A deskilling and challenging journey: the lived experience of Indonesian nurse returnees

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Introduction
Cross-country mobility of nurses has been evolving along with the demand of health care (World Health Organization 2014).The movement of nurses has become a global issue with profound impact on countries involved (Adhikari & Grigulis 2014).Notwithstanding the adoption of the World Health Organization (WHO) global code on the international recruitment of health personnel, this non-binding code has been less successful in preventing the move of health professionals from developing to developed countries (Tankwanchi et al. 2014).In some source countries with a shortage of nurses, low employment opportunity, substandard working conditions and poor wages are among factors leading to the migration of nurses (Spetz 2011).
Indonesia has been actively engaged in the migration of workforce, and the nursing profession is no exception (BNP2TKI 2015a).Paradoxically, despite the large number of annual nursing graduates, hospitals and health centres in Indonesia still suffer from a severe nursing shortage due to the lack of capacity to recruit (Anderson et al. 2014;Rosskam & Kurniati 2014).An unsupportive domestic labour market has driven the Indonesian government to allow the migration of nurses to other countries through the establishment of national and international policies (Efendi et al. 2015).Under the umbrella of the Economic Partnership Agreement (EPA), Japan has invited Indonesia to send candidates for nurses and caregivers to support the Japan's ageing society since 2008 (Kaneko 2016).However, recruiting caregivers from those with a nursing education background has caused different opinions among Indonesian stakeholders, as caregivers in Japan (kaigofukushishi) are seen as less professional than nurses (kangoshi).The Indonesian National Nurses Association (INNA) considered that the recruitment of Indonesian nurses as caregivers in Japan disregarded their nursing competence (Maskur 2010).
Within the EPA scheme, a caregiver must be 'skilled' in accordance with the immigration policy, but, in practice, this job position is vaguely defined and contested (Ogawa 2012).Foreign nurses who fill such positions are regarded as caregiver candidates until they pass the national caregiving certification examination in Japan.This examination can be taken by the caregiver candidates in the final year during their 4year stay in the country.Candidates who pass the examination are licensed as certified caregivers and allowed to work for an unlimited period of time (Ogawa 2012).From 2008 to 2014, Indonesia sent 1235 nurses to Japan, of which 754 worked as caregiver candidates (BNP2TKI 2015b).Although the original intention of the EPA was that foreign caregivers would pass the national qualification process and continue working in Japan, the number of nurses returning to Indonesia is quite high.As of May 2014, at least 173 nurses had returned to Indonesia, including 40 of 126 certified caregivers (32%; BNP2TKI 2015b).This increasing number has raised concerns about their professional status, especially when they return to Indonesia and come back to nursing practice.
Only a few studies analyse the situation of Indonesian nurse returnees after working and living in Japan as caregivers.Most of the related studies focus on the pre-migration and during migration phases, thus ignoring the importance of the post-migration stage.The current study aimed to describe the lived experiences of Indonesian nurse returnees by exploring their reasons for return, as well as how they have coped working and living in their country of origin.This research is expected to help in developing a so-called brain gain strategy for nurse returnees and maximize the benefits of such returns for the sending countries.

Study design
Hermeneutic phenomenology was chosen to unveil the nature of being returnees in Indonesia.This method allows researchers to undertake an interpretation of the intended phenomenon and is fit for understanding the structure and meaning of human experience (van Manen 1990).Adopting the six steps of van Manen's phenomenological approach, the research activities included: (1) focusing on the phenomenon by constructing the research question on the experience of becoming Indonesian nurse returnees; (2) selecting participants and conducting face-to-face interviews to investigate the experience; (3) identifying and reflecting on the essential themes; (4) writing and rewriting to describe the phenomenon; (5) maintaining the focus through in-depth exploration; and (6) assessing the parts and the whole to balance the research context.

Sample and setting
Participants were selected through purposive sampling from among Indonesian nurses in Java Island who had returned to Indonesia after working as caregivers in Japan under EPA, who we termed returnees.A snowball sampling technique was employed.Returnees who were known by the researchers were approached and asked to recommend other returnees as potential participants.The inclusion criteria for selecting the study participants were (1) an Indonesian educated nurse, (2) having lived and worked as caregivers in Japan for at least a year, and (3) voluntarily agreed to participate and speak about their life and work experiences.In total, 17 returnees were contacted by researchers, but two did not respond for further communication, leaving 15 returnees participating in this study.

Data collection
Semi-structured individual interviews were conducted and included the following questions: 'Please tell me the reasons for you to return to Indonesia?', 'How do you feel about your previous experience as a caregiver in Japan influencing your professional skills and your choice of employment?', 'What are your thoughts about utilizing your skills for the elderly care service in Indonesia?' and 'What particular supports are required for returnees to improve the EPA programme?' Interviews were conducted in Bahasa, Indonesia, by AK and FE who are Indonesian researchers in the health workforce area.AK had been involved in the EPA implementation at the Indonesia Ministry of Health (MoH), while FE is a registered nurse with research interest in nurse migration.Each interview lasted approximately 60 min.Interviews were carried out in four provinces from August to October 2015, at a place and time determined by the participants.All interviews were digitally recorded and transcribed into text.

Ethical considerations
Approval to conduct the study was granted by the Research Center and Community Services (LPPM) Airlangga University, Surabaya, Indonesia (Number 1814/UN3.14/LT/2015).Prior to participation in the study, participants were informed about the research details and the right to withdraw from the study at any time.All participants submitted written informed consent.Confidentiality of the data was assured, and only researchers could access it.
Data analysis van Manen's (1990) hermeneutic strategy was applied to conduct data analysis and interpretation.First, interview transcripts were read several times by the Indonesian researchers to understand the whole meaning.Afterwards, both researchers individually highlighted or selected statements and phrases that seemed important to the study with the help of QSR NVIVO 10 software.Significant concepts were thus developed through extraction of the texts to formulate the meaning which further identifies the initial themes and categories.The Indonesian authors conducted several collaborative analysis sessions to examine similarities and differences, and to modify the structure of initial themes and categories.Those findings were then translated from Bahasa Indonesian to English language.Next, the results were shared and discussed collaboratively by all authors until the final structure of themes was decided.

Rigour and trustworthiness
The four standards of Lincoln & Guba (1985), namely credibility, confirmability, dependability and transferability, were applied to ensure the rigour and trustworthiness of this work.Credibility was demonstrated through member checking by inviting the participants to verify consistency of the initial findings and provide feedback.Dependability and confirmability were established by auditing the main analysis process.A diary was maintained with regard to the researchers' trail of methodological decisions and related concepts.Transferability was achieved through the inclusion of sufficient descriptive data for readers to evaluate the applicability of the findings to other settings.

Findings
Fifteen returnees aged 27-34 matched inclusion criteria and participated in this study, with a roughly equal number of males and females.All participants except two were married, with or without children.Five participants had a bachelor degree in nursing, while the remaining held a nursing diploma from a 3-year vocational education taken after completing senior high school.Seven participants had worked as nurses before emigrating to Japan.All participants had taken the national examination, but only two succeeded.Three participants worked in a nursing area, six worked in other areas, and the rest were unemployed at the time of interview.Their monthly incomes varied from approximately 200 to 900 USD per month.Four themes emerged and are described below.

Theme 1: returning home
In this first theme, the participants described major situations driving them to return to Indonesia.While some of them had no choice because of contract termination, others made their own decisions due to family and other psychological reasons.

Involuntary homecoming
All participants were aware of the consequence of failing the examination on their caregiving careers.Each care facility applied different employment policy for foreign caregivers.Not all institutions would offer any extension opportunity for failed candidates.In this case, candidates would be sent to their home countries against their expectation to continue working in Japan.
I had to return.I did not pass kokkashiken (the national exam), the contract was expired and not renewed.It also depended on each care facility. ... But my care facility had a strict policy; they did not extend my contract.

Back to family
Family plays a major role in influencing the choice to migrate as well as to return.The participants would consult their parents or spouses for consideration.One participant said that his migration duration and the return had been arranged with his family in advance.Such a return is intended to maintain family ties, and this was most often the case when the participants had to attend to certain family responsibilities, especially taking care of their children or elderly parents.
After three years working, I did not pass the exam.My care facility offered me a one-year extension.Unfortunately, my mother fell ill, so I declined the offer.I decided to return and take care of her.(Participant 13) Escape from the pressure Living and working in Japan were described by the participants as extremely high cost and hard work.As caregiver candidates, they were overburdened with full-time work and study for the national examination.Inability to balance work and life made them feel stressed and influenced their decision to return.In a similar way, those who had been licensed as a certified caregiver also decided to discontinue their career because of feeling exhausted by work.I was tired of my monotonous life and heavy workload there.I did pass the exam, so I had the right to stay and work (in Japan). . .but I just wanted to return and try something new.For the time being, I don't want to be a nurse.(Participant 2) Theme 2: going back to zero The deskilling process often begins from the first day of work as a caregiver.This situation had not been anticipated by returnees, as Participant 7 said: 'I was so shocked when starting my job there.Why is it different?In the care facility, my duty was only feeding, bathing, taking patients for a walk'.
Prior to their departure to Japan, upon receiving information on the caregiving job, participants assumed that it would not be much different from the nursing job in Indonesia.Two categories in this second theme described the brain waste from neglecting their nursing skill and their loss of skills and confidence as a nurse.

Neglected nursing skills
The participants recalled that their nursing skills were not much use in their work as caregivers in Japan.Their main task was strictly to assist the provision of the basic human needs.No medical and nursing interventions were permitted.One participant mentioned that his job could actually be handled by a nurse assistant from the secondary level of education.This situation made them feel that their nursing talents had been wasted.Unlike working in a hospital, all my nursing skills that I learnt from my school were wasted.I was not allowed to do injections or infusions there.It was different because my job status was kaigofukushishi (caregiver).(Participant 2) Losing skill and confidence Despite having trained as professional nurses, the participants' skills gradually declined along with the duration of their stay in Japan.The decreased nursing skills made them feel incompetent.They realized that it was difficult for former caregivers to just go back and work as nurses.This feeling also undermined the participants' confidence when they were unable to demonstrate any advances in nursing skills after years of working in Japan.I applied for a job in a hospital and they asked me: 'What did you get (learn) from Japan?' Frankly speaking, I forgot and trembled.I felt (I was) going back to zero.Why?When you become a kaigofukushishi there, there is no development in your nursing skills.(Participant 5) Theme 3: walking through a difficult journey Various challenges were experienced by returnees, but the biggest hurdle was getting a job.Only three participants were quickly employed after return, while some of them reported taking at least 6 months to get hired.Two participants voiced how their employers disregarded their previous work experience in Japan and treated them as 'fresh graduates'.

Being jobless
Having been through a tight selection procedure and employed in a developed country boosted the participants' self-esteem.Finding themselves ending up jobless was, therefore, beyond their imagination.Returnees expressed their frustration that their working experience was unhelpful to enhance their opportunities.Yes, I sent job applications to some private hospitals.I felt confident, experienced from Japan.I should have been shortlisted, but, in fact, not even a call.Once I had an interview in a general company, no success.(Participant 4) Job seeking is a fierce competition as the number of vacancies available is always less than the number of nursing graduates.One participant thought, helplessly, that younger nurses were more likely to be hired because of their willingness to accept a low salary.

Searching for appropriate jobs
Job scarcity and their declining nursing skill left returnees with only a few choices.However, some participants were selective in accepting jobs that met their criteria.For example, two participants said that they were giving up jobs because the salary was too low and was 'not worth the effort', while others talked about an unpromising career.Location is also important when it comes to family considerations.
Perhaps finding a suitable job is not too difficult if you want to go far away to a big city.I am just looking for a job around here (a small city), which is not too far from home.(Participant 1) Theme 4: overcoming barriers In this final theme, there were five categories reflecting participants' suggestions on strategies to address deskilling and the challenges experienced by returnees.

Refresh nursing skills
The first category reflected the need of participants to restore their nursing competency and the benefit of the training for those who stayed in the profession.I like working as a nurse, so I joined a professional nurse training course.I am happy working with people, making communication, and giving direct care for those who need me.(Participant 14) Two participants suggested that the Indonesian National Nurses Association should facilitate the refresher training and a professional registration process to enable returnees to go back to the nursing workforce.

Positive character
The second category reflected participants' acknowledgement of how Japanese positive behaviour influenced them in their social life and work.Participant 5 confessed: 'No matter what the religion, I learned from Japanese people how to become a good person: helpful, respectful and honest'.Participants also adopted a positive attitude to guide their work as nurses or as family caregivers.
Living in Japan has changed my life, a lot.I am more disciplined and punctual in every situation.I appreciate time more than before.I handle all patients' complaints with a smile and patience.I also take care of my parents, just like I did to my elderly patients in Japan, caring with full respect and love.(Participant 6)

Japanese competency
The third category described participants' view on the benefit of mastering the Japanese language not only for their work in Japan, but also to find a proper job after return.Possessing a proficiency certificate in the Japanese language increased their chance of employment when nursing jobs were scarce or financially unattractive.I suggest when you work in Japan, use your free time to learn Japanese as well, because, to me, it is very useful.I can work here (a Japanese company) because I understand Japanese.(Participant 2)

Financial capital
The fourth category reflected another strategy used by the participants to generate income.During their stay in Japan, the participants sent remittances to support their families.Some participants used the money to buy properties and invest.Participant 5 said: 'When I worked in Japan I could send money to build a photography studio; my hobby is in this field.So when coming home, at least we have got a backup plan'.The participants believed that making good preparation before their return would help in mitigating their misery.

Need a helping hand from the government
The last category depicted participants' expectations of the Indonesian's government support.Some participants expressed their disappointment at how their return was managed.They demanded that the Indonesian government should have a reutilization programme for returnees.As voiced by Participant 8: 'We expect attention from our government.For example, employing us in the local government hospitals, so we have no problem finding jobs'.Other participants also suggested that the government should make more efforts in helping the former caregivers, for example by creating an alumni database: ". . .so we know how many of us who need a job and what job qualifications are required.'(Participant 9)

Discussion
For returnees in this study, their homecoming was driven by contract termination as a result of failing the examination, family consideration and the feeling of being under pressure in Japan.This finding is in line with other return migration studies.Expired contracts have been among reasons compelling the return of Filipino nurses to their home country (Lorenzo et al. 2007).Cassarino (2008) reported that 12.6% of North African migrants were forced to return home due to losing their job.Family was among the strong motives for returning home considered by Ghanaian health professionals (Adzei & Sakyi 2014) and Indonesian nurses (Hirano et al. 2012).In our study, returnees who were both certified and non-certified caregivers claimed their stressful work experience in Japan contributed to their decision to return.Feeling distressed has also been reported by internationally educated nurses working in Iceland (Magnusdottir 2005) and the USA (Jose 2011).Language and communication barriers, discrimination and different working environment are among common stressors experienced by foreign educated nurses (Moyce et al. 2015).Brain waste occurs when overseas educated health professionals are unable to apply their professional skills in the destination countries (Alam et al. 2015), and this is referred to by Kingma (2006) as a gradual deskilling process.Deskilling has been experienced by migrant nurses who worked as professional nurses (Alexis & Shillingford 2015;Pung & Goh 2016) or as lower-skilled health workers (Salami et al. 2014).For the returnees examined in this study, inability to perform nursing interventions had decreased their skills.Deskilling was unforeseen, because Indonesian nurses were unfamiliar with the caregiver job description (Nugraha & Hirano 2016) and they expected to improve their nursing career and learn advanced technology in Japan (Hirano et al. 2012).The migration policy of Indonesian nurses emphasizes on the expansion of work opportunities and acquisition of new knowledge, skills and work experience (MoH 2012).The dispatch of Indonesian nurses to Japan as caregivers, therefore, is mainly a way to overcome the saturated domestic labour market, but has not yet fully addressed the issue of deskilling and reintegration of returned professionals.
Retaining nurses within the nursing profession has remained a global concern in maintaining a robust health system (International Council of Nurses 2013).The difficulties faced by returnees are particularly related to their return to nursing or their career path.In this study, only three of the 15 returnees (20%) were employed in nursing areas, which is in contrast to a previous study on the return migration of Jamaican nurses by Brown (1996), which found that 76% of these returned to nursing practice.Sadly, Efendi et al. (2013) also found that Indonesian returnees who previously worked as nurses in Japan under the EPA also had a problem in finding jobs.Although there are no clear data on nursing unemployment, Indonesia's labour market is reported to have low capacity to absorb new nursing graduates (Suwandono et al. 2005).The overall unemployment rate in Indonesia is quite high, at 6.18% in 2015, or approximately 7.56 million people of productive age unemployed (BPS 2015).
As noted by the returnees in this study, supports from the Indonesian government and the Indonesian National Nursing Association are strongly required in facilitating their return.Having refresher training is crucial to enable them to go back to the nursing profession.Constructing a returnees' database and the placement in public hospitals in underserved areas would be a significant contribution in strengthening the health workforce.Haour-Knipe & Davies (2008) emphasized the important role of government in developing such a mechanism.In general, returned Indonesian migrants lack support and urge the government to intervene (International Labour Organization 2015).Both the Japanese and Indonesian governments regularly run job fairs once a year to link between prospective employers and returnees (Efendi et al. 2013).This collaborative effort should be strengthened further by aligning returnees' competency into the national ageing policy.The caregiving background of nurse returnees would be beneficial for leveraging the quality of care in the elderly long-term care industry in Indonesia.
Returnees who were unable or unwilling to join the nursing workforce utilized the financial and human capital gained in Japan to support their living in their home country.This is parallel with the global pattern of nurse migration in which returnees bring back financial, human and social capitals (Haour-Knipe & Davies 2008).This financial capital is often used to improve the economic status of the family or to start businesses.A migration study of doctors and nurses carried out by Brown & Connel (2004) found that returnees chose self-employment or establishing their own businesses using capital collected from savings and remittances which might compensate their skill drain.The human capital, as expressed by the study participants, is manifested in the acquisition of Japanese language proficiency and positive work attitude.Proficiency in the Japanese language helped some of the participants to be employed at Japanese companies or health facilities.Returnees' positive influences from their work experience were also confirmed in a previous study by Efendi et al. (2016), which found that Indonesian migrant nurses in Japan adopted discipline as a work ethic and way of life.

Limitations
This study is not without limitations.First, although coming from the same cultural background, the interviewers were not known by most returnees.The participants might be cautious or hesitant about speaking more openly.Second, only participants from Java Island were recruited, thus ignoring disparities among regions in Indonesia.

Conclusions
This study's findings provide critical insights on the lived experience of Indonesian nurse returnees after pursuing a career as caregivers in Japan.While their return might be forced by contract termination or influenced by other personal motives, most returnees were not prepared to face the tough competition in both the nursing and non-nursing job markets in their home country.For many of them, deskilling had contributed to the difficulties in seeking suitable jobs.The results of this study suggest that more efforts in the reintegration process are needed to promote the brain gain, such as through a refresher training programme and a mentoring system in health and care facilities facilitated by the local government.A further study is recommended to examine the impact of return migration on individual nurses and the source country in optimizing the benefits of their return.Exploring the views of policy makers in responding to the complex issues related to return migration of nurses under this bilateral agreement would be useful for tangible solutions.

Implications for nursing and health policy
Deskilling is a real phenomenon which should be taken into consideration in this context.The Indonesian government should mobilize support from local and international care institutions to help returnees re-enter the labour market and utilize their knowledge and skills, by adopting a 'brain gain' strategy.First, the migration for Indonesian nurses should be strengthened, emphasizing not only on the period before departure and the related placement process, but also on the post-migration stage.This policy should include a reintegration and development framework for returnees.Second, the national health workforce plan should incorporate the nurse returnees within the nursing workforce supply and requirement.Third, the assignment of returnees to facilities requiring staff with geriatric nursing skills, such as hospitals with geriatric services, nursing homes, ageing-friendly community health centres, senior living residences and home care facilities, is highly recommended to address the issue of deskilling and wasted talent.A return to practice programme should be provided for those who are still interested in or have a passion for working as nurses, but may need a refresher.This can be carried out by partnering with the private sector and professional associations, including development assistance from the Japan International Cooperation Agency in Indonesia.In the long run, innovations such as the development of senior living residences in several big cities in Indonesia, which would require large numbers of geriatric nursing staff, may be carried out in partnership with the Japanese long-term care sector.Finally, both countries involved in this programme should promote an orderly and regulated return migration of nurses using a comprehensive approach to enhance benefits for all parties.