International nursing recruitment: We must do better

This editorial urges the global nursing community to take stock of the serious ethical issues surrounding international nurse recruitment and for western governments to adopt a more reciprocal relationship with developing nations. As global health care systems face an unprecedented squeeze on resources the full implementation of the World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel is overdue. Perhaps the most substantial challenge facing health services, as national economies attempt to rebound from the impact of the pandemic, is the shortage of nurses and midwives. Globally, there is a deficit of 4.3 million health workers, including in excess of 1 million in Africa alone (WHO, 2020a). The negative effects of this crisis are felt most acutely in the global south while actions of richer western nations to remedy their own workforce deficits will exacerbate the strain on fragile healthcare systems if pursued without mitigation. Recent years have witnessed a substantial increase in nurses and physicians from low-income countries migrating to fill vacancies in higher income countries (WHO, 2020b). Relatively affluent western nations have always substantially recruited internationally-educated nurses to fill workforce shortages at home and are likely to continue to do so. In this regard, the UK government is in the vanguard, pledging a 50,000 increase in nursing numbers by 2025. Efforts to expand the workforce through increased training and retention will not be enough to meet this target without huge recruitment of nurses from other nations. From the early days of the NHS, the United Kingdom has benefited from migration. International nurses already comprise roughly one in five of the NHS nursing workforce and one quarter of recent joiners. Around 190,000 NHS staff report a nationality other than ‘British’; the largest group of over 28,000 coming from the Philippines with significant fractions from continental Europe, Africa and India (Palmer et al., 2021). This number does not include migrants that have now naturalised and identify as British or who are dual nationals. Many more overseas staff work in social care settings. Our services are more effective because of the skills and knowledge they bring and they provide a welcome diversity, mirroring that of our own populations and so offering a more complete understanding of the needs of populations we serve. The heavy recruitment of healthcare workers internationally is, however, ethically questionable; even more so in this age of Covid-19. We support the right of our colleagues to travel and work with freedom but must question the dependence of richer nations on overseas recruitment in order to maintain a workforce capable of meeting prevailing demands. The plea for ethically appropriate remedies is not new (e.g. Delucas, 2014; Singh et al., 2003). Ultimately, the affluent west has an important role to play in addressing the marked global inequalities which make migration so attractive to nurses in developing countries. Strategies must involve programmes of aid and debt forgiveness alongside more progressive trading relationships to promote economic growth for countries in the global south. Global peace and policies of economic justice would assist developing nations to reduce the strain on their fragile healthcare systems and ‘hopefully dissuade their health care workers from migrating’ (Singh et al., 2003: p. 669). As international recruitment continues at scale genuinely reciprocal relationships should be developed between nations which support the source country to replenish and strengthen its domestic health workforce. Of their own accord, developing nations are able to address some ethical concerns which can precipitate nurse migration. For instance, appropriately valuing their own nurses or tackling corruption and economic inequalities within their own borders. Notwithstanding this, realistically and morally the impetus and leadership for change has to start with richer countries like our own. Developed western health economies must target longstanding inadequacies of workforce planning and assertively address prevailing shortcomings on domestic recruitment and retention of nurses, doctors and allied health professionals. International recruitment on the cheap has too often been a safety net. Worryingly, part of the appeal of recent right-wing populism has been the valorization of isolationism, demonization of migrants and dilution of overseas aid commitments. Only last year, the UK government slashed its global aid programme. Corollary immigration, asylum seeker and refugee policies do not signal that a more ethical future imminently beckons. The gaps left by an absence of enforceable regulation on international recruitment are exploited by agents who operate at the front line of international nurse recruitment. Often unscrupulous and almost wholly unaccountable, their existence operates to absolve or outsource any ethical obligations on employing authorities. Paradoxically, while we aim to attract healthcare workers, our government continues to pursue a ‘hostile environment’ policy which makes life more difficult for incoming migrants. Despite the disproportionate toll from Covid-19 which healthcare staff from ethnic minorities endured, migrant health workers faced impoverishment because they had ‘No recourse to public funds’, often also being excluded from sick pay provisions. Others are separated from their families because of the government's harsh attitude towards family reunification, forcing them to experience isolation or consider beginning again elsewhere. In the workplace, many continue to face racism, wider discrimination and unfair employment practices; the NHS Race and Health observatory reported this year that ethnic minority staff faced racism from patients and other staff and that there was evidence of an ethnic ‘pay gap’ (NHS Race and Health Observatory, 2022). Some migrant nurses report being unable to progress their careers fairly in the NHS and iniquitous ‘repayment clauses’ force others to remain in exploitative workplaces because they cannot afford to leave (Das, 2022). While there is some good practice and proactive approaches being taken in the NHS, there remain far too many examples of exploitation. The explicit voluntarism of the WHO Code is insufficient to constrain the most predatory excesses of international recruitment. We are aware of a number of disturbing cases. One Asian nurse colleague, working in a care home, was treated appallingly while adjusting to her new career in England. When she complained and asked for more support she was subjected to racism and threatened by her bosses. When she sought a job in the NHS they told her she would be deported for leaving her job and threatened to report her to the Nursing and Midwifery Council, the relevant UK professional regulatory body, for dishonesty. Compounding this maltreatment, these employers also wrote to her family in her own country demanding money to pay off her training costs. This is not an isolated case. Solidarity with overseas nurses must start with empathetic and compassionate recognition of these personal and collective challenges. Such appreciation must also be translated into supportive and meaningful action on the part of nursing communities at home. We contend that this is best mobilised by empowered nurses acting within and with the support of their trade unions. Nursing trade unions are well placed to hold politicians and healthcare organizations to account, to support the negotiation of appropriate reciprocal international policies and to ensure that individual migrant nurses are afforded the protections they rightly deserve. As members or allies of Unison, the largest UK public service union representing nurses, we are proud to work in solidarity with overseas colleagues and learn a great deal from them. Our union has democratically agreed policies to resist the hostile environment, to look after the welfare of overseas nurses, and to advocate for an ethical view of international recruitment. Our most recent delegate conference has committed the union to a number of important actions which could also be adopted by the global nursing community. It is time to make countries like the United Kingdom truly a place where all of our colleagues can thrive and where a genuinely mutually beneficial approach is taken to international recruitment. The examples we have shared are illustrative of the powerful, emotive stories of nurse migrants and these ought to move the global constituency of nurses and healthcare workers to act. We believe it is time for legally enforceable expectations of good ethical practice with meaningful sanctions for transgression. The global nurse workforce shortage and subsequent rush to recruit overseas requires a progressive response from the international nursing community to pressure those with the power to act. This must begin with nurses themselves acting in solidarity through their collective and representative organizations; recognizing that ‘an injury to one is an injury to all’. No conflict of interest is declared for any of the authors. Data sharing not applicable to this article as no datasets were generated or analysed during the current study