ajn@wolterskluwer.com AJN t December 2008 t Vol. 108, No. 12 25

The Ethics of Recruiting Foreign-Educated Nurses

Can a new code ensure ethical treatment?

It’s estimated that some 90,000 foreign-educated nurses now work in the UnitedStates, representing about 4% of the nursingworkforce. While the nurses have to complywith immigration requirements, the agencies

and employers that recruit them are largely unreg-ulated, and unfair practices have occurred. (See“An American Dream Gone Wrong,” In the News,August 2007.)

In September a group of health care organiza-tions issued guidelines for employers and recruitersof foreign-educated nurses. The Voluntary Code ofEthical Conduct for the Recruitment of Foreign-Educated Nurses to the United States (www.fairinternationalrecruitment.org/TheCode.pdf)seeks to protect foreign-educated nurses fromexploitation and abuse and to define the minimumstandards of treatment. A unique feature of the codeis that recruiters and employers who subscribe to itagree to be monitored for compliance.

Patricia Pittman, executive vice president ofAcademyHealth, a leading health care research andpolicy organization and the group that led the effortto develop the code, says the guidelines grew out of aresearch project on the international nurse recruit-ment industry. In focus groups with foreign-educatednurses who had recently arrived in the United States,the exploitation and mistreatment of migrant healthcare workers by recruiters and employers came tolight as the more important issue. “When we talkedto the foreign-educated nurses it became clear thatthere were important issues related to their rightsboth here and in the source countries when they’reinitially recruited,” Pittman said. “We didn’t realizeuntil we had done the research what the relativeimportance of the different issues was going to be.”

The task force assembled to address the problemwas composed of representatives of the internationalnursing recruitment industry, including placementand staffing agencies; employers, represented by theAmerican Hospital Association and individual facili-ties; nursing associations, such as the AmericanNurses Association, the American Association of

Colleges of Nursing, the American Organization ofNurse Executives, and the National Council of StateBoards of Nursing; nurses’ unions; and foreign-educated-nurse advocacy groups. The research andconsensus-building processes were funded by agrant from the John D. and Catherine T. MacArthurFoundation.

Pittman noted that other organizations, includingthe World Health Organization (WHO) and theWorld Medical Association, have issued statementson the recruitment of health professionals in the past,but said, “Two things differentiate this initiativefrom other statements: first, it’s the product of multi-stakeholder negotiations; it’s not just a statement ofwishful thinking. Second, it’s going to be monitored.It’s a tool that’s going to be used in the context of themarket. There’s going to be an incentive to complywith the code, because those who do will be seen asthe good guys, the responsible citizens.”

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In 2001 Ethel Tellez, RN, foreground, emigrated from the Philippines to work atMercy Hospital in Scranton, Pennsylvania. Since then, the hospital has hired morethan 40 other Filipino migrant RNs to help it deal with a critical shortage of nurses.

to live and work abroad. “As soon as you startpointing out countries where active recruitmentshould not take place, it can easily degenerate andbecome a discriminatory practice,” she said. Shenoted further, “A lot of people have made a moraljudgment that it’s not appropriate to recruit anurse from a developing country, and yet they’renot seeing that there are nurses living in very dra-matic circumstances. They’re being paid verypoorly, so they can’t meet the financial needs oftheir families. In some countries, they’re earningsalaries below the poverty level, and in otherplaces there’s a freeze on public sector employ-ment, so that new graduates can’t be employed inthe health system.”

Kingma, who is the author of Nurses On theMove, a book on nurse migration, also said, “Wedon’t have enough data to prove that migration isn’tprimarily temporary, and if it’s temporary, then whenthat person returns, she returns with enriched skills.”

ICN first issued a position statement on nursemigration and recruitment in 2001, and Kingmanoted that the code echoes many of that document’srecommendations. “In [ICN’s] position statementwe call for the regulation of recruiters, and I thinkthis is the only way that we’re going to be able toeliminate abuse in the migration process,” she said.

Participants in the task force acknowledged thatnegotiations over the code were difficult at times.In general, recruiters and employers took the posi-tion that the nursing shortage makes it necessaryto import nurses. On the other hand, nursingunions and some nursing advocacy organizationsargued that because the shortage results fromunderlying problems—poor working conditionsand inadequate pay—that lead many qualifiednurses to leave the field, importing foreign workersisn’t a lasting solution.

Lolita Compas, past president of the New YorkState Nurses Association, the Philippine NursesAssociation of New York, and the Philippine NursesAssociation of America, was a member of the taskforce. “The code is a great achievement,” Compassaid. “We finally have a document that recognizesthe concerns of foreign-educated nurses.” Althoughcompliance with the code is voluntary, she notedthat “having a document like this is very important.Different stakeholders were able to sit down andwork together to address the issues. . . . I hope thatmore recruiters will voluntarily subscribe to thecode because this is the right thing to do.”—JamesM. Stubenrauch, senior editor t

WHAT’S IN THE CODEThe first part of the code is a set of minimum stan-dards specifying recruiters’ and employers’ obliga-tions to comply with both U.S. and source countrylaws. It also outlines fair and transparent practicesrelating to terms of employment, communication,educational requirements, support for daily living,and professional support. Compliance with thesestandards will be monitored by a board composedof members of the task force organizations.

The second part of the code sets forth best prac-tices recruiters and employers are encouraged touse to lessen the negative impact of emigration onsource countries. These include provisions such aspartnering with foreign facilities to provide visitingfaculty and medical supplies, matching and direct-ing to foreign health care organizations a portion ofremittances sent home by recruited nurses, estab-lishing scholarship funds, and offering recruitednurses home leave so they can provide technicalassistance to foreign facilities. Compliance withthese practices will not be monitored.

Perhaps the most controversial of these bestpractices is the last:

Avoiding active overseas recruitment inthose countries or areas within countriesthat are experiencing either a temporaryhealth crisis during which health profes-sionals are in dire need, or a chronic short-age of health workers. . . .

This provision reflects the concerns of those whomaintain that recruiting nurses from developingcountries is unethical because it deprives fragilehealth care systems of qualified professionals whoare needed to care for vulnerable populations.According to figures that Jean Yan, chief scientistand coordinator at the WHO Office of Nursing andMidwifery, presented at a May meeting of govern-ment chief nurses, 37 of the 57 countries with criticalnursing shortages are in Africa.

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

ICN’S POSITIONMireille Kingma, a consultant on nursing and healthpolicy at the International Council of Nurses (ICN)and director of the International Center for HumanResources in Nursing, defended the right of nurses

26 AJN t December 2008 t Vol. 108, No. 12 http://www.nursingcenter.com