Ethical international recruitment: Many faces, one goal – part 2

Last month in part 1, we addressed the challenges regarding the origins and entry of internationally educated nurses (IENs). We also reviewed the types of recruiting agencies used to attract IENs to our country. Here, we’ll explore their work environment, specific ethical principles regarding hiring processes, and best practices for recruiting these individuals.

Work environment

Uninformed individuals may think that foreign nurses will be more docile, tractable employees who won’t question management decisions. These persons operate under the assumption that IENs are so happy to work for higher salaries that working conditions don’t matter as much as they do to their domestic counterparts. Research, however, demonstrates that IENs are no more likely to accept a poor working environment than their U.S. colleagues, nor are they less likely to experience burnout.¹

For you as the manager, this means taking a critical look at why you have vacancies on the unit in the first place. Are the reasons unit-based, institutional, or external? If problems with the institutional or unit work environment have weighted down retention rates, hiring IENs will only provide a short-term solution, since the same factors that drive away U.S. nurses from working on the unit will discourage foreign nurses from staying with the organization. These losses result in significant financial costs to the organization related to poor returns on the recruitment investment in the IEN, consequences to the quality of patient care, and costs related to patient complications due to poor staffing.^2,3

Ethical principles

How can you apply ethical principles to the decision-making process involved in the international recruitment of nurses? Generally, the core ethical principles most important to nursing are beneficence and nonmaleficence, autonomy, veracity, fidelity, and justice.⁴ All link together when acting in the nursing role at the bedside or as a manager.

In the context of international nurse recruitment, however, justice is the most relevant core ethical principle because its primary focus in nursing relates to access to health services.⁵

The core ethical principle: justice

Justice, also known as fairness, is the main ethical principle involved with international recruitment.^2,5 In nursing, justice ensures that patients have access to the kind and amount of resources they need to resolve their illness or manage their chronic condition.⁴ As the principle is needs-based, it allows people with more nursing care requirements to receive them as long as they have access to the system providing the care. Patients receive just or fair care when there are enough nurses to attend to their needs in both the acute care and community setting.

In international nurse recruitment, justice fails mainly in two areas: 1) during the individual recruitment of the nurse, and 2) if recruitment depletes nursing human resources so badly that the health system of the nurse’s home country is unable to function. When justice fails in these two areas, the other core ethical principles related to nursing also fail.

Justice fails in individual international recruitment when the recruiter exploits the IEN’s circumstances through wage garnishing, hiding their passports, or offering work contracts that violate U.S. labor laws or that U.S. nurses wouldn’t take. Exploitative recruitment practices compromise the IEN’s ability to adhere to the ethical principle of fidelity, known as the ability to remain faithful to one’s commitments.

Nurses working under these circumstances don’t have equal access or opportunities to work within the same circumstances as their U.S. counterparts. The IEN’s performance may be affected because of the added stress related to the abusive contractual terms of their recruitment. Negative practices like these also violate the individual autonomy of the IEN because they don’t work under the same circumstances as nurses in their new country. Finally, recruiters hiring nurses under exploitative conditions fail to adhere to the ethical principle of veracity, or telling the truth.

From a broader perspective, countries with the fewest resources experience the greatest amount of injustice due to the international recruitment of IENs. International recruitment of nurses has, in some countries, crippled the healthcare system and denied access to care for millions of people around the world. If you recruit nurses from countries with the fewest resources, you’re not practicing ethical international recruitment. Indiscriminate recruitment impairs a country’s ability to act autonomously in delivering healthcare services to its people, thereby compromising fidelity-based policies designed to provide healthcare to its population. It also goes against the ethical principle of nonmaleficence because it causes harm to patients in the sending country.

Circumstances beyond the control of the manager

Some circumstances that drive the international migration of nurses are beyond your control. Nonetheless, they’ll still influence the selection process involved with IEN recruitment. These include the political situation of the country, the domestic work environment in the IEN’s home country, and a lack of career advancement opportunities in the home country of the IEN.

The political situation of a country will push nurses to migrate.⁶ Political circumstances driving nurses to migrate include war, ethnic or racial genocide, or dictatorial regimes that restrict basic human rights. Such circumstances are more common in developing countries.

For many nurses, the work environment is the biggest factor driving their desire to work outside their home country. A large number of international studies have demonstrated that a lack of role-based autonomy, inability to deliver what they perceive as quality nursing care, poor working relationships with both physicians and other nurses, poor institutional leadership, and a lack of psychological support for coping with workplace stressors will drive nurses to leave institutions everywhere. It’s more common for nurses in developed countries, or those designated as “high income” by the World Bank, to leave their countries due to poor working environments.

Finally, a lack of career advancement opportunities drives many nurses to migrate to work internationally. When countries haven’t invested in developing professional infrastructure for nurses, career opportunities aren’t available to them. Some of the institutional hiring practices of healthcare organizations within an IEN’s home country can take as long as 6 months or more due to complicated bureaucracies and inefficient personnel management. Both these problems limit domestic career opportunities for IENs and drive nurses to seek employment outside their home countries.

Countries might not invest in infrastructure to resolve these problems because they may be more interested in the money that nurses send home to their families, known as remittances. Finance ministers in those countries calculate that income as part of the country’s gross national product (GNP), and it improves the country’s international economic standing. Therefore, when countries rely on remittances from nurses working abroad, they often have little incentive to invest in infrastructure that supports nursing practice in their home countries.

All of the circumstances above are important factors to consider in the ethical decision-making process involved in hiring an IEN. Knowing the circumstances shaping the reasons for the international migration of nurses is a key element in making a sound ethical decision about international nurse recruitment.

Best practices

Ideally, a nurse manager practices justice-oriented international recruitment by respecting the autonomy of the individual nurse and recruiting in ways that don’t deliberately contribute to decreased access to care in countries that already have too few nursing human resources. The following are suggestions for practicing justice-oriented international recruitment.

1. Think globally, but first act locally

International recruitment requires a significant investment in financial and personnel resources, so improving local recruitment may provide a more immediate solution that’s less costly in the long run. Before recruiting internationally, you and your management team should consider if the organization habitually overlooks qualified local candidates, especially those from minority groups.

Take a closer look at the local immigrant population already in the service area. Many individuals in these communities may already have nursing training, but haven’t worked as U.S. nurses. For example, a Chicago area recruitment initiative actively sought out nurses from Latin American countries to work in local hospitals.⁷ Area universities and hospitals collaborated to provide knowledge-base, skills refresher, and English-as-a-Second-Language programs to these nurses. The year-long program created a pool of bilingual nurses that were able to obtain legal forms of work and nursing jobs by the end of the program. Since the nurses were already in the country, recruitment didn’t contribute to depleting a country’s resources.

2. Be selective about the country chosen for recruitment

If everyone recruits from the same five countries, then an injustice occurs because all those countries will have problems with access to healthcare. Limiting the number of nurses recruited from a single country and expanding the number of countries selected for recruitment will minimize harm that could come to the country through international recruitment. Not recruiting from countries the World Bank designates as “low income” or “low-middle-income” will also ensure that the least resourced countries don’t lose more nurses.

3. Choose experience

The nursing literature has long established that nurses with 5 or more years of experience are at an expert level. They require less orientation and possess critical organizational skills that allow them to adapt to a variety of patient care situations. By recruiting nurses with 5 or more years of experience in their home country, you’ll improve the odds of obtaining a quality nurse for your organization. In doing so, you’ll also have recruited a nurse who has worked in her own country long enough to repay the investment in state-subsidized education and has contributed to the local economy through her income. This hiring practice ensures justice by keeping some nurses in the country for a sustained period, but doesn’t infringe upon their individual right to migrate, as they still have the option later in their careers.

4. Collaborate with recruitment experts

A collaborative but employer-led recruitment model offers the best opportunity for U.S. healthcare organizations to conduct ethical recruitment internationally.⁸ This model is designed for high levels of employer selectivity and direct control over the recruitment process. Along with the private recruiting firm’s legal expertise, it helps ensure the autonomy of the IEN, the fidelity and veracity of the recruitment process, and helps the organization adhere to principles of beneficence and nonmaleficence. Most importantly, it offers the greatest chance of ensuring a just process because your organization can have greater control over directing recruitment.

Beyond our borders

The world of the 21st century is a global one. As global citizens, nurse managers and their international recruitment teams face a new challenge that requires a conscious, active approach to international recruitment—one that reduces the risk for IENs to get exploited by the process, and one that doesn’t exacerbate problems some countries have with access to healthcare for their citizens. As U.S. citizens, nurse managers participating in international recruitment have an ethically based responsibility to U.S. health-care consumers to provide enough staff to care for patients.

This two-part series provided critical background information to help guide nurse managers’ decision-making processes about international recruitment. It’s clear that international recruitment is more than just a logistically complex issue—it’s an ethically complex one, too. By incorporating the information provided in this article into your recruitment practices, you’re embracing ethically based international recruitment that may produce the least amount of harm and fulfill your ethical obligations as a nurse.