The Ethics of Recruiting Foreign Nurses

November-December 2005


Dr. Carney is system director, ethics, PeaceHealth, Bellevue, WA.

How Should Catholic Organizations Approach This Troubling Question?

Because they face a growing nursing shortage, many U.S. health care institutions have turned to recruiting foreign nurses. For foreign nurses, the practice is often an opportunity to make a better life for themselves and their families. And it helps solve a serious problem for the U.S. organizations involved.

But the recruitment of foreign nurses raises a number of ethical questions. The first article here examines the practice as seen from three viewpoints, the global, that of the particular recruiting health care organization, and that of the recruited foreign nurse. The author concludes that the practice can be both a "blessing" and a "curse."

The second article discusses the practice as seen from a Third World nation from which the United States, along with other Western countries, is recruiting nurses. The author, who formerly supported the practice, now opposes it.

The most critical issue facing health care systems is the shortage of people who make them work.
— World Health Organization1

A nursing shortage is not just an organizational challenge or a topic for economic analysis; it has a major negative impact on health care. Failure to deal with a nursing shortage — be it local, regional, national or global — is likely to lead to failure to maintain or improve health care.
— J. Buchan and L. Calman2

The supply of nurses available to care for patients does not meet the increasing demand for their services, either in the
United States or globally. The U.S. Department of Health and Human Services's National Center for Health Workforce Analysis notes that this nation had a shortfall of 110,707 nurses in 2000 and predicts that the shortfalls will be 275,215 in 2010 and 808,416 in 2020. 3

In the United States, the factors contributing to the shortage are closely linked. On one hand, our population is both growing in size and aging, and each of these trends contributes to an increase in health care costs per person. At the same time, the nursing population itself is aging, and the annual number of nursing school graduates is insufficient to replace the annual number of retiring nurses. Furthermore, nursing has traditionally been a predominantly female profession. The current generation of women, which has many better-paying career alternatives open to it than did earlier generations, finds nursing less attractive. 4

A variety of short — and long-term measures intended to reduce the nursing shortages in this country are being pursued by health care systems, facilities, educators, professional nursing groups, and lawmakers. Their recommendations include the following:

  • Improve the recruitment and retention of practicing nurses and attract nonpracticing nurses back into the profession.
  • Partner with community colleges and universities to "grow their own" nurses from among current employee populations or graduating high school seniors.
  • Add nursing faculty, so that students are not turned away.
  • Increase the use of temporary nurses from employment agencies.
  • Recruit more nurses from other countries. 5

Recruiting from Poorer Countries
Despite their success in solving some nursing shortages, wealthy developed countries such as the United States, Canada, and Great Britain continue to need to recruit nurses from less developed countries.

I want to focus in this article on the strategy that involves recruiting nurses from poorer countries to solve nursing shortages in the United States. This strategy, which is recommended by some health care professionals, seems to be a viable one. But, in fact, the strategy is itself problematic because it exacerbates nursing shortages in developing countries, which are already far worse than our own, by drawing away those countries' best and brightest nurses (see Edward David, "India Is Losing Its Nurses to the West," p. 35). 6

The nursing shortages in poorer developing countries stem from three major challenges.

HIV/AIDS Epidemic The HIV/AIDS epidemic in sub-Saharan Africa has increased the need for nurses in those countries — especially because the illness has taken many nurses' lives.

External and Internal Migration The emigration of nurses to other countries is one cause of shortages in developing nations. So, too, however, is "internal migration" — the movement of nurses "from rural to urban areas, from public sector employment to private sector employment, and from nursing employment to non-nursing employment (or no employment)."7

Nursing Workforce Issues Developing countries have failed to attract candidates to the nursing profession in part because they have not adequately addressed such issues as low nurses' pay, long working hours and poor working conditions, insufficient educational opportunities and training, and the inappropriate use of skills.8

These three factors considerably affect the number of nurses available to provide care in developing countries, thereby aggravating a nursing shortage that was already substantially greater than those in the United States and other developed countries. The average nurse-to-population ratio in this and other developed countries is almost eight times greater than the ratio in developing countries. For example, Uganda has six nurses for every 100,000 people, whereas the United States has 773 nurses for every 100,000 people. 9 Of course, the low nurse-to-patient ratio found in developing countries is driven even lower when nurses emigrate to developed countries.

The United States and other developed countries can take advantage of the many factors in poorer developing countries that cause nurses to emigrate. They can do so by offering better pay and working conditions; educational advancement; and an environment in which nursing is valued, not disparaged as "women's work." 10 Developing countries clearly cannot match the salaries and working conditions of the wealthier countries. But the emigration of nurses impoverishes them even further because developing countries then lose the resources they invested in the lost nurses' education. As an example, two experts note that "in 2000 more than 500 nurses left Ghana to work in other industrialized countries: that is more than twice the number of new nurses who graduated from nursing programmes in the country that year." 11

Still, not all countries see the emigration of nurses to wealthier developed countries as a loss. Some view it as a gain. The Philippines, for example, educates a large portion of its population as nurses, intending many of them to emigrate to developed countries. A nurse who remains in the Philippines earns $250 a month from the government. The approximately 15,000 nurses who leave the Philippines each year for other countries earn salaries as much as 20 times larger than those than they would earn at home. These higher salaries help them to support their families back home. More importantly, from the Filipino government's perspective, the money helps to support a struggling national economy. In 2004, workers from the Philippines sent home about 8 billion dollars officially (and as much or more sent home unofficially), thus helping to "generate foreign exchange, sustain the economy and keep [the] balance of payments at a healthy level."12

The Ethics of Recruitment
How can the United States — and, specifically, U.S. Catholic health care — ethically use recruitment of foreign nurses as a solution to the nursing shortage? America certainly will continue to utilize every solution available to solve the nurse shortage, including recruitment of foreign nurses. And nurses from other countries will continue to emigrate to the United States and other developed countries in search of a better life for themselves and their families.

What, then, is an ethically acceptable approach, reflective of the principles of Catholic social teaching: human dignity, justice (social and distributive), and the common good? Our approach must be one that addresses the nursing shortage and the recruitment strategies employed to solve it at the individual level, the institutional level, and the societal/global level.

The Societal/Global Level
We must listen to health care professionals who are attempting to address the broader issue of the nursing shortage, both as it concerns their respective nations and internationally. Then, as we strive for justice and to support the common good, we must tailor our solutions to the nurse shortage so as to fit the social, economic, and cultural context of each country involved, keeping in mind the impact these solutions may have on other countries. As a step toward achieving this broad goal, in April 2005 the International Council of Nurses (ICN), Geneva, Switzerland, sponsored the International Summit on the Nursing Workforce in Taipei, Taiwan, which was attended by delegates from the American Nurses' Association, the American Medical Association, and similar groups from other nations. In concluding its work, the group agreed on four key points:

  • All countries must strive to attain self-sufficiency in their health care workforces without generating adverse consequences for other countries.
  • Developed countries must assist developing countries to expand their capacity to train and retain physicians and nurses, to enable them to become self-sufficient.
  • All countries must ensure that their health care workers are educated, funded, and supported to meet the health care needs of their populations.
  • Action to combat the skills drain in this area must balance the right to health of populations and other individual human rights.13

The United States and other developed nations should keep these recommendations in mind as they enact laws that affect their own workforces and those of countries undergoing development.

Developed nations should also heed the advice of the International Centre on Nurse Migration, established by the ICN and the Commission on Graduates of Foreign Nursing Schools (CGFNS), Philadelphia. The center is intended "to serve as a global resource for the development, promotion and dissemination of research, policy and information on nurse migration" and promote "ethical recruitment and equitable treatment of migrating nurses." 14

As those of us who work in Catholic health care seek to ease the nursing crisis in our own country and help develop health care ministries in other countries, we must listen to these voices. We must seriously consider their recommendations as we strive for a just solution that respects the dignity of those who work in the field of nursing. As Americans, we must address the root causes of our own nursing shortages with solutions directed at long-term resolution of those root causes, before moving to recruit foreign nurse. If, however, we do decide to recruit foreign nurses, we must act as advocates for an immigration process that respects both the nurse and his or her family.

The Institutional Level
Responding ethically to the imbalance in the supply and demand for nurses at the institutional level requires each system and facility to ensure, first, that its nurses from foreign countries are clinically and culturally competent and able to provide safe, high-quality care. 15 The CGFNS, National Council of State Boards of Nursing (NCSBN), and U.S. Citizenship and Immigration Services (CIS) provide a rigorous screening process to ensure that nurses from one country are competent to practice in health care facilities in other countries. To practice in the United States, a foreign nurse, in addition to being licensed in his or her own country, must have a certificate from the CGFNS indicating that the nurse has passed the CGFNS exam and/or evidence that he or she has passed the NCSBN's NCLEX-RN licensing exam, depending on the state in which the nurse is planning to work.*

*Information about the CGFNS exam is available at www.cgfns.org; information about the NCLEX-RN can be found at www.ncsbn.org.

In addition, a foreign nurse must comply with the CIS's VisaScreen regulations, whose requirements include passing scores on one of three English language tests. U.S. institutions must work with these organizations and with reputable, ethical, recruitment agencies to ensure that foreign nurses are technically competent and are treated justly and respectfully at all stages of the process.

The ICN, in its 2001 Position Statement on Ethical Nurse Recruitment identified 13 key principles to be recognized when undertaking ethical recruitment of nurses from other countries.16 This statement provides a useful tool with which a health care organization can either assess its current institutional process for recruitment of foreign nurses or, should it not have one, develop such a process. The ICN statement highlights such areas as, good faith contracting, equal pay for work of equal value, freedom from discrimination, and access to full employment, which it describes as four principles essential to a foreign nurse recruitment process.

The ICN statement says that "effective orientation/mentoring/supervision" must be provided to foreign nurses in order for them to give patients high-quality care. Foreign nurses, moreover, will require orientation to cultural differences in values and clinical practice if they are to succeed in the communities where they find employment.

Then, too, many foreign nurses struggle with the challenges involved in, first, being away from their homes and families and, second, reintegrating back into their own cultures after working in the United States. They need programs both to support them while in this country and to ease their reentry when they go home. At present, no studies exist to help determine "whether foreign nurses' cultural orientation and technical competence produce differences in patient outcomes when compared with their domestic counterparts." 17 If, to solve America's nurse shortage, we are going to continue recruiting nurses from other countries, we should monitor their work so as to understand more fully the impact of recruitment of foreign nurses on the provision of high-quality patient care.

The Individual Level
At the individual level, doing justice and respecting human dignity requires us to look at the nursing shortage's root causes (some of which were identified earlier in this article) in each of our own institutions and to develop solutions in each of our own communities that will minimize and, we hope, eventually solve the problem.

Assuming that a health care organization has decided to institute a foreign nurse-recruitment process, it should also prepare to address the needs of both the foreign nurses who are recruited and the staff members who will work with them. Human resources departments can use statements of principles such as the ICN's to develop a foreign recruitment process that, first, treats each nurse justly and with dignity as he or she moves through the lengthy, rigorous application process; and, second, supports such nurses as they struggle to succeed in their new positions.18

Cultural competency training will be needed for both the foreign nurse and the institution's staff, so that they can effectively communicate with each other and with patients. The nursing staff's own fears and anxieties must be addressed — specifically the fear that, by giving jobs to foreign nurses, the institution is depriving American nurses. Finally, our health care institutions need to create processes to mentor nurses from other countries (and their families) as they settle into their new environments, and to help them make the transition back to their own countries when their work is finished.

A "Curse" and a "Blessing"
The nursing shortage will be both a "curse" and a "blessing" for us in the United States as we work to provide high-quality patient care for all. We are "cursed" with the challenges involved in finding effective ethical solutions to our nursing shortages while, at the same time, not worsening the global shortage of nurses, particularly the shortage in poorer developing countries.

On the other hand, we are "blessed" that one of these ethically effective solutions can be the recruitment of nurses from other countries. Through the presence of these women and men in our hospitals we both increase the cultural diversity of our staffs and increase the number of caregivers available to provide care to our patients.


  1. World Health Organization, The World Health Report 2003: Shaping the Future, Geneva, Switzerland, 2003, p. 110.
  2. J. Buchan and L. Calman, Global Shortage of Registered Nurses: An Overview of Issues and Actions, International Council of Nurses, Geneva, Switzerland, 2005, p.1, available at www.icn.ch/global/shortage.pdf.
  3. U.S. Bureau of Health Professions, Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020, July 2000, p. 13, available at http://bhpr.hrsa.gov/healthcareworkforce/reports/rnproject/report.htm; American Association of Colleges of Nursing, Nursing Shortage Fact Sheet, available at www.aacn.nche.edu/media/Backgrounders/shortagefacts.htm.
  4. U.S. Bureau of Health Professions, p. 4.
  5. P. I. Buerhaus, D. O. Staiger, and D. I. Auerbach, "Is the Current Shortage of Hospital Nurses Ending?" Health Affairs, vol. 22, no. 6, November-December 2003, pp. 191-192.
  6. P. Reilly, "Importing Controversy: U.S. Hospitals' Recruitment of Foreign Nurses Stirs Debate as Poorer Countries Struggle with Staffing Shortages of Their Own," Modern Healthcare, vol. 33, no. 13, March 31, 2003, pp. 20-24.
  7. Buchan and Calman, p. 6.
  8. Buchan and Calman, pp. 7-12.
  9. Buchan and Calman, p. 4.
  10. D. S. Kline, "Push and Pull Factors in International Nurse Migration, Journal of Nursing Scholarship, vol. 35, no. 2, 2003, pp.107-111.
  11. J. Buchan and J. Sochalski, "The Migration of Nurses: Trends and Policies," Bulletin of the World Health Organization, vol. 82, no. 8, August 2004, p. 588.
  12. S. Inskeep and R. Montagne, "Report on Filipino Health Care Professionals Working Abroad, " Morning Edition, National Public Radio transcript, February 3, 2005; B. L. Brush, J. Sochalski, and A. M. Berger, "Imported Care: Recruiting Foreign Nurses to U.S. Health Care Facilities," Health Affairs, vol. 23, no. 3, May-June 2004, p. 79.
  13. See http://bma.org.uk/ap.nsf/Content/skillsdrain. This is a British website and may be difficult to access. If it is, search for "skillsdrain."
  14. See http://intlnursemigration.org.
  15. Brush, Sochalski, and Berger, p. 82.
  16. International Council of Nurses, Position Statement on Ethical Nurse Recruitment, Geneva, Switzerland, 2001, available at www.icn.ch/ psrecruit01.htm.
  17. Brush, Sochalski, and Berger.
  18. International Council of Nurses; see also American Federation of Teachers, Position Statement on Recruitment and Rights of Foreign Nurses, available at www.aft.org/topics/immig-healthcare/immigrts_10_03.pdf.


Copyright © 2005 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

The Ethics of Recruiting Foreign Nurses

Copyright © 2005 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.