Migrant nurses in Brazil: demographic characteristics, migration flow and relationship with the training process

Objective to analyze the migration of nurses in Brazil, describe the demographic characteristics of migrant nurses, the main migration flows, and establish relationships with the training process. Method a descriptive, exploratory study, based on 2010 Census data. The data were analyzed using descriptive statistics. Result there were 355,383 nurses in Brazil in 2010. Of these, 36,479 (10.3%) reported having moved compared to the year 2005: 18,073 (5.1%) for intrastate migration, 17,525 (4.8%) interstate migration, and 871 (0.2%) international migration. Females (86.3%), Caucasians (65.2%), and unmarried (48.3%) nurses prevailed in the population, without considerable variation between groups according to migration situation. The findings indicate that the migration flows are driven by the training process for states that concentrate a greater number of courses and positions in undergraduate and graduate studies, and the motivation of employment opportunity in regions of economic expansion in the country. Conclusion it is necessary to deepen the discussion on the movement of nurses in Brazil, their motivations, and international migration.


Introduction
In Brazil, the nursing workforce is made up of professional nurses, nurse technicians and nurse auxiliaries. According to the Federal Council of Nursing, 1,535,568 nursing professionals were registered in March of 2011: 314,127 (20.46%) professional nurses, 698,697 (45.5%) nurse technicians, and 508,182 (33.09%) nurse auxiliaries. Of this registered workforce, 55.67% were in the southeast, 19.61% in the northeast, 15.82% in the south, 5.45% in the north, and 3.45% in the Midwestern portion of the country (1) .
In the last two decades there has been a movement to expand nursing education in Brazil, with the creation of schools in all regions. Data on enrollments in undergraduate nursing programs show that there has been an increase of approximately 100% in four years, considering data from 2004 to 2008, when enrollment rose from 120,851 to 224,330 (2) . This movement results from the democratization of access to higher education, and results in more availability of nurses in the marketplace.
Despite the size of the nursing workforce, in absolute numbers, and the increase of the number of nursing schools in the last decade in the country, the concentration of schools and the availability of nurses per capita are quite uneven in different regions (3) .
Nursing schools are concentrated in the states that are most densely populated and which have the greatest income concentration, accompanying the distribution of gross domestic product (GDP) and economic and social inequalities of the Brazilian regions.
The health labor market has grown in the past two decades in both the public and the private sectors.
Among the factors that contributed to this growth are the implementation of the Unified Health System and the change in the care model, with the creation of new jobs, especially in primary care (4) . In this sense, the Family Health Strategy (FHS) has represented an important expansion of the health labor market.
The growth of FHS in Brazil is accompanied by opportunities and challenges for the training of health and nursing professionals, both regarding the quantitative aspect, the distribution of professionals, and the possibilities of qualification of the professionals in the labor market (3) .
The increase in jobs, however, has not accompanied the expansion of nursing schools and vacancies in undergraduate courses to the same extent in Brazil.
These aspects raise questions about the relationship between the expansion of nursing schools, market growth and migration of nurses in Brazil. Due to the increased number of programs, Brazil is referred to as a country with a large supply of these professionals. It is therefore necessary to monitor the labor market and the flow of nurses within and out of the country (5) .
Elsewhere in the world, the nursing labor market has often been characterized by numerous imbalances, especially in relation to unemployment and underemployment. Imbalances are characterized by governmental actions that usually influence the supply of health professionals in response to political issues, driven by financial concerns, rather than the rationality of the market or epidemiological reality (6) . In Brazil, the labor market for health professionals in general, which includes nurses, has been facing a crisis characterized by the deficit of professionals and the regional, national and sub-national inequality in the distribution and access to the health workforce, particularly affecting the rural areas, urban neighborhoods, or those that are difficult to access (7) .
Studies have shown that factors linked to job prospects, such as better working conditions and quality of life, are some of the key issues that influence the migration of health professionals (5)(6)(8)(9) . The geographical distribution of these migration movements shows a concentration of professionals in the capital and areas of economic development (10) . This process must be analyzed considering its complexity, since high levels of migration can cause problems such as rising unemployment, conflicts between migrants and natives, broader questions are asked on migration conditions, education, labor, income, and fertility (11) .
In this study, data from the Census sample were used, which stand out a priori for the possibility of identifying the population of nurses through the education and work criteria. Nurses were identified in the Census data based on two criteria: (i) degree in nursing, www.eerp.usp.br/rlae at the time of census completion, which was about 300,000. In this sense, consistency was applied to the data, disregarding the cases with education that was lower than an undergraduate level degree, and those aged less than 21 years. This exercise is particularly necessary in the case of nursing, due to the high number of nurse technicians and assistants who registered with the occupation of "higher degree nursing professional", although the Census also offers the option "mid-level nursing professional" in its occupational classification.

Results
The Census found that there were 355,383 nurses living in Brazil in 2010, an amount corresponding to the expansion of the sample of 30,655. Table 1 shows the general characteristics of the population of nurses, according to migration status.  international migrants (6.8%), which also showed no economically active ratios above the general.
The mean income of nurses in all jobs was R$ 2,341.17 and the mean household income was R$ 5,798.41. The analysis of income according to immigration status did not have significant differences, except for international migrants, who had lower mean incomes. Table 2 shows the data of the population of immigrants and emigrant nurses, net migration and liquid net migration rate among the states and regions of the country.

Discussion
Regarding the sociodemographic profile, data on gender and age in this study are consistent with the results of Brazilian studies (12)(13)(14) . A study that characterized the sociodemographic profile of nurses qualified to enter the labor market in Minas Gerais, between 2005 and 2009, showed the predominance of female gender and age group of young adults, the most prevalent group being those less than 30, followed by those between 30 and 40 years (12) . Federation, in order to know and analyze the profile of nursing categories (13) . regions of the country, but also within each region (9)(10)(11)(12)(13)(14) .
Thus, the southeast attracts students to nursing courses in other regions of the country, who then return, in most cases, to their countries of origin to obtain the title.
A study on the increased number of undergraduate nursing courses, given the movement of expansion of higher education in Brazil over the last two decades, showed that the expansion of nursing undergraduate courses was not accompanied by a study of the specific needs and demands of each region. This movement has reflected the logic of commodification of education, which considers the market needs and demands, and therefore does not contribute to meet the need for training of qualified professionals, aimed at resolving regional inequalities. The authors emphasize that it is necessary to increase the number of nurses in the country, ensuring that professionals are educated in recognized quality courses that can provide nurses with the profile and competence to intervene with proposals in the health care models (15) . insecurity about the market, employment, income, employment and skills (5) .
The other factors (5,(16)(17) . A study conducted with migrant nurses in Ireland about their future intentions regarding migration, revealed that more than half of respondents considered migrating in the future, because the target country had failed to provide them with sufficient stability, especially in relation to citizenship and the ability for their family members to migrate with them.
The factors outside the health system are reasons for respondents to migrate again (18) .
Another study, conducted in Chile, to investigate the cultural experiences of nurses who immigrated to the country, reported that in general, immigrant nurses identified as being satisfied with their professional achievements and with those related to their projects and lifestyles. In the process of establishing oneself as a nurse in the new country, the primary incentives consisted of the existence of employment opportunities, with some similarities in vocational education, and support on the part of patients. The difficulties were related to cultural and linguistic aspects, difficult relationship with colleagues, lack of health policies, and new responsibilities in care management (19) .  (17)(18)(19)(20). An integrative literature review found a need for more studies to answer questions about how and why nurses migrate (17) .
Migration flows occur due to influences of different socioeconomic conditions between countries, between regions within the same country, and within the same area. The movement of professionals is caused by the low economic development of countries and regions, the deficiencies in living conditions, and the lack of opportunities for professional development (8) . Migration flows occur to seek a labor market that better meets the demands of nurses, with better wages, geopolitical, cultural and linguistic conditions, equivalence in the level of training and education, and for individual factors (8,21) .
A systematic review on the migration of nurses working in educational institutions identified that the migration of this group differs from those of nurses working in direct care. According to the authors, the migration of nurse educators is a neglected issue that needs to be urgently investigated. The migration of nurses working in education is driven by better remuneration and infrastructure, which is influenced by institutional mobility programs (22) .

Conclusion
The findings of this study enabled the development