Nursing Shift: The ethics of recruiting foreign health care workers

During a recent hospital stay, I was impressed by the care, dedication and efficiency of the nurses and nursing assistants. Yet I could hardly fail to notice the heavy demands made upon them, physically and emotionally. Many work 10- or 12-hour shifts, maintain computerized records on nearly every move their patients make and still manage to smile and be courteous. Several of my nurses and assistants were from outside the United States. They worked just as tirelessly as the others; I wondered whether they received the same pay and benefits. At times, some talked about the demands of the job and their physical fatigue.

The largest nursing strike in U.S. history took place last June, as more than 12,000 registered nurses in Minnesota mounted a protest to pressure hospitals to cap the number of patients per nurse. The imposition of such caps would benefit patients as well as nurses. A study by the University of Pennsylvania revealed that smaller workloads lower the risk of death to patients during surgery.

The United States is suffering a severe and troublesome nursing shortage. According to the Bureau of Labor Statistics, more than one million new and replacement nurses will be needed by 2016. As baby boomers age, they are requiring more care. The need for trained nurses is rising even as the supply is diminishing, and the nurses themselves are aging. In a recent survey 35 percent of nurses between the ages of 45 and 60 said they plan to retire, switch to a less demanding role or work as a travel nurse in the next few years. Surprisingly, nurses under the age of 30 show the same inclinations: Fully one-third said, even before they graduated, that they would leave nursing within a year of graduation. The realities of the work itself include dissatisfaction, burnout, turnover and physical and emotional stress.

Where can the nation obtain qualified nurses? From abroad, of course. To paraphrase Pete Seeger’s popular ballad from the 1960s: “Where have all the nurses gone? To the United States, the United Kingdom and Canada, every one.” Currently, about 5 percent of all nurses in the United States are foreign-educated. In 2003 foreign-educated nurses made up 14 percent of all newly licensed nurses; the proportion continues to rise. Most of the recruiting has been undertaken by health care agencies using private organizations and government agencies. More recently private, for-profit agencies have entered the market with little regulation nationally or internationally. These agencies, many of which are run by private individuals, often operate on behalf of developed countries. The recruitment process raises a host of ethical questions: Is such recruitment simply the operation of the free market in a globalized economy? If so, are nurses now seen as commodities?

Certainly the push-and-pull factors affecting the decisions of nurses to emigrate are powerful. Push factors include low pay, poor working conditions, limited career and educational opportunities, economic uncertainty and dangerous situations like those involving H.I.V./AIDS and war.

Nursing opportunities in the United States, the United Kingdom and elsewhere offer nurses better salaries and more benefits than they can obtain in their own poorer countries. These nurses also learn new methods of nursing, skills, remedies and techniques. Most can send part of their salaries home in the form of remittances to relatives, who benefit from the income and spend it in their local economy. At the same time, recruitment of nurses from the developing world leads to a brain and resource drain, not just of nurses in general but of those who are most highly qualified. The export of nurses means fewer are available for the home country, a decline in the quality of its patient care and a weakening of its health system.

The Philippine Experience

The Philippines serves as something of a case study, demonstrating these factors at play. More than 150,000 nurses from the Philippines are working internationally (85 percent of all their nurses currently employed). Yet the Philippines has a nursing shortage of its own—with some 30,000 unfilled positions. This affects poor and rural communities the most. Such unregulated recruitment resembles a new form of poaching, by which a poor nation’s scarce resources are drawn away for the benefit of a developed country.

In the countries that import foreign nurses, nursing associations have raised objections. First, they say, the practice merely rotates nurses; it does not actually increase the number of nurses worldwide, which is required to solve global shortages. Second, as nurses from countries with very traditional cultures and fixed gender roles enter the United States or other nursing systems, they indirectly undermine the ability of local nurses to establish more positive and independent roles in relation to doctors, administrators and others in the medical establishment.

A further consideration concerns the issue of H.I.V./AIDS. Many countries exporting nurses, like South Africa, have large populations with H.I.V./AIDS. The resulting infections and deaths put a tremendous strain on the nurses who stay while others leave. At the same time, nurses in those countries experience the “push” factor to earn more in order to support those at home who are ill and cannot work or provide for themselves. Do the benefits to individual nurses imported to developed countries outweigh the losses of those same educated nurses to their own countries, where nursing shortages are keen?

Catholic Social Teaching

Foreign nurses may face discrimination in the workplace—subtle prejudices that affect promotion, shift rotation and support. After the right to a just wage, perhaps no other right is as essential to protecting the workers’ basic dignity as is the right to organize and build unions. In his encyclical “On Human Work” (1981), Pope John Paul II wrote: “The experience of history teaches that organizations of this type [unions] are...a mouthpiece for the struggle for social justice, for the just rights of working people in accordance with their individual professions.” But do foreign workers organize or join existing unions? Can they?

As globalization affects the nursing profession, the principles of the common good and the church’s preferential option for the poor raise other questions: Is the recruitment of foreign nurses sustainable? Does it contribute to the well-being of the nurses and also help promote the health of developing countries? Do the current arrangements guiding international recruitment of nurses accentuate existing poverty gaps by straining resources in the exporting country, leaving more people, usually the poorest and most marginalized, without health care?

The code of the International Council of Nurses reflects several of the major principles of Catholic social teaching. Many code provisions, for example, are based on the principle of human dignity. The guidelines address concern for fair wages, healthy working conditions, a balance of interests around the common good, protections for poor nations with a shortage of nurses, the right to join nursing associations and freedom from discrimination. Of special note is the I.C.N.’s concern that while nurses have a right to migrate, international migration may have adverse effects on the “health care quality in countries seriously depleted of their nursing workforce.” The I.C.N. strongly condemns recruiting by countries that have not dealt with the basic problems that cause their own nurses to leave the profession.

Three possible approaches could be taken in developing guidelines for the international recruitment of nurses. The first relies on a cost/benefit model and adopts the perspective of free market capitalism. This approach considers the situation as an open market in which nurses, as free agents, look for the best wages, the best setting in which to develop their skills and increasing economic and political security.

The second approach takes a highly critical view of the current arrangements, calling continued reliance on market forces unsustainable and unjust, an irresponsible drain upon the scarce resources of developing countries. In this structural view, adopted by liberation groups and human rights workers, the globalization of nurses, primarily women, is part of a pattern of trafficking, a new colonialism of people as “resources.” The recruitment of foreign nurses should proceed only under heavy international regulation. The goal would be to address the dysfunctional health care systems in host/importing countries, while sustaining health care systems in developing countries.

The third approach, which follows the themes of Catholic social teaching and the code of the I.C.N., stresses the protection of human rights and the improvement of working conditions through cooperation among national and international groups and nongovernmental organizations. Initially, there is a call to the host countries to compensate developing countries formally for the loss of their scarce resources. Then, international regulation and supervision must ensure both that host countries revive their nursing recruitment programs at home and that developing countries are not left with too few nurses to serve their own people.

A 2003 statement of the American Federation of Teachers health care program refers to “a delicate balance” among the needs of host countries and the strains and losses to the health systems of the exporting countries. The difficult circumstances faced by many developing countries—such as H.I.V./AIDS pandemics, poor nutrition, high rates of communicable diseases, along with inadequate health services and the loss of nurses to fill the shortages in the developed world—indeed raise critical ethical questions of justice.

Without such remedies as compensation and international regulation, the continued globalization of nurses will result in benefits for some nurses and a short-term solution to shortages in host countries; but it could also spell long-term disaster for developing countries while failing to solve the long-term problem of host countries. National regulations for managing international nurse recruitment have been introduced in some countries, but they are difficult to enforce. The nurse-recruitment process must undergo some form of international regulation. The crisis in the United States and in the international recruitment of nurses calls for immediate international regulation and oversight. Meanwhile, the developed countries should redouble their efforts to train nurses of their own.