A New Skilled Emigration Dynamic: Portuguese Nurses and Recruitment in the Southern European Periphery

Philippine and Indian nurses have been emigrating for many years, but Portuguese nurses and other South and East Europeans have recently started to replace them in the UK. This study focuses on the recent migration of Portuguese nurses – both as emigrants and immigrants – within the European area.


Introduction
It was doing fieldwork among qualified Portuguese nationals 1 in London that led me to study Portuguese nurses in England and other countries. During the 5 months that I was in London in 2013 -interviewing and conducting participant observation among qualified Portuguese nationals for a post-doctoral project -I realised that Portuguese nurses stood out clearly from other professional groups, whether information technology personnel, economists, managers, teachers, musicians or others. I found myself meeting more Portuguese nurses in London, and heard frequent references to their increasing numbers, both in the capital and elsewhere. This prompted me to look into the statistics. They showed clearly how "numbers speak"; indeed, since the previous year (2012), Portuguese nurses had been the second main nationality among foreign nurses in England. It was clear that some major change was taking place because in 2008, 91 Portuguese nurses had arrived in the country, in 2010 the number had almost tripled to 249, and by 2012 it had increased to 781. At this point, I was still unaware that in 2013 the number of nurses that had started working in the country surpassed the milestone of 1000 to stand at 1211. The investigation continued and the interest of the Portuguese Nurses' Council in the study led to my interviewing 20 Portuguese nurses resident in 12 countries (Pereira 2015). The statistical investigation of the number of Portuguese nurses was expanded and supplemented with a survey of 349 nurses in the United Kingdom (UK) conducted in collaboration with others , as well as interviews with four recruitment agencies that came to Portugal to recruit. 1 The research refers only to people born in Portugal.
C. Pereira (*) Instituto Universitário de Lisboa (ISCTE-IUL), Centro de Investigação e Estudos de Sociologia (CIES-IUL), Observatório da Emigração, Lisbon, Portugal e-mail: claudia. pereira@iscte-iul.pt This topic is important because new dynamics of qualified emigration among nurses in particular reflect the dynamics of recent emigration in general within Europe. But also because emigration in this specific sector was distinguished by its unusually high numbers in the second decade of the twenty-first century, as well as by its demographic and socioeconomic impact. The implications have been considerable in both the origin and destination countries.
There are studies on the recent emigration of qualified people in the European Union (EU), originating from other European countries. There is also research on immigrant nurses in the countries with highest demand -such as Indian and Filipino nurses in the UK -but this focuses on the receiving country and on selection policies. There is a gap in the literature on the recent specific and very significant movement of nurses from the Eastern and Southern periphery of Europe to its Northern and Western countries, which it is important to relate to other emigration flows in Europe.
This study deepens research into the recent migration of Portuguese nurses within Europe, from the perspective of both origin and destination countries. It follows the recommendation of the geographer Raghuram (2008) that the contexts of emigration and immigration should be analysed together when considering the migration of qualified people.
The main finding is that although the push factor of economic recession and increased unemployment that hit the European periphery after the 2008 financial crisis played a role in the outflow of Portuguese nurses, it was a pull factor that was more significant. Health agencies started to recruit heavily among Portuguese nurses, which often led to their decision to leave the country with a guaranteed job abroad. However, these dynamics instigated by formal networks (a meso-level factor), were actually caused by a macro-level structural factor: the immigration policies of Portuguese nurses' main destination country, England, which erected barriers to the contracting of nurses from outside the EU, who were traditionally Indians and Filipinos. This government policy led British employment agencies and hospitals to recruit nurses inside the European area. By coincidence, in that same year, 2011, Southern European countries such as Spain, Italy and Portugal were undergoing economic recessions, and another of these countries -Romania -had entered the EU a few years earlier, in 2008, with nurses seeking employment. The decision to migrate is always individual (micro level) and the choice of the majority of the Portuguese nurses that emigrated was influenced by the fact that they were simultaneously experiencing a period of economic austerity -and thus knew that there would not be any job offers in Portugal -and an ideal life stage for mobility, completing their higher education degree and now searching for their first job, with many having been recruited even before they finished their university degree.
The second key finding is that this new mass emigration of Portuguese nurses is not just a Portuguese phenomenon but rather follows the model of South European migration (cf. King 2015). There is a general dynamic of migrants moving from the southern 'periphery' of Europe to its Northern and Western countries, principally the UK and Germany, which are in the geographic and economic 'centre' of the European area.

Recruitment and Economic Austerity in the Southern Periphery of Europe
A recent survey of Portuguese nurses in the UK found that more than three quarters (83%) were employed through agencies (Pereira et al. 2015, 4,5). 2 Another survey of UK-based foreign nurses from various different countries concluded that about two thirds were employed through recruitment agencies (Buchan et al. 2006). Portuguese nurses' main destination country is the UK (Pereira 2015), and recruitment by agencies plays a crucial role in their decision to move here. The emigration of Portuguese nurses only took on significant dimensions after 2010-2011; up to this point Portugal had principally been a receiving country, welcoming primarily Spanish nurses (Ribeiro et al. 2014). Although recent, there are already studies on the departure of Portuguese nurses conducted in the sending country, Portugal (Gomes et al. 2014;Leal 2013;Leone et al. 2015;Reis 2016;Ribeiro et al. 2014), and some that complement this with the perspective of the receiving country Pereira 2015;Stoehr 2015).
Why did so many nurses began to emigrate from 2010-2011 onwards? In this chapter, I argue that the principal pull factor emerged at the macro level: from 2010 onwards, in a drive to limit immigration, the Conservative UK government erected barriers to the contracting of health professionals from countries outside the European Union 3 (Carvalho 2015; The Migration Observatory 2011). However, given that the British national health service is dependent on the work of foreign nurses and doctors (Bach 2010), the hospitals and employment agencies had to strengthen their recruitment efforts within the European Union. No longer able to resort to the nurses of India and the Philippines -who were predominant at the beginning of the twenty-first century -the British national health service and the recruiting agencies, among which were the four recruiting companies interviewed, started to recruit nurses from the Southern and Eastern peripheries of Europe, "pulling them" to work in the United Kingdom. Coincidentally, during that same period, while Northern and Western European governments slowly began to recover stability in the aftermath of the 2008 financial crisis, those of Portugal and other geographically peripheral countries in Europe, such as Spain, had to resort to external assistance to pay their sovereign debt. From 2010 to 2011 onwards, the peripheral countries descended into a period of austerity, during which the unemployment rate swelled, leading a large number of individuals to decide to seek employment in other countries (Observatório da Emigração 2014). So when agencies were 2 The nursing profession and, consequently, the migrant nurse population, are largely female dominated. 3 In addition to the barriers put in place against the immigration of health professionals from non-EU countries, the UK government reduced the number of places for nursing students in the country. However, the fact that it was no longer possible to contract such a high number of Filipino and Indian nurses had a far greater impact than the reduction of the number of education places for UK students, who were already unable to meet the system's requirements (cf. Buchan and Seccombe 2012;Bach 2010). 100 compelled to recruit within Europe, there was a considerable number of unemployed nurses available to work abroad.
A United Nations report highlights the role of intermediaries such as recruiters in contemporary migration, contextualising its value and cost: Despite this diversity among intermediaries, all except those who deceive and exploit migrants satisfy an overarching goal -bridging the gap between employers or sponsors and prospective migrants. Despite globalization, this gap has remained significant, allowing intermediaries to assume important roles. [...] Intermediaries [...] expand migrants' range of choice, increasing the possibility that they will be able to pursue lives that they value (Agunias 2009, 10).
In fact, the role of recruitment intermediaries in international labour migration is one of the most understudied (Martin 2005, 1). This is likewise the case for the role of recruitment in the emigration of Portuguese nationals, particularly nurses, to which very little research has so far been dedicated (Pereira 2015). Although recruitment is barely studied in international migration, its decisive role in global health care migration -including nurses' migration -has been identified (Maybud and Wiskow 2006;Connell and Stilwell 2006;Kingma 2006;Buchan 2007;Kroezen et al. 2015;Dussault et al. 2016). This chapter does not directly analyse the phenomenon of recruitment, but rather its role in Portuguese nurses' decision to emigrate.
The countries seeking to address critical shortages of nurses -which have consequently played the largest role in Portuguese nurses' recent recruitment -are those of Western and Northern Europe, in which there is already a higher number of nurses per inhabitant in comparison to Portugal (Barros and Moura 2015, 34, based on OECD Health Data): the United Kingdom, Germany and France. Indeed, the international recruitment of nurses has historically been one of the measures favoured by policymakers and officials to compensate for the scarcity of nurses (Gabriel 2013), although this has been a recent experience for Portuguese nurses.
The international migration and, consequently, recruitment of nurses crucially requires the existence of mutual recognition agreements on their qualifications (Yeates 2008, 158), even more so than the free movement of people between countries. Within the EU, despite the free movement of people there was actually very little internal migration of nurses as recently as 2003 (Buchan et al. 2003). It was only in 2005 that mutual recognition of diplomas and other documentation for the nursing profession was established in the EU, and this subsequently opened the gates to mobility for health professionals within Europe (Galbany-Estragués and Nelson 2016, 117).
The year of the financial crisis, 2008, marked the first time in the twenty-first century that the number of European nurses exceeded the number of nurses from Non-EU countries working in England, and have remained in the majority ever since. Moreover, since 2010 the number of nurses who have emigrated to England from other European countries has progressively increased (see Fig. 5.1). As we shall see in the section on "Findings", these nurses originate from countries of the Eastern and Southern peripheries of Europe.
Globally, 'the general flow [of nurses] is from countries on the periphery of the world economy to countries at its core' (Yeates 2008, 154, my emphasis). This means that the majority migrate from developing to industrialised countries, mainly in Europe, North America and the high-income countries of the Western Pacific (Sarfati 2003;Kingma 2007).
The novelty in the European continent is that this migration has shifted so that it now flows from its own periphery to its core. That is, mainly from the sending countries of Southern and Eastern Europe (Spain, Portugal, Romania and Poland) to the receiving countries of Westerm and Northern Europe. The OECD data confirm this: in Europe, Germany is the main destination country for foreign nurses, followed by the UK (OECD 2015, 115, from the Database on Immigrants in OECD Countries, DIOC, 2010, Labour Force Survey, LFS, 2009/2012. The top destination for Portuguese nurses is England while Germany comes in second or third, depending on the year. The international mobility of nurses, as noted above, 'is not a new phenomenon, but its scope and importance in the current period has intensified' (Gabriel 2013). In this context, it is important to analyse the different conditions and motivations that lead to nurses' -in this case Portuguese nurses' -decision to migrate.
I will now move on to consider the chapter's theoretical framework, in particular the role of macro level dynamics (economic austerity and barriers to hiring nurses in England from outside the EU) in Portuguese nurses' decision to emigrate, together with the meso (recruitment) and micro (individual) level dynamics (cf. Goldin et al. 2011). This will be linked to the phenomenon of the 'new global cosmopolitan elite' (Bauman 2013).

Theoretical Framework
The primary theoretical basis for my analysis of Portuguese emigration is a framework that highlights the interplay of macro, meso and micro dynamics in the decision to leave home, highlighting immigration policies (macro) in the regulation of migrant flows (Massey et al. 2002;Goldin et al. 2011). This analysis is combined with the insights of the diagram produced by Coleman-Lindenberg (Coleman 1988; the analysis of the diagram by Pires 2014) to identify the results and causes of social phenomena, in this case, migration. Secondly, the case being studied fits the Southern European model of migration, suggesting migration with centre-periphery dynamics (King 2015). Lastly, the phenomenon under study is framed using the concept of the 'new cosmopolitan elite' (Bauman 2013). The decision to migrate is a choice that can be influenced or constrained by diverse factors, such as networks. For our study, meso-level institutional networks (there are also social networks, family and friends) help to explain the beginning of any given migration. They … assist migration in areas where social networks are not sufficiently well developed to facilitate cross-border movement (Manolo, 2004). State-supported or private labor recruiters help to initiate migrant flows by spreading (often limited) information about the destination country and offering jobs, accommodation, and support for potential migrants (Goldin et al. 2011, 105, my emphasis). As a (meso-level) social phenomenon, networks connect the individual agency of the migrant (micro level), with the economic, demographic and political structures (macro level), that influence the decision to migrate.
"Push" and "pull" factors are determinant on the macro level, driving the desire to leave the home country (push) and/or attracting towards the destination country (pull). For this study, at the macro level the economic and demographic conditions are important, and government policies -particularly immigration policies -appear to play a preponderant role. The volume of migrant flows is largely influenced, directly and indirectly, by immigration policies. In the words of the migration sociologist Douglas Massey and other co-authors, "In the world of the late twentieth century, distances are small but the barriers erected by governments are large, and the latter have become the principal factor determining the size and character of contemporary labor flows" (Massey et al. 2002, 14).
The actual decision to migrate is decided at an individual level by weighing up the meso and macro dimensions, taking stock of the risks, costs and uncertainties and contrasting them with potential opportunities and benefits. The decision to migrate is complex, and depends on the migrant's level of education, financial resources, social capital, access to information, among other factors (Goldin et al. 2011).
Through Coleman-Lindenberg's diagram, sociological theory shows that -put simply -when it comes to social phenomena, macro-level effects originate from individual causes (micro) -from individual actions -which in turn are influenced by macro-level causes (Coleman 1988; see the analysis of the diagram by Pires 2014). Applying this to Portuguese nurses' decision to migrate, we find the common sense empirical explanation that there was a massive emigration of nurses (macro result) due to the crisis and economic austerity (macro cause). Nevertheless, the diagram draws our attention to the fact that the ultimate cause lies in the micro sphere, at an individual level. In this case it could be the completion of a nursing degree and the search for a first job (micro cause), which, in turn, might have been hindered by the economic austerity that led to a reduction of employment offers (macro causes).
The Southern European model of migration frames current Portuguese migration taking place in Europe in the general context of migration from Southern European countries. The migration geographer Russell King shows that there is a historical sequence of migration common to the Southern European countries of Spain, Greece, Italy and Portugal, which started in the post-war period (King 2000) and is currently in its fourth phase. This fourth phase is characterised by the "'new emigration' of young, well-educated people seeking employment and new lifestyle experiences in Northern Europe, since the nineties, accelerating after 2008" (King 2015, 139).
King argues that two crises have combined to give rise to the present 'new emigration', one cyclical and the other structural, and both economic. The emigration of qualified young people from Southern Europe was the outcome of the 2008 financial crisis, but also reflected a much deeper structural crisis that had been pervasively entrenched for around two decades before this date: that of graduate unemployment (King 2015, 158).
According to the same author, this model is related to the 'centre-periphery framework'. Southern European countries' geographic peripherality overlaps with their economic peripherality, and their economies have been revealed as fragile with the reappearance of their structural dependency on the economies of the 'centre', i.e. Northern and Western European countries (Germany, the UK and others) (King 2015).
These conditions have been exacerbated for Southern European countries by conditions that operate as pull and push factors for the emigration of qualified young people such as nurses. The Portuguese Emigration Observatory (Observatório da Emigração) demonstrates the impact on emigration due to the 'push factor' of economic austerity: 'the asymmetrical nature of the sovereign debt crisis dating from 2010 and the recessionary effects of austerity policies have caused [Portuguese] emigration to rise faster than it had during the period before the crisis' (Observatório da Emigração 2014, 12). In the following year, 2011, the UK raised barriers to the contracting of qualified immigrants coming from countries outside the EU, a measure supposedly aimed at reducing immigration in this country (The Migration Observatory 2011;Carvalho 2015).
There are also non-economic, non-political factors that have influenced recent emigration, i.e. cultural factors -and specifically the phenomenon of a 'new global cosmopolitan elite'. Particularly for emigrants of Southern European countries, where '… a lengthening of young people's home, […] and family dependency' was widespread, a new attitude has emerged due to the high graduate unemployment that has led to them to seek employment abroad (Domínguez-Mujica and Gracía 2017, 43). This change of mentality falls under the broader phenomenon identified by the sociologist and philosopher Zygmunt Bauman: the recent appearance of a new cosmopolitan elite that has emerged due to the weakening of the welfare state in Europe and is consequently 'seeking safety in an insecure world' through the idea of mobility. The 'permanent address' is that of the email or mobile telephone and is no longer a concrete physical location/country: Whatever else the new 'cosmopolitanism' of the new global elite may be, it is born to be selective. [...] What their lifestyle celebrates is the irrelevance of place, a condition most conspicuously beyond the reach of ordinary folks, of the 'natives' tied fast to the ground [...]. The message of the 'cosmopolitan' way of being is simple and blunt: it does not matter where we are, what matters is that we are there (Bauman 2013, 56).
… because at no other social location has that certainty and security -and particularly the reassuring feeling of 'knowing for sure what is going to happen' -collapsed so spectacularly as in the underdefined, underinstitutionalized, underregulated and all too often anomic territory of exterritoriality inhabited by the new cosmopolitans (Bauman 2013, 60).

Mixed Methodologies
This study combines extensive and intensive methodologies. The extensive research focused both on the statistical collection and interpretation of data about Portuguese nurses in destination countries, as well as the analysis of a questionnaire-based survey conducted among nurses in the United Kingdom.
The intensive research consisted of ethnography conducted through interviews and participant observation among Portuguese nurses (and other qualified professionals). This took place in London over 5 months in 2013. The interviews sought to encompass the heterogeneity of the profiles of emigrant Portuguese nurses: 20 were interviewed in 12 different African, European and Asian countries; 3 were interviewed at different moments in 2013, 2014 and 2015, in order to follow the evolution of their expectations, and the remaining 17 were interviewed in 2015.
The interviewees included young recent graduates searching for their first job, but also others with a contract for an indefinite period who decided to leave the country. For a deeper understanding of what leads them to be selected in particular rather than nurses of other nationalities, interviews were conducted with four recruitment agency professionals and two hospital nursing officers in England with Portuguese nurses in their team. The interviews were conducted in person, through the Internet by Skype and in writing. Their total duration was between one and seven hours -depending on the flow of the conversation -and the majority lasted around four hours.
This study involved finding the numbers of Portuguese nurses that have gone abroad -statistics that have not been published internationally or even within the host countries. In order to discover the number of nurses that leave the country each year, the methodology used by the UN, OECD and World Bank -i.e. finding out the number of foreigners that arrive in the countries of destination, in this case Portuguese nurses -was followed to calculate the number of international immigrants. This means that the number of Portuguese nurses leaving the country was calculated based on data about entries recorded by institutions in the foreign countries in which they have to register.
During the statistical research into the number of Portuguese nurses in the destination countries, various difficulties emerged: (a) not all the countries have socio-professional associations in which registration is compulsory (this is the case for Germany and Switzerland); (b) the registration of nurses is calculated using various sources from institutions of a different nature (for example, the Norwegian Nurses' Association, the Federal Office for Migration in Switzerland, the Federal Employment Agency in Germany or the Ministry of Health in Belgium); (c) where they exist, socio-professional nurses' organisations generally provide data on the number of nurses by country of qualification, and this does not always align with nationality; (d) there are countries that simply do not authorise the disclosure of data on foreign nurses in the country (such as Saudi Arabia); (e) the lack of response from some countries in which Portuguese nurses are found. 4

The Numbers. Emigration of Portuguese Nurses and Countries Chosen
In the findings I shall begin by presenting the statistical research into the number of Portuguese nurses that left the country in the wake of the 2008 financial crisis. This analysis will be related to the emigration of nurses from Southern Europe, who are currently working in North and Western European countries. In the following section, this scenario will be contextualised using both the results of a questionnaire completed by Portuguese nurses and material from the 20 interviews conducted. The emigration of Portuguese nurses intensified around 2011, the year when close to 1000 nurses left the country (see Table 5.1). Up until this date less than 500 emigrated per year. The departure of nurses reached its peak in 2013 and 2014 when the number surpassed 2000 per year. In other words, from 2012 to 2013 it increased to double, and this level was maintained in the following year. In 2015 and 2016 the number of nurses leaving to go abroad diminished, but even so still remained at high at around 1000. These numbers are drawn from the records of nurses in the destination countries.

Over Half of the Portuguese Nurses Who Had Emigrated Chose England
The emigration of nurses can be related to that of the Portuguese population in general. According to the data of the Emigration Observatory, there was a general increase in emigration from 2011. The specific emigration of nurses reflected this general trend. In 2013 approximately 120 thousand Portuguese nationals emigrated to other countries (Observatório da Emigração 2017, 20). The 2366 Portuguese nurses that moved abroad that year corresponded to around 2% of the total emigration of Portuguese nationals over the same period 5 -and this proportion was the same in 2014. The fact that nursing -in contrast to most other professionsaccounts for more than merely a fraction of a percentage of total Portuguese emigration makes this a highly visible outflow. ." refers to data not available. The symbol "*" means that this data is provisional as the numbers of nurses in the countries with this symbol ".." are still not available and could not be counted for this reason. The data was provided following a request for the purposes of this study. The values refer to the number of nurses who graduated in Portugal, except for Switzerland and Germany, where the data corresponds to nationality. In all the other four countries the figures by country of qualification and by nationality appear to be similar. The numbers of Portuguese nurses are detailed below by country: United Kingdom -number of nurse registrations, compulsory to work in this country; France -number of nurse registrations; Germany -number of Portuguese nurses that started working in the respective years; Switzerland -number of Portuguese nurses in the country, including those who have permanent and temporary authorisation; Belgium and Norway -number of nurse registrations. It should be noted that the Saudi Commission for Health Specialities of Saudi Arabia answered our request stating that the number of Portuguese nurses in the country is confidential information, and that they could not disclose the figures. Some Swiss cantons, though not all, require registration at the Red Cross and according to this source the numbers of Portuguese nurses registered in the country by year are as follows: 2010-38; 2011-61; 2012-114; 2013-204; 2014-224 The Portuguese Nursing Council provides the number of requests for professional equivalence to enable working abroad -but these values are numerically inflated as they record the intention to emigrate and not the effective outflow 6 (see Table 5.2). Nevertheless, the number of requests follows the same upward trend until 2014, falling in the two subsequent years, but maintaining a high absolute level.

Portuguese Nurses: Increased Intention to Emigrate
Over half of the Portuguese nurses emigrated to England. A major increase took place from 2011/12 onwards. An illustrative example is the fact that 91 Portuguese nurses started working in this country in 2008, while in 2013 this number stood at 1210 (see Fig. 5.2).
The same trend can be observed in Portuguese emigration in general, whose main country of destination since 2011 has been England, in the United Kingdom (Observatório da Emigração 2017). In fact, 4% of the total number of Portuguese nationals who moved to UK in 2013 (30,121) were nurses. This is a highly significant percentage given that it represents only one profession. 6 Nurses who choose to work in European countries must ask the Portuguese Nurses' Association to issue a statement certifying that their nursing qualifications comply with European Directive 2013/55/EC (www.ordemenfermeiros.pt/comunicacao/Documents/2014/Diretiva_2013_55_EU_ modernizacaoDiretiva2005_36.pdf).

400% Increase in the Inflow of Portuguese Nurses into the United Kingdom, 2010-2014, and Recent Decrease While Maintaining High Values
The other countries chosen by Portuguese nurses are Germany, France, Switzerland and Belgium (see Fig. 5.3). As well as being "receiving-countries" of Portuguese nurses, these countries are also those that contract the most immigrant nurses in Europe (OECD 2015, 115, from DIOC 2010/11, LFS 2009/12), as noted above. Sources and notes: Same as Table 5.1

Increased Emigration of Portuguese Nurses Compared With Spanish and Italian Nurses
In England, Portuguese nurses were the second main foreign nationality (following the Spanish) between 2012 and 2014. Portuguese nurses, combined with Spanish, Romanian and Italian nurses, substantially replaced the Indian and Filipino nurses in the United Kingdom between 2012 and 2014. In 2015 the emigration of Filipino nurses started to increase although they no longer represent one of the three top nationalities (see Fig. 5.4).

Portuguese Nurses in England Among the Top 5 Nationalities from 2012 Onwards
These four Southern and Eastern European nationalities (Portuguese, Spanish, Italian and Romanian) are also the principal nationalities of the nurses in Belgium, together with the French (see Fig. 5.5).

Portuguese Nurses Are the Main Foreign Nationality in Belgium in 2013
In terms of demographic impact, we can draw two conclusions. Firstly, nurses only flow outwards, constituting a migratory movement which is not offset by inflows of foreign nurses. This is due to the low (or null) attractiveness of the Portuguese employment market as a result of austerity policies in the National Health Service (cf. Correia et al. 2015). German nurses, for example, emigrate to work in Switzerland and the Scandinavian countries (among others), but the outflows are offset by foreign nurses who come into the country (Ognyanova et al. 2014), in contrast to what happens in Portugal, which no longer receives immigrant foreign nurses. Secondly, based on the profiles of the Portuguese nurses who moved to England in 2013 -the destination country of over half the nurses that leave Portugal -the majority of emigrant Portuguese nurses appear to be women and young adults. The majority of Portuguese nurses in England are women (77%), consistent with a profession that is largely female dominated. 75% are up to 29 years old (see Fig. 5.6). Of these, 40% are 24 years old or less, which means that nearly half moved soon after attaining their degree. generally of young single women, aged less than 30, who are recent graduates who found their first job in this country . As a rule, their employment in the UK was obtained through employer agencies (83%) that recruit Portuguese nurses either in this country or in Portugal. Professionally-organised formal recruitment processes therefore clearly predominate over informal and individual processes of emigration. Emigration not only enabled access to employment, both for recent graduates and unemployed professionals, but it also opened up paths towards professional promotion in the majority of the cases. Over half have no intention to return to Portugal before their retirement.

The Decision to Leave the Country. "At the Recruitment Company I Had Been Selected Even Before I Had Finished My Course"
In this section I focus on the actual voice of the nurses, specifically on their motivations for emigrating at the individual level (micro), which are related to the politicaleconomic dimension (macro) and the role of the recruitment networks (meso) (cf. Goldin et al. 2011), as well as to their particular profile. My boyfriend and I -he is also a nurse -decided to wait for three months and if there were no alternatives we would emigrate. After three months, we contacted the company […] that had already made a presentation at the School. I was torn between choosing England or Belgium because they were the countries presented as the best to work in. As I have always preferred the French language, I decided on Belgium. Then they explained all the steps that had to be taken: how to apply for authorisation to work as a nurse in Belgium, the French course, among others. [Cátia, 26 years old, nurse in Belgium, 2015] 7 At the network level, even before completing their university degree, various Portuguese nursing students had received information from employment agencies on working in countries such as the United Kingdom and Belgium. Other nurses, who finished their course before 2010, easily found advertisements on employment websites on the Internet and in Facebook groups, which listed opportunities in France, Switzerland, Germany and Ireland. Others heard about opportunities through friends and attended presentation sessions on working conditions in Saudi Arabia and the United Arab Emirates. Recruitment was also identified as the main driver for Portuguese nurses leaving to work in Germany, according to sociologist and German teacher Anne Stoehr (Stoehr 2015).
At an individual level, the twenty interviews conducted among emigrated nurses revealed that the causes "pushing" them to leave the country are heterogenous. For those who are unemployed or seeking their first job, it is the guarantee of being able to work in nursing. For those who are employed, it is professional demotivation due to three factors: (i) the impossibility of progressing professionally because career trajectories are frozen; (ii) the salary cuts due to economic austerity; and (iii) the scant communication with managers that makes them feel undervalued and, in their opinion, rather inefficient personnel management.
Moreover, the majority of the employed nurses have two jobs, one at a public hospital and another in a private institution. This is partly because overtime in public hospitals is not paid but exchanged for free time, which the senior staff decide when employees can take, informing the nurses only a few days beforehand, thus precluding the possibility of programming holidays. This dissatisfaction at work is exacerbated by the lack of communication along the hierarchical chain and particularly with the administrative boards, which are largely unreceptive to the complaints, needs and suggestions of the nurses: I left Portugal due to professional demotivation, especially in terms of recognition and the way that we are treated by our senior staff.
[…] I knew that they were contracting for Saudi Arabia and I applied.
[…] They should give nurses the opportunity to continue to study, facilitating their work hours so they can attend post-graduate, specialisation or doctoral classes. In my case, what did I want? I wanted more flexible work hours, not to take a course during work hours, but the possibility of adjusting them [Alexandra, 51 years old, a nurse that re-emigrated from Saudi Arabia to the United Arab Emirates, 2015].
The number of nurses searching for their first job increased from 2008 onwards. A questionnaire-based survey of the Portuguese Nurses' Council covering 730 professionals -around half of whom completed their university degree in 2008 -reveals that 49% had not found a job 6 months later and 77% had not received any offer of employment in Portugal. The same survey revealed that only about 1% of the sample of nurses who graduated in 2006 and 2007 were unemployed (Fernandes et al. 2009, 7)). In the words of one nurse who completed her course in 2010 and searched for employment in nursing for over a year: I continued to look for job offers and I saw this opportunity here in Germany and another in England. That was when I decided, "OK, now I am going abroad" … […] In the case of Germany it was wonderful opportunity because it offered accommodation at a ridiculously low price for a little over a year; it was the hospital that directly came to fetch the nurses and offered a German course at the Goethe-Institut.
[…] I saw the opportunity, I found it interesting and within a week it was settled [Sandra, 29 years old, nurse in Germany, 2015].
The high number of Portuguese nurses that emigrate has been widely disclosed not only in the national media, 8 but also by the British media, among others in The Guardian newspaper and on BBC radio. 9 Due to the weakness of the welfare state, these nurses hold the contemporary mindset of a new global and cosmopolitan elite (Bauman 2013), among whom what has become permanent is their electronic contact details rather than their physical address. Both the interviews with nurses as well as the participant observation conducted in Lisbon and London revealed that nurses do not always remain in the country they first emigrate to beyond the year in which they emigrate: some return to Portugal; others re-emigrate from Saudi Arabia to England, from Saudi Arabia to the United Arab Emirates, from France to Switzerland, from Spain to Norway, from Spain to England. In the words of a nurse who emigrated to Spain and then reemigrated to England: From another perspective, due to the lack of nursing employment in Portugal, I had met Spanish doctors and nurses who had worked in Portugal and then returned to Spain. (…) I was facing a dilemma, I would either go to Spain or Switzerland. I saw the advertisements of the agencies on the Internet and at Chaves Higher Education School [Portugal]. How come there's such a shortage of nurses in these places and how is it possible that they pay these wages and offer these conditions? I asked myself, why doesn't this exist in Portugal? In the meantime, I was called to a meeting at Chaves job centre about the recruitment of nurses to work abroad [Nuno, 28 years old, nurse who re-emigrated from Spain to England, 2015]. 8 Among various news items, this was disclosed in "Portugal trains nurses and Great Britain takes advantage" (Rádio Renascença: http://rr.sapo.pt/informacao_detalhe.aspx?fid= 31&did=117953) and "The nurses of the others" (Antena 1: http://www.rtp.pt /play/p309/e158192/reportagemantena-1). For more news items, see Amaral and Marques 2013. 9 For example: "West Suffolk Hospital recruits nurses in Portugal" (BBC: http://www.bbc.com/ news/uk-england-suffolk-21181861); "NHS fills nursing shortage by turning to Spain and Portugal" (The Independent: http://www.independent.co.uk/life-style/health-and-families/healthnews/nhs-fills-nursing-shortage-by-turning-to-spain-and-portugal-8877745.html); "Portuguese nurses arrive at troubled Barking, Havering and Redbridge University NHS Trust hospitals" (The Guardian: www.guardian-series.co.uk/news /11533329.Portuguese_nurses_arrive_at_troubled_ hospitals_trust/?ref=mr); "NHS nurse recruitment from EU 'too aggressive'" (BBC: http://www. bbc.com/news/health-33691084).
Nurses are not an isolated case; other authors in this book, such as Peixoto et al., have analysed the return of Portuguese nationals to the country using the global perspective of the census, and still others, such as Queirós, the re-emigration of another professional sector -construction workers. Still, as indicated by the academic literature, nursing is undoubtedly a transnational profession (Prescott and Nichter 2014). Consistent with this observation, Portuguese nurses prove to be mobile, not only in their decision to leave, but also in their mobility between countries.

Conclusion
The emigration of qualified Portuguese nationals increased between 2001 and 2011, according to the censuses of their destination countries (Observatório da Emigração 2015; . Recent research presented in this book shows that this number continued to increase from 2011 onwards. Due to the educational efforts of different governments, the Portuguese population is more highly qualified in this century than it has been previously -and, for this reason, it is only natural that a higher number of qualified Portuguese nationals have left the country than in previous decades.
Among Portuguese emigrants with higher education degrees, nurses have one feature that differentiates them from most other qualified professionals: they are obliged to register with the bodies equivalent to the Nurses' Council in the country where they are going to work. This enables investigation into the numbers of emigrants in this specific professional group. This registration takes place because the equivalence of higher education degrees in nursing is recognised by EU member states. Other professions -such as informatics, finance and teaching, among others -are also recognised but do not demand professional registration.
The statistical research conducted for this study showed that sometimes "the numbers speak for themselves". The significance of Portuguese nurses' emigration was revealed in its impact on not just the country of origin, but also the destination countries.
From the perspective of the sending-country, Portugal, there are three pertinent facts. First, there was a shift from fewer than 500 nurses leaving the country per year in around 2010, to more than 2000 in 2013 and 2014, a figure that has remained high ever since. Second, this specific trend in the outflow of Portuguese nurses reflected changes in Portuguese emigration in general. Both took on massive proportions in 2011 and England was the main destination country in both cases (Observatório da Emigração 2017 and Pires' chapter in this book). Third, because it stood at 2% of the total outflow of Portuguese nationals in 2013 and 2014, the outflow of this professional class has been highly visible.
From the perspective of the receiving country, the inflow of this group became highly visible in 2012 and 2013 because Portuguese was the second main nationality among new immigrant nurses working in England-and in 2013 the first in Belgium. In other countries, such as Switzerland and Germany, its size increased considerably in comparison to previous years.
The causes that led to this phenomenon are heterogenous. One of the main findings of this research, supported by the theory of migrations (cf. Goldin et al. 2011), is that the beginning of this new emigration among qualified Portuguese nationalsand nurses in particular -was due to the visible emergence of recruitment networks (a meso-level factor). This in turn was driven by the preponderant factor -though this lacked visibility -of immigration policies in the United Kingdom (macrolevel), which led to the individual decision (micro-level) of nurses to leave Portugal. The majority of these nurses were in the early period of a new stage of life: having completed higher education, they were searching for their first job. This change of life stage -through access to a profession -instigates geographic mobility according to Savage (1988, 560-63). In this study, through a questionnaire, statistics and interviews, I confirmed that the majority of nurses migrate to the United Kingdom right after finishing their course.
In this context, the 'pull factor' played a determinant role in the outflow of Portuguese nurses to England, their main destination. The fact that in 2011 British agencies and hospitals were barred from recruiting in countries from which nurses had historically emigrated, such as India and the Philippines, compelled them to search for nurses inside Europe. At the same time, coincidentally, austerity was taking place in Southern European countries. This pull factor performed the decisive role of the 'macro cause' -Portuguese nurses might have been facing economic austerity, with fewer job opportunities, but they could also work in other areas, even in unqualified jobs, or continue their job search. When employment agencies started to recruit in Portugal and "pull" them abroad, nurses in Portugal knew that under austerity new jobs would not be created, and those that were employed saw their salaries cut and their career trajectories frozen, preventing them from achieving professional fulfilment and from working in their speciality. In addition to a salary, the job vacancies in the United Kingdom offered paid overtime -and time spent on training or post-graduate study was recorded in the work schedule and paid. Therefore, the fact that British agencies and hospitals started coming to universities and job fairs to recruit Portuguese nurses directly -bringing them access to information about how to work in England as well direct employment offers -played a determinant role in their decision to leave the country from 2011 onwards.
Recruitment networks pulled together the macro political-economic structure and the micro individual reasons to leave; nonetheless, the decision to migrate is always individual. The argument is schematised below (see Fig. 5.7), based on Coleman-Lindenberg's sociological diagram of the causes and effects of social phenomena. In this case, the social phenomenon in question is the emigration of Southern European nurses, specifically Portuguese and Spanish nationals.
From the point of view of the employment agency professionals interviewed, so many Portuguese nurses are selected for jobs in the United Kingdom and other countries because their training includes a 4-year university course -which involves internships with a practical component from the first year onwards -and because they speak good English. In comparison, applicants from other European countries have less training and practical experience. The same opinion is voiced by Debbie Knight (NHS Professionals 2014), who came to Portugal to recruit nurses to work under temporary and flexible arrangements in the south of England: We looked at nurses across the whole of the EU, but Portugal has the four-year training programme and is commensurate with the nursing training that we have here in the UK. They have the really good technical base to their training and their English is excellent.
The second key finding is that this new emigration of Portuguese nurses -following the general trend of rising emigration from the peripheral countries of Europe -is not only a Portuguese phenomenon but rather is in keeping with the Southern European model of emigration (cf. King 2015), in this case applied to European nurse emigration. Thus the dynamic of migration from the periphery to the centre continues. In the specific case of transnational care labour, in which nurses are included, these new dynamics in Europe further extend the general trend of a flow from the global south to the industrialised north (Peterson 2003), specifically from the peripheral east and south of Europe to the industrialised north and west. They also reflect the asymmetries of global -and in this case European -political economy.
Let us consider this issue from the perspective of the second main receivingcountry of immigrant nurses (OECD 2015) and the first main receiving-country of Source: Macro, meso and micro dynamics in the decision of Portuguese and Spanish nurses to migrate. Text in italics by the author, based on Pires (2014: 38). Diagram Coleman-Lindenberg, from Coleman (1988). Notes: Data on Spanish nurses based on the research of Galbany-Estragués and Nelson (2016); *not originally in the diagram, by the author Portuguese nurses in the EU -the UK. During the twenty-first century, the immigration of nurses to England primarily came from countries outside the EU until 2008-2009, as illustrated above in Fig. 5.1. From this date onwards, the number of nurses arriving from EU countries surpassed those from non-EU countries. In 2010 there was a significant increase in the immigration of nurses from EU countriesand this group has maintained its clear majority position in relation to those from outside the EU ever since. The numbers found for this study demonstrate that this emigration of European nurses to England, the 'core' country of immigration, essentially comes from the 'periphery' of Europe: from Romania in the east, and from Spain, Italy and Portugal in the south (see Fig. 5.4). As noted above, a decisive role was played in this shift by a structural factor of macro order: the barriers of UK immigration policy against nurses coming from outside the EU, from about 2011 onwards, which paved the way for nurses from other European countries experiencing economic recession to move.
Portugal is differentiated from the other European sending countries by the demographic and, consequently, socioeconomic implications of its nurses' emigration. Considering that the total population of Spain (around 47 million) is four times higher than that of Portugal, that of Italy (around 60 million) is almost six times higher, and that of Romania (around 21 million) is double, we can conclude that the outflow of Portuguese nurses has a greater impact on the population of Portugal than the departure of nurses of other nationalities has on their Southern and Eastern European countries of origin. Moreover, Portuguese nurses' departure from the country is not offset by the entry of foreign nurses, in contrast to what happens in other countries. Now that the social and formal networks of this new emigration outflow have been created, it is possible that nurses will continue to leave. But it will be crucial to investigate just what the consequences of the UK government's barriers to the contracting of nurses within the European area will be in the wake of Brexit. Indeed, the specific emigration of Southern European nurses is simultaneously reproducing existing socioeconomic inequalities and developing new professional and geographic disparities.
Acknowledgments and Funding This research was supported by a grant (SFRH/ BPD/78853/2011) from the Fundação para a Ciência e a Tecnologia (Foundation for Science and Technology, FCT) to carry out statistical and ethnographic research in London and Lisbon for the author's postdoctoral project, "Skilled Portuguese nationals in London and the financial crisis". The chapter received the support of the Fundação para a Ciência e a Tecnologia for its translation, through Strategic Funding: UID/SOC/03126/2013. The proofreading of this chapter was funded by the Portuguese Emigration Observatory (Observatório da Emigração).
Some data in the introduction, methodology and findings have been presented in the book published in Portuguese by the author, Vidas Partidas. Enfermeiros Portugueses no Estrangeiro [Divided Lives. Portuguese Nurses Abroad] (2015), and were further analysed and updated for this chapter. I would like to thank the nurses that I interviewed, as well as the recruitment agents. I would also like to thank the institutions that sent unpublished data on Portuguese nurses in the respective countries. I am grateful to Rui Pena Pires for the theoretical insights, in particular about the importance of the obstacles put in place by the United Kingdom to the entry of immigrants from outside the European Union, which consequently led to the recruitment of nurses in Portugal. I thank the anonymous reviewers for their insightful comments.
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