A new ethics code for recruitment of foreign-educated nurses

The American population is aging, and as it does, there will be increased demand for health care resources, including human resources. Even though the greying of America has not really kicked in yet, there is already a perceived shortage of nursing staff. The American Association of the College of Nurses has a long list of indicators of current nursing shortages and how the gap between demand and supply is likely to widen significantly in the coming decades.

One common response to this situation is to hire nurses from elsewhere, and this is increasingly occuring, such that some nursing stations in US hospitals are starting to look like United Nations gatherings. But the hiring of foreign-educated nurses is an ethically charged practice. These nurses often come from countries where the shortage of health care workers is much worse than in the United States. In the US, there are roughly 9 nurses per 1000 population. In Ghana, there is 0.74 per 1000 population; in Malawi, 0.59; in Uganda, 0.55. You get the picture: recruiting foreign-educated nurses to work in the United States is very likely to have very negative consequences for health systems in resource-poor countries.

Last week, a myriad of stakeholders issued the first code of ethics in regard to this issue in the United States, entitled Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the United States. The code is directed to agencies that recruit and/or employ foreign-educated nurses, such as third-party recruitment firms, staffing agencies, hospitals, long-term care organizations and health systems. The code is divided into two sections: minimum legal/ethical standards that such agencies can voluntarily agree to, and 'best practices' that such agencies can pursue as aspirational goals.

In this reader's opinion, the code is painfully non-binding and unambitious. In the first section, it basically asks agencies hiring foreign-educated nurses to voluntarily obey established laws in the United States, such as the Fair Labor Standards Act or the Americans with Disabilities Act. Perhaps it aims to remind such agencies that foreign-educated nurses, with legitimate work visas, are covered by such laws, something that you would think (or hope) is obvious. In the second section, which recruiting and employment agencies don't even have to voluntarily agree to, there is some reference to the impact of recruiting nurses from foreign countries, and some suggestions to soften the impact, such as seeking partnership agreements with local health institutions, establishing scholarship funds, sending money to foreign health care organizations and allowing nurses to periodically return home to provide technical assistance. One aspirational goal is to avoid active overseas recruitment in countries where there are fewer than 2.5 health care workers per 1000 population. If that piece of guidance were to be followed, there would be much less recruitment of nurses from African countries, because that would rule out Angola, Benin, Burkina Faso, Burundi, Cape Verdi, Central African Republic, Chad, Comoros, Ivory Coast, the Democratic Republic of Congo, the Republic of Congo, Equatorial Guinea, Eritea, Ethiopia, the Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, São Tomé and Príncipe, Senegal, Sierra Leone, Sudan, Tanzania, Togo, Uganda, Zambia and Zimbabwe. Which leaves you with Botswana, South Africa, Gabon, Mauritius, Namibia, Seychelles and Swaziland, where you can apparently recruit in good conscience.

The Code is a fair cry from a recent Lancet article that floated the idea that recruitment of health care workers from sub-Saharan Africa could be regarded -- in the light of its likely consequences -- as a criminal act. An act that should be robustly discouraged by enforceable laws. The Voluntary Code, on the other hand, seems to contain little to discourage the current brain drain status quo. It assumes -- or rather hopes -- that the relevant agencies will do the right thing, even if it is not in their own economic self-interest, out of the sheer goodness of their hearts.

Shameless self-promotion, somewhat connected to the nursing theme: this blog was selected this week as a Top 50 Medical Professor blog by the Nursing School Search website. Awhile back, the Online Nursing Degree Directory website also named this blog in its list of the top 100 Academic Medical Blogs. We greatly appreciate this recognition from the nursing community, and if we could increase your numbers by a snap of the fingers, we most certainly would.