategies that they have taken and have to be taken in the future. Also, the data
will help the BDEHRH and relevant policy makers analyze and make effective
policies to regulate and mitigate the negative impacts of the international
migration of Indonesian nurses. The researcher also expects that findings will help
the Indonesian government regulate or manage nursing profession while the
country is progressing toward UHC. Consequently, the country does not need to
suffer from severe nursing shortage while progressing toward UHC by 2019.

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3. Indonesian Nursing Profession and Nurses
The researcher expects that the findings will have an influence on the
government. Thus, decisions and actions that the government make will directly
and indirectly be in the Indonesian nurses’ favor. The researcher hopes that the
findings will affect the national government in several ways.
First, the study will reveal why the Indonesian nurses prefer to leave the
country to work overseas. The researcher hopes that the nurses’ reasons for
migrating will help inform the country’s health system weaknesses that have to be
evaluated and corrected. Second, the study will inform the government challenges
or issues that the returning Indonesian nurses experience. Since Indonesia
progresses toward UHC and the country requires many qualified and skillful
nurses, the researcher expects that the government can help the returning nurses
overcome challenges that they may have. One example of a possible challenge is
finding a nursing job in Indonesia. Additionally, the researcher hopes that the
national government can facilitate the returning nurses to reintegrate easily, which
will contribute to the Indonesian nurses motivation and retention.
Finally, the study will reveal how local recruitment agencies carry out
recruitment and placement. Any unethical recruitment or placement practice that
harm the Indonesian nurses will be disclosed. The researcher expects that the
government can use the evidence to regulate recruitment agencies. Thus, the
Indonesian nurses who plan to migrate in the future, regardless of their reasons,
will be treated fairly and honestly.

49

4. Nursing Organizations
The study will disclose how relevant stakeholders collaborate with each other to
regulate the international migration of Indonesian nurses. The collaboration
includes monitoring the Indonesian nurses’ movement and developing nursing
information systems that do not exist yet. The researcher expects that the finding
will help strengthen the synergy between Indonesian National Nurses
Associations in Indonesia and overseas. The synergy will not only fortify nursing
profession, but also the role and functions of nursing organization for Indonesian
nurses.
5. International Health Organizations Concerned with Ethical International
Recruitment and Human Resources for Health Migration.
Health organizations, such as the WHO, call for stakeholders, including all people
who are concerned about international nursing migration, to get involved in
conducting sustainable research about this issue. The findings of the series of
studies that the researcher will carry out can help the WHO comprehensively
discern the phenomenon of the international migration of Indonesian nurses.
Accordingly, understanding this phenomenon can help not only the WHO but also
the WHO’s member states to make a careful decision about recruiting Indonesian
nurses.

50

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tml

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APPENDIX A
Informed Consent Form for the Indonesian Embassy Overseas
Topic of the Research Project: The International Migration of Indonesian Nurses
Name of the Researcher: Nila Kusumawati Elison
Researcher’s Email Address: gbc_nia@yahoo.com
A. Purpose and Background
The researcher (Nila Kusumawati Elison) is a member of the Indonesian National
Nurses Association.
The purpose of the project is to help understand the International migration of
Indonesian nurses.
B. Procedures
You are being asked to respond to the questionnaire. The questionnaire will ask
you about:
a. The regulation of recruitment agencies’ recruitment and placement practices
b. Promotion of return migration of the Indonesian nurses
c. Indonesian nurses movement tracking actions
In addition, you will be asked about some general information.
C. Risks
A few of the research questions will request information that may cause discomfort.
However, you are free to refuse to respond or withdraw from the interview at any
time without penalty.
D. Benefits
There are no direct benefits for your participation in this research. However,
information you give will help improve the regulation of the international migration
of Indonesian nurses.
E. Confidentiality
Your agency name will not be recorded. Your responses will be kept anonymous and
confidential.
F. Alternatives
If you choose not to participate in the study, then an alternative procedure is not
required
G. Compensations
There will be no compensation in this study.

55

H. Questions
If you have any questions related to the study, you can send queries by email to the
researcher (Nila Kusumawati Elison) at gbc_nia@yahoo.com or by phone
081310303086.
I. Agreement: Informed Consent
PARTICIPATION IN THE RESEARCH STUDY IS VOLUNTARY. I am free to decline
to participate in this research study, or I may withdraw my participation at any point
without penalty.
Research Participant
Signature Date
Researcher
Signature Date

56

APPENDIX B
Informed Consent Form for Returning Nurses
Nurses Association.
The purpose of the project is to help understand the international migration of
Indonesian nurses, especially return migration experience of the Indonesian nurses
who no longer work overseas and have returned to Indonesia.
B. Procedures
You are being asked to attend an interview. The interview is conducted in
Indonesian for not more 90 minutes. The conversation will be recorded by a tape
recorder. The interview will request information about your experiences with:
a. Return process
b. Reintegration
In addition, you will be asked for your current information and personal
information before working overseas.
C. Risks
A few of research questions will request some personal information that may cause
discomfort. However, you are free to refuse to respond or withdraw from the
interview at any time without penalty.
D. Benefits
You will receive an incentive 50,000 rupiah ($5) if you complete the interview.
E. Confidentiality
Your name will not be recorded. Your responses will be kept anonymous and
confidential.
F. Alternatives
If you choose not to participate in the study, an alternative procedure is not required
G. Compensations
There will be no compensation in this study

57

H. Questions
081310303086.
without penalty.
Signature Date
Researcher
Signature Date

58

APPENDIX C
Informed Consent Form for Recruitment Agencies
Nurses Association.
The purpose of the research is to help understand the nurses’ recruitment and
placement practices performed by local recruitment agencies.
B. Procedures
You are being asked to attend an interview. The interview is conducted in Indonesian
for not more than one hour. The conversation is recorded by a tape recorder. The
interview will request information about your experiences with:
a. Recruitment and placement practice
b. Promotion of return migration
c. Nurses movement track down
In addition, you will be asked for some general information.
C. Risks
A few of research questions will request information about the nature of your work that
may cause discomfort or stress. However, you are free to refuse to respond or withdraw
from the interview at any time without penalty.
D. Benefits
There are no direct benefits for your participation in this research. However, information
you give will help regulate international migration of the Indonesian nurses.
E. Confidentiality
confidential.
F. Alternatives
G. Compensations

59

H. Questions
081310303086.
without penalty.
Signature Date
Researcher
Signature Date

60

APPENDIX D
Informed Consent Form for the Board for Development and Empowerment Human
Resources for Health Ministry of Health of Indonesia
Nurses Association.
The purpose of the project is to help understand the regulation of the International
migration of Indonesian nurses.
B. Procedures
Indonesian for not more than 90 minutes. The conversation will be recorded by a tape
c. Indonesian nurses movement track down
C. Risks
A few of research questions will request information that may cause discomfort.
time without any penalty.
D. Benefits
of the Indonesian nurses.
E. Confidentiality
confidential.
F. Alternatives
G. Compensations

61

H. Questions
081310303086.
without penalty.
Signature Date
Researcher
Signature Date

62

APPENDIX E
Informed Consent Form for the National Protection Board for Indonesian Overseas
Workers
Nurses Association.
The purpose of the research is to help understand the regulation of the
International migration of Indonesian nurses.
B. Procedures
Indonesian for not more than 90 minutes. The conversation will be recorded by a tape
C. Risks
D. Benefits
E. Confidentiality
confidential.
F. Alternatives
G. Compensations

63

H. Questions
081310303086.
without penalty.
Signature Date
Researcher
Signature Date

64

APPENDIX F
Informed Consent Form for the Central Board of the Indonesian National Nurses
Associations Jakarta
Nurses Association.
The purpose of the research is to help understand the regulation of the
International migration of Indonesian nurses.
B. Procedures
Indonesian for not more than one hour. The conversation will be recorded by a tape
C. Risks
D. Benefits
E. Confidentiality
confidential.
F. Alternatives
G. Compensations

65

H. Questions
081310303086.
without penalty.
Signature Date
Researcher
Signature Date

66

APPENDIX G
Informed Consent Form for the Branches of the Indonesian National Nurses
Associations Overseas
Nurses Association.
The purpose of the research is to help understand the International migration of
Indonesian nurses.
B. Procedures
Indonesian for not more than one hour. The conversation is recorded by a tape
a. Promotion of return migration of the Indonesian nurses
b. Indonesian nurses movement track down
C. Risks
time without any penalty.
D. Benefits
E. Confidentiality
confidential.
F. Alternatives
G. Compensations

67

H. Questions
081310303086.
without penalty.
Signature Date
Researcher
Signature Date

68

APPENDIX H
Topic Guide on the Return Migration Experiences of the Returning Nurses
I. Personal Information before working overseas:
Can you tell me about what you did before you migrated and worked
overseas?
Expected important information and prompts:
a. Nurse’s age
b. Nursing education
c. Years of nursing experience
d. Nursing position
e. Workplace and its location
Tell me why you chose to work overseas for the first time?
a. Reasons for migrating
b. Agency facilitated this nurse to work overseas
c. Fees this nurse had to pay to the agency and its payment methods
d. Positive and negative experiences with recruiting agency
II. Personal Information while working overseas
Tell me about your experience when you firstly arrived overseas?
a. Immigration process this nurse had to go through in the Indonesian embassy
b. Recruitment agency’s action
c. Communication with branch INNA
Can you tell me about your professional experience when you were working
overseas?
a. Workplace
b. Nursing position
c. Years of working
d. Working contract; promised salary, benefits, and other working conditions
e. Advanced education continuation
f. Communication with agency and branch INNA

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III. Return Process to Indonesia
Why did you return to Indonesia?
Can you tell me about your experience when you were about to return to
Indonesia?
a. Nurse’s feeling
b. Process this nurse had to go through
c. Communication with INNA and embassy overseas as well as recruiting
agency?
What did you do to prepare for your nursing career in Indonesia?
a. Did this nurse apply for a job while being overseas?
b. Where did she get information about nursing jobs in Indonesia?
c. What was the response from the nursing institution she applied for?
IV. Reintegration Process in Indonesia
Can you tell me about your experience in finding a nursing job in Indonesia?
a. Challenges in finding a job
b. Waiting time to get a job
c. Workplace
d. Challenges in applying skills and knowledge acquired overseas
e. Other challenges in workplace
f. Roles of relevant stakeholders in facilitating this nurse
What will you do if there is another chance for you to go migrate and work
overseas?
Expected important information and prompt:
a. The occurrence of circular migration

70

APPENDIX I
Topic Guide on Recruitment Agencies
I. General Information
Can you tell me about the Indonesian nurses that you sent overseas?
a. To which countries does this agency send Indonesian nurses?
b. Based on your current data, how many Indonesian nurses has this agency
sent to each country?
II. Recruitment and Placement Practice
Can you tell me about your experience of finding overseas nursing jobs for
Indonesian nurses?
a. Complete process that the agency has to go through until this agency can
legally recruit and send nurses overseas
b. Stakeholders that this agency involves
How do you recruit Indonesian nurses?
a. The media this agency uses to advertise the program
b. The process this agency uses to recruit nurses
c. Information they give to nurses
d. Characteristics of nurses they prefer to recruit
How do you place those nurses overseas?
a. Stakeholders they involve
b. Fees nurses have to pay and its payment methods
What do you think about the laws/policies/regulations/position statements
that regulate international nursing migration?
a. Knowledge of sanctions for unethical nursing recruitment
b. International nursing migration policies that this agency implements

71

III. Nurses’ Movement Monitoring
What do you normally do with the data regarding nurses you sent
overseas?
Prompts or important information that is expected:
a. Data of nurses this agency sent overseas
b. Data of nurses who move on to another foreign country
c. Data of nurses who return to Indonesia
d. Stakeholders this agency involves
e. Reporting system this agency uses
IV. Return Migration Promotion
What do you think about return migration of nurses?
a. Negotiation this agency does with recruiting countries/agencies
b. The nurses’ working contracts with respect to return migration

72

APPENDIX J
Topic Guide on the International Migration of Indonesian Nurses for the Board for
Development and Empowerment Human Resources for Health, Ministry of Health
of Indonesia (BDEHRH)
I. Recruitment Agencies’ Recruitment and Placement Practice Regulation
Would you like to let me know about local recruitment agencies that send
Indonesian nurses overseas?
a. Number of local recruitment agencies actively sending the Indonesian nurses
overseas
b. Location of local recruitment agencies
c. Process that local recruitment agencies have to get through to recruit and send
nurses overseas
How do you regulate local recruitment agencies that send nurses overseas?
a. Laws, policies or regulations that the government agencies have to regulate
nurses
b. The implementation of the WHO’s code in Indonesia
c. Dissemination of those policies
d. Policies implementation monitoring
e. Government’s actions for local recruitment agencies that violate ethical
recruitment and placement practices
f. Disciplinary action for local recruiting agencies that violate ethical nurses
recruitment and placement? Who developed it? What have you done to
disseminate it? To whom have you disseminated it?
g. Collaboration with relevant stakeholders studied in the series of studies.
II. Nurses’ Movement Monitoring
What should the government do to monitor the nurses’ movement?
a. Government’s information system for nurses
b. The availability of nurses’ database
c. Collaboration with other stakeholders, mainly those studied in this series of
study

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III. Return Migration Support
As Indonesia is progressing toward UHC, what should the government do to
promote the return migration of nurses?
a. Strategies the government has to improve nurses’ motivation and retention
b. Collaboration with other stakeholders, mainly those studied in this series of
studies
c. G-to-G agreements with receiving countries

74

APPENDIX K
Topic Guide on the International Migration of Indonesian Nurses for the National
Protection Board for Indonesian Overseas Workers (BNP2TKI)
I. Recruitment Agencies’ Recruitment and Placement Practice Regulation
Would you like to let me know about local recruitment agencies that send
Indonesian nurses overseas?
a. Numbers of local recruitment agencies actively send the Indonesian nurses
overseas
b. Location of local recruitment agencies
c. Process that local recruitment agencies have to get through to recruit and send
nurses overseas
How do you regulate local recruitment agencies that send nurses overseas?
a. Laws, policies or regulations that the government agencies have to regulate
nurses
b. The implementation of the WHO’s code in Indonesia
c. Dissemination of those policies
d. Policies implementation monitoring
e. Government’s actions for local recruitment agencies that violate ethical
recruitment and placement practices
f. Disciplinary action for local recruiting agencies that violate ethical nurses
recruitment and placement? Who developed it? What have you done to you
disseminated it? To whom have you disseminated it?
g. Collaboration with relevant stakeholders studied in the series of studies.
What should the government do to monitor the nurses’ movement?
a. Government’s information system for nurses
b. The availability of nurses’ database
c. Collaboration with other stakeholders, mainly those studied in this series of
study
What should government do to promote the return migration of nurses
concerning Indonesia is progressing toward UHC?

75

a. Strategies the government has to improve nurses’ motivation and retention
b. Collaboration with other stakeholders, mainly those studied in this series of
study
c. G-to-G agreements with receiving countries

76

APPENDIX L
Topic Guide on the International Migration of Indonesian Nurses for the Central
Board of the Indonesian National Nurses Association (INNA) Jakarta
Can you tell me about this organization?
a. Year of establishment
b. Number of members
c. Functions related to international nursing migration
d. Department in INNA responsible for international nursing migration regulation
II. Recruitment Agencies’ Recruitment and Placement Practice Regulation
How do you regulate the international migration of Indonesian nurses with
respect to local recruitment agencies?
a. Knowledge about existing local recruitment agencies that send nurses overseas:
number, location, and recruitment and placement practices of local recruitment
agencies
b. INNA’s collaboration with recruitment agencies
c. Policies or position statements that INNA establishes to regulate recruitment
agencies
d. INNA’s actions against recruitment agencies for unethical recruitment and
placement practices of nurses
e. The issue of international migration of Indonesian nurses in the nursing
legislation
III.Nurses' Movement Monitoring
Can you tell me about Indonesian nurses who have migrated overseas?
a. Knowledge about Indonesian nurses who leave the country to work in another
foreign country: destination country, numbers of nurses per each foreign
country, nurses who moved on to another foreign country, and nurses who
return to Indonesia
b. Collaborations with stakeholders: local recruitment agencies, Indonesian
embassies in foreign countries, and INNAs overseas, to monitor nurses’
movement
c. Information system and nurses’ database

77

IV.Return Migration Support
What do you do to support return migration of nurses?
a. Collaborations with INNAs overseas to disseminate nursing job vacancies in
Indonesia
b. INNA’s actions to facilitate returning nurses to get a nursing job
c. INNA’s action to prevent circular migration of returning nurses

78

APPENDIX M
Topic Guide on the International Migration of Indonesian Nurses for the Branches
of the Indonesian National Nurses Association (INNA) Overseas
Can you tell me about this branch INNA?
a. Location
b. Role and function of branch INNA with respect to migrating nurses
Can you tell me about the Indonesian nurses in this country?
a. Number of nurses
b. The actions of monitoring the nurses’ movement
c. Database and its maintenance
d. Information system
e. Communication with the central board INNA Jakarta
f. The existence of communication with the Indonesian embassy and recruitment
agencies
What do you think about the return migration of the Indonesian nurses?
a. Dissemination of nursing job vacancies in Indonesia
b. Collaboration with the central board INNA Jakarta with respect to nursing job
vacancies in Indonesia for nurses who plans to return.

79

APPENDIX N
Topic Guide on the International Migration of Indonesian Nurses for the
Indonesian Embassies Overseas
Would you like to tell me about this embassy with respect to the international
migration of Indonesian nurses?
a. Location of the embassy
b. The existence of counselors’ office that deals with the international migration
of Indonesian nurses
c. Functions of existing counselors’ office that deals with the international
migration of Indonesian nurses
II. Recruitment Agencies’ Recruitment and Placement Practices Regulation
What is your experience with the International migration of Indonesian
nurses?
a. The availability of regulation for recruiting agencies that plan to recruit
Indonesian nurses?
b. Process
III. Nurses Movement Monitoring
What do you do with the Indonesian nurses who come to this country?
a. Number of nurses that do a self-report to the embassy
b. The actions of monitoring the nurses’ movement
c. Database and its maintenance
d. Information system
e. Collaborations with relevant stakeholders in Indonesia
IV. Return Migration Support
What do you think about the return migration of Indonesian nurses?
a. Collaborations with relevant stakeholders in Indonesia to provide nursing
vacancies available in Indonesia

80

APPENDIX O
Survey on Reasons for the International Migration of Indonesian Nurses in
Indonesian
Informasi yang anda berikan akan sangat membantu untuk memahami alasan perawat
Indonesia bekerja ke luar negeri. Jawaban anda bersifat rahasia dan hanya diketahui oleh
peneliti.
I. Alasan Bekerja Sebagai Perawat di Luar Negeri
Petunjuk: Apakah alasan anda bekerja ke luar negeri. Tentukan seberapa kuat
alasan tersebut?
A Faktor Personal
(Berkaitan
dengan alasan
pribadi)
Sangat
Kuat
Kuat Agak
Kuat
Agak
Lemah
Lemah Sangat
Lemah
1 Bekerja di luar
negeri adalah
mimpi saya
2 Saya ingin
merasakan hidup
dengan cara
yang berbeda
3 Saya ingin
melihat dunia
B Faktor Sosial
(Berkaitan
dengan
keluarga dan
masyarakat)
Sangat
Kuat
Kuat Agak
Kuat
Agak
Lemah
Lemah Sangat
Lemah
1 Saya ingin
meningkatkan
kesejahteraan
keluarga saya
2 Saya termotivasi
oleh teman yang
bekerja di luar
negeri
3 Bekerja di luar
negeri
menguntungkan
bagi

81

perkembangan
anak-anak saya.
C Faktor
Pekerjaan dan
Pendidikan
(Berkaitan
dengan
pekerjaan anda
sebagai
perawat)
Sangat
Kuat
Kuat Agak
Kuat
Agak
Lemah
Lemah Sangat
Lemah
1 Kondisi kerja di
Indonesia buruk
(contoh: beban
kerja yang berat)
2 Lingkungan
pekerjaan tidak
mendukung
peningkatan
kompetensi dan
keahlian saya
3 Saya tidak puas
dengan
pekerjaan saya
sebagai perawat
4 Penghargaan
masyarakat
untuk perawat
rendah
5 Hubungan dokter
dan perawat
buruk
6 Kesempatan
untuk
melanjutkan
pendidikan
kurang
D Faktor
Ekonomi
(Berkaitan
dengan
keuangan)
Sangat
Kuat
Kuat Agak
Kuat
Agak
Lemah
Lemah Sangat
Lemah
1 Gaji yang saya
terima tidak
sesuai dengan

82

beban kerja
2 Gaji saya tidak
cukup membantu
keuangan
keluarga
3 Situasi ekonomi
di Indonesia
tidak stabil
4 Fasilitas yang
didapatkan
sebagai perawat
di luar negeri
lebih
menggiurkan
(contoh: jumlah
hari cuti)
E Faktor Politik
(Berkaitan
dengan
pemerintahan)
Sangat
Kuat
Kuat Agak
Kuat
Agak
Lemah
Lemah Sangat
Lemah
1 Undang-undang
keperawawatan
tidak ada untuk
melindungi saya
sebagai perawat
2 Adanya nepotisme
di lingkungan
pekerjaan saya
3 Saya kecewa
dengan sikap
pemerintah
terhadap
perkembangan
profesi
keperawatan
II. Jika anda mempunyai alasan lain yang tidak tercantum pada tabel di atas,
silahkan isi pada tempat yang tersedia di bawah ini dan cantumkan seberapa
kuat alasan tersebut.
1…………………………..
2…………………………..

83

III. Informasi Sebelum Berangkat ke Luar Negeri
1. Berapa umur anda saat bekerja ke luar negeri untuk yang pertama kalinya?
20 – 25
26 – 30 tahun
31 – 35 tahun
35 tahun ke atas
2. Apa pendidikan terakhir anda sebelum bekerja ke luar negeri untuk yang pertama
kalinya?
SPK
Diploma III
Sarjana Keperawatan (S. Kep)
Ners
S2 Keperawatan
3. Berapa jumlah tahun pengalaman bekerja anda sebagai perawat sebelum bekerja
ke luar negeri untuk yang pertama kalinya
1-2 tahun
3 - 4 tahun
5- 6 tahun
Lebih dari 7 tahun
4. Dimana anda bekerja sebelum berangkat ke luar negeri?
Rumah sakit
Puskesmas
Klinik
Institusi pendidikan keperawatan
5. Apa posisi terkahir anda di institusi ini?
Staf perawat
Perawat spesialis di rumah sakit
Klinikal Instruktur
Manajer Keperawatan
Tenaga pengajar
Kepala Institutusi pendidikan
Bila posisi anda tidak disebutkan di atas, silahakan tulis disini……
6. Apa jenis institusi ini?
Institusi pemerintah
Institusi swasta
7. Dimana Institusi tempat bekerja anda ini berada?
Di daerah terpencil
Di kota
8. Siapa yang memfasilitasi anda bekerja ke luar negeri untuk yang pertama kalinya?

84

Pemerintah Indonesia
Perusahaan perekrutan dan penempatan Indonesia
Perusahaan perekrutan dan penempatan asing
Bukan salah satu di atas
9. Apakah anda pernah mengalami pengalaman beruk dengan agency yang
menempatkan anda ke luar negeri?
Ya
Tidak
IV. Informasi saat ini:
1. Negara tempat bekerja saat ini:
2. Jenis Kelamin:Perempuan Laki-laki
3. Apa pendidikan keperawatan anda saat ini?
SPK
Diploma III
Sarjana Keperawatan (S.Kep)
Ners (Post-undergraduate program)
S2 Keperawatan
S3 Keperawatan
4. Dimana anda bekerja saat ini?
Rumah sakit
Institusi pendidikan keperawatan
Bila institusi tempat anda bekerja tidak tertulis di atas, silahkan tulis disini………
5. Apa posisi anda di institusi ini?
Staf perawat
Spesialis keperawatan di rumah sakit
Klinikal Instruktur
Manajer Keperawatan
Tenaga pengajar
Kepala Institutusi pendidikan
Bila posisi anda tidak disebutkan di atas, silahakan tulis disini……
6. Apa kewarganegaraan anda saat ini?
Saya penduduk Indonesia
Indonesia namun saya juga pemegang green card / permanent residency
Saya sudah menjadi warga negara asing
7. Apakah anda berencana untuk bekerja di Indonesia suatu saat nanti?
Ya Tidak Saya belum yakin

85

APPENDIX P
Survey on Reasons for the International Migration of Indonesian Nurses in English
All information received on this questionnaire will be treated as confidential. Please fill
out the questionnaire completely and accurately. The information is essential to
understand the reasons for international nursing migration.
I. Reasons for Working in Nursing Profession Overseas
Direction: Select reasons that motivated you to work overseas for the first time.
Determine how strong they were.
A Personal Factor
(Related to your
personal needs
or desires)
Very
strong
Strong Somewhat
strong
Somewhat
weak
Weak Very
weak
1 Working
overseas was one
of my dreams
2 I wanted to
experience a
different way of
living
3 I wanted to see
the world
B Social Factor
(Related to your
family and
broader society)
Very
strong
Strong Somewhat
strong
Somewhat
weak
Weak Very
weak
1 I wanted to
improve my
family’s
prosperity
2 I was
encouraged by
someone who
worked overseas
(ex: spouse,
family or
friends)
3 Working
overseas
benefitted my

86

children in many
aspects (ex,
culture,
education,
foreign
language)
C Professional/
Educational
Factor
(Related to your
job as a nurse)
Very
strong
Strong Somewhat
strong
Somewhat
weak
Weak Very
weak
1 Working
conditions in
Indonesia were
poor (ex: job
workload, hours
of work,
imbalance nurse-
to-patient ratio)
2 Work
environment did
not support me
to improve my
nursing
professionalism
(ex: competency,
skills)
3 I was not
satisfied with my
nursing job
4 There was low
societal respect
for nursing
profession
5 There was poor
collaboration
with other health
professionals
6 Chances to
pursue an
advanced
nursing
education in
Indonesia were
very few

87

D Economic
Factor
(Related to
money or
financial issues)
Very
strong
Strong Somewhat
strong
Somewhat
weak
Weak Very
weak
1 My salary in
Indonesia was
not
commensurate
with my
responsibilities
2 My salary in
Indonesia was
not enough to
support my
family
financially (ex:
spouse, parents)
3 Economic
situation in
Indonesiawas
unstable
4 Employment in a
foreign country
offered a better
benefits package
(ex: annual
leave)
E Political Factor
(Related to
government
power or
decisions
towards nursing
profession)
Very
strong
Strong Somewhat
strong
Somewhat
weak
Weak Very
weak
1 The Nurses Act
in Indonesia was
not in place
2 There was
nepotism in
work
environment in
my country
3 I was

88

disappointed
with how
government did
not support
nursing
profession
development in
Indonesia
II. What are your other reasons for migrating overseas? In the space below
indicate whether they are very strong, strong, somewhat strong, somewhat
weak, weak or very weak.
1………………………….
2………………………….
III. Personal Information Before Working Overseas:
1. What was your age when you worked overseas for the first time?
20 - 25 years old
26 - 30 years old
31 - 35 years old
Over 36 years old
2. What was the highest nursing education you had obtained before working
overseas?
SPK
Diploma III
Sarjana Keperawatan (BSN)
MSN
3. How many years was your total nursing experience before working overseas?
1-2 years
3 - 4 years
5- 6 years
Over 7 years
4. In which nursing institution did you last work before working overseas?
Hospital
Community health center (Puskesmas)
Health Clinic
Nursing school

89

5. What was your last nursing position in this institution?
Staff nurses
Clinical nurse specialist
Clinical Instructor
Nursing manager
Faculty member of nursing school
The head of nursing school
If your nursing profession is not stated above, please specify here…
6. What was this institution?
Government institution
Private institution
7. Where was this institution located?
In rural area
In urban area
8. What agency facilitated you to migrate overseas for the first time?
Indonesian Government
Indonesian-based recruiting agency
Overseas-based recruiting agency
None of the above
9. Did you ever have any negative experience with your placement process?
Yes
No
IV. Current Personal Information:
1. In which country does you currently work?
2. What is your gender? Female Male
3. What is your current nursing education level?
SPK
Diploma III
Sarjana Keperawatan (BSN)
MSN
PhD in Nursing
4. Where do you currently work? You might be working in several different
workplaces. If so, please select or specify the institution in which you spend most
of your working hours in a week.
Hospital
University
If your workplace is not stated above, please specify here…

90

5. What is your current nursing position?
Staff nurse
Clinical nurse specialist
Clinical Instructor
Nursing manager
Faculty member of nursing school
The head of nursing school
If your nursing profession is not stated above, please specify here…
6. What is your current citizenship?
I am an Indonesian citizen
I am an Indonesian citizen, but I am also a green card / permanent residency
holder
I am no longer an Indonesian citizen
7. Do you plan to work in Indonesia in the future?
Yes No I am not sure

91

APPENDIX Q
Research Timeline
June July August September October NovemberDecember January February March April May June July August September October November
PilotTests
Questionnairesandinterview
topicguidepilottests
IRBApplication
MinistryofHealthof
Indonesia
DataCollection
MigratingNurses
ReturningNurses
IndonesianEmbassies
Overseas
RecruitmentAgencies
BDEHRH
BNP2TKI
IndonesianNationalNurses
AssociationinJakarta
IndonesianNationalNurses
AssociationOverseas
DataAnalysis
ResearchQuestion1&2
(MigratingNurses)
ResearchQuestion3
(ReturningNurses)
ResearchQuestion4
(recruitmentAgencies)
ResearchQuestion5(The
IndonesianGovernmentand
NursesAssociations)
ManuscriptWriting
Manuscript1onreasonsfor
migration
Manuscript2onreturnand
circularmigrationexperiences
Manuscript3onrecruitment
agenciesandtheactionsofthe
Indonesiangovernmentand
nursesassociations
DataDissemination
Manuscript1
Manuscript2
Manuscript3
Year
2014
TimelineofaSeriesofStudiestoExploretheInternationalMigrationofIndonesianNurses
2015
Activities
No
3
1
2
4
5
6

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