Friday, September 12, 2008

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.


Blogger PPittman said...

Thank you for your efforts to foster discussion on this issue. As the author of the research that informed this effort and the convener of the task force that authored the code itself, I did want to respond to a couple of points in your post.

We acknowledge that provisions for enforcement are *currently* missing. However, in the coming months representatives from key stakeholder groups will be working to establish a monitoring entity, a process for tracking compliance, and the means to address situations of non-compliance. As you rightly point out, the Code is voluntary – it was drafted by key stakeholders committed to proactively addressing the potential for abuses in the practice of international recruitment and is not required by any legal or regulatory body. Therefore it’s likely that market-based forces will be the primary incentive to compliance. In short, those who adhere to the Code will be publicly listed for employers’ and nurses’ consideration; those who are then found to be in non-compliance will be de-listed. Because representatives of the nation’s largest recruiters, employers, unions, nurse educators and advocates were a part of the task force and have already signed on in support of the Code, it isn’t a stretch to foresee that NOT being listed would be a competitive disadvantage. If doing the right thing isn’t enough of an incentive to comply, our hope is that the loss of quality recruits and paying clients will be.

Second, you state: "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." The unfortunate truth is that it is not obvious – particularly to the nurses themselves. Foreign-educated nurses have little or no knowledge of their rights and protections, and their fear of deportation is a real disincentive to report employers or recruiters who violate U.S. labor laws. Our research uncovered abuses and revealed genuine fear on the part of the nurses to speak publicly about their treatment. Adherence to the Code requires that nurses receive a copy of the Code as part of their recruitment – informing them of their rights and, hopefully, empowering them to seek help if it is required. (See the posted video of Archiel Buagas at for an example of the potential impact of the code from a nurse’s perspective.)

Finally, despite its limitations, we believe the Code is a significant first step in addressing both the brain drain from less developed countries and the ethical treatment of nurses recruited to the United States. The task force disagreed on a number of points – not the least of which was the extent of the U.S. nurse shortage and the viability of international nurse recruitment as a solution – yet all agreed that IF recruitment is taking place it should be done in an ethical and transparent manner. We believe this point of consensus is not the end of the ethical discussion, but the beginning.

We hope you’ll continue to follow the process as we move toward implementation of an enforcement strategy.

Patricia Pittman, Ph.D.

3:32 PM  
Blogger Stuart Rennie said...

Dear Patricia,

Thank you for taking the time to write your informative response.

If the incentive to avoid de-listing and empowerment of nurses in their labor relations is effective, this could be part of a model for other countries involved in recruitment foreign-educated nurses. This would be an important contribution to a very significant problem.

I will keep an eye open for the future development of the Code, and wish you and your collaborators every success.

Best regards, Stuart

8:19 PM  
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The Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the United States reflects the mutual recognition of stakeholder interests relevant to the recruitment of foreign educated nurses. It is based on an acknowledgement of the rights of individuals to migrate, as well as an understanding that the legitimate interests and responsibilities of nurses, source countries, and employers in the destination country may conflict. It affirms that a careful balancing of those individual and collective interests offers the best course for maximizing the benefits and reducing the potential harm to all parties.

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