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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000342060.39299.8c
AJN Reports

The Ethics of Recruiting Foreign‐Educated Nurses

Stubenrauch, James M. Senior Editor

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Can a new code ensure ethical treatment?

It's estimated that some 90,000 foreign-educated nurses now work in the United States, representing about 4% of the nursing workforce. While the nurses have to comply with immigration requirements, the agencies and employers that recruit them are largely unregulated, and unfair practices have occurred. (See "An American Dream Gone Wrong," In the News, August 2007.)

In September a group of health care organizations issued guidelines for employers and recruiters of foreign-educated nurses. The Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the United States ( seeks to protect foreign-educated nurses from exploitation and abuse and to define the minimum standards of treatment. A unique feature of the code is that recruiters and employers who subscribe to it agree to be monitored for compliance.

Patricia Pittman, executive vice president of AcademyHealth, a leading health care research and policy organization and the group that led the effort to develop the code, says the guidelines grew out of a research project on the international nurse recruitment industry. In focus groups with foreign-educated nurses who had recently arrived in the United States, the exploitation and mistreatment of migrant health care workers by recruiters and employers came to light as the more important issue. "When we talked to the foreign-educated nurses it became clear that there were important issues related to their rights both here and in the source countries when they're initially recruited," Pittman said. "We didn't realize until we had done the research what the relative importance of the different issues was going to be."

Figure. In 2001 Ethe...
Figure. In 2001 Ethe...
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The task force assembled to address the problem was composed of representatives of the international nursing recruitment industry, including placement and staffing agencies; employers, represented by the American Hospital Association and individual facilities; nursing associations, such as the American Nurses Association, the American Association of Colleges of Nursing, the American Organization of Nurse Executives, and the National Council of State Boards of Nursing; nurses' unions; and foreign-educated-nurse advocacy groups. The research and consensus-building processes were funded by a grant from the John D. and Catherine T. MacArthur Foundation.

Pittman noted that other organizations, including the World Health Organization (WHO) and the World Medical Association, have issued statements on the recruitment of health professionals in the past, but said, "Two things differentiate this initiative from other statements: first, it's the product of multistakeholder negotiations; it's not just a statement of wishful thinking. Second, it's going to be monitored. It's a tool that's going to be used in the context of the market. There's going to be an incentive to comply with the code, because those who do will be seen as the good guys, the responsible citizens."

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The first part of the code is a set of minimum standards specifying recruiters' and employers' obligations to comply with both U.S. and source country laws. It also outlines fair and transparent practices relating to terms of employment, communication, educational requirements, support for daily living, and professional support. Compliance with these standards will be monitored by a board composed of members of the task force organizations.

The second part of the code sets forth best practices recruiters and employers are encouraged to use to lessen the negative impact of emigration on source countries. These include provisions such as partnering with foreign facilities to provide visiting faculty and medical supplies, matching and directing to foreign health care organizations a portion of remittances sent home by recruited nurses, establishing scholarship funds, and offering recruited nurses home leave so they can provide technical assistance to foreign facilities. Compliance with these practices will not be monitored.

Perhaps the most controversial of these best practices is the last:

Avoiding active overseas recruitment in those countries or areas within countries that are experiencing either a temporary health crisis during which health professionals are in dire need, or a chronic shortage of health workers….

This provision reflects the concerns of those who maintain that recruiting nurses from developing countries is unethical because it deprives fragile health care systems of qualified professionals who are needed to care for vulnerable populations. According to figures that Jean Yan, chief scientist and coordinator at the WHO Office of Nursing and Midwifery, presented at a May meeting of government chief nurses, 37 of the 57 countries with critical nursing shortages are in Africa.

Of this point Pittman said, "The right of the nurse to migrate is acknowledged up front in the code, and the task force firmly defended that right; at the same time they said that recruitment should be done with caution in the very poorest countries. Those two things are not incompatible."

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Mireille Kingma, a consultant on nursing and health policy at the International Council of Nurses (ICN) and director of the International Center for Human Resources in Nursing, defended the right of nurses to live and work abroad. "As soon as you start pointing out countries where active recruitment should not take place, it can easily degenerate and become a discriminatory practice," she said. She noted further, "A lot of people have made a moral judgment that it's not appropriate to recruit a nurse from a developing country, and yet they're not seeing that there are nurses living in very dramatic circumstances. They're being paid very poorly, so they can't meet the financial needs of their families. In some countries, they're earning salaries below the poverty level, and in other places there's a freeze on public sector employment, so that new graduates can't be employed in the health system."

Kingma, who is the author of Nurses On the Move, a book on nurse migration, also said, "We don't have enough data to prove that migration isn't primarily temporary, and if it's temporary, then when that person returns, she returns with enriched skills."

ICN first issued a position statement on nurse migration and recruitment in 2001, and Kingma noted that the code echoes many of that document's recommendations. "In [ICN's] position statement we call for the regulation of recruiters, and I think this is the only way that we're going to be able to eliminate abuse in the migration process," she said.

Participants in the task force acknowledged that negotiations over the code were difficult at times. In general, recruiters and employers took the position that the nursing shortage makes it necessary to import nurses. On the other hand, nursing unions and some nursing advocacy organizations argued that because the shortage results from underlying problems—poor working conditions and inadequate pay—that lead many qualified nurses to leave the field, importing foreign workers isn't a lasting solution.

Lolita Compas, past president of the New York State Nurses Association, the Philippine Nurses Association of New York, and the Philippine Nurses Association of America, was a member of the task force. "The code is a great achievement," Compas said. "We finally have a document that recognizes the concerns of foreign-educated nurses." Although compliance with the code is voluntary, she noted that "having a document like this is very important. Different stakeholders were able to sit down and work together to address the issues…. I hope that more recruiters will voluntarily subscribe to the code because this is the right thing to do."

James M. Stubenrauch

Senior Editor

© 2008 Lippincott Williams & Wilkins, Inc.


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