Since the 1630s and the arrival of apothecaries, nurses, and surgeons in New France, the people of what is now Canada have benefited from the healing arts of health-care professionals who have been internationally educated. The many contributions that internationally educated nurses (IENs) have made to health-care in Canada, and the many contributions that nurses educated in Canada have made to health-care while nursing internationally, are to be cherished. However, given the global nursing shortage, there is an urgent need to re-evaluate health human resources (HHR) policies that focus on the targeted recruitment of internationally educated nurses to Canada.
Consistent with the Universal Declaration of Human Rights and the position of the International Council of Nurses, the Registered Nurses’ Association of Ontario (RNAO) recognizes the human right of individual nurses to migrate. RNAO has been a strong advocate in support of internationally educated nurses who choose to make Ontario their home. For example, the Association endorsed permanent funding for bridging programs for internationally educated nurses in its provincial-election political platform. While recognizing the right of individual nurses to migrate, the International Council of Nurses also “acknowledges the adverse effect that international migration may have on health care quality in countries seriously depleted of their nursing workforce.”
The tension between the human right to migrate and the human right to health that is threatened by faltering health-care systems is at the heart of the dilemma of ethical recruitment of health care professionals. This tension is heightened by worsening global trends of economic and health inequalities on the one side and shortage of health care professionals on the other. This background paper outlines some of the underlying dynamics of globalization that are driving escalating nurse migration, identifies pertinent issues within this dilemma, and outlines divergent perspectives on recruitment.
Modern globalization, often characterized as an accelerated movement of information, capital, goods, and people across political and geographical borders, provides the underlying dynamic of nurse migration. A key “push” factor that has driven nurses from their home countries has been economic structural adjustment programs and fiscal restraint programs that resulted in cuts to health services, increased casualization of the nursing workforce, and nursing unemployment. Both industrialized and developing countries alike are faced with the paradox of nursing shortages existing alongside unemployed nurses.
A key ethical concern in a context of global shortage of 4.3 million health workers is the growing disparity as poor nations with the fewest nurses lose them to wealthy countries with the most nurses. Africa is a compelling example of a region suffering from an exodus of health professionals. In that region, structural adjustment pushes nurses away by lowering standards of living and compromising work environments at the same time as international recruitment pulls them to more affluent countries. While the Philippines is often given as an ethical source from which to recruit nurses, new evidence suggests that the impact of massive nurse and physician-turned-nurse migration is increasing health disparities, especially in rural areas and among vulnerable populations.
Perceiving and utilizing IENs as a quick fix for developed countries that have not addressed their own HHR needs has a negative impact on those nations as well. Normalizing and expanding recruitment of IENs has potential implications for public safety, the viability of nursing as a self-regulating profession, and for the sustainability of the nursing workforce. Trade agreements and pressure to facilitate nurse migration raise significant concerns about threats of downward harmonization of nursing credentials that run counter to both public safety and self-regulation.
Is it possible to have “ethical” international recruitment? The evidence suggests that existing frameworks for ethical recruitment provide an insufficient basis to establish real-world recruitment efforts that are, in fact, ethical. Such is the case with the International Council of Nurses’ key principles to support an ethical framework for nurse recruitment. These principles are contingent on the International Council of Nurses’ premise which “condemns the practice of recruiting nurses to countries where authorities have failed to implement sound human resource planning and to seriously address problems which cause nurses to leave the profession and discourage them from returning to nursing.” It is a major concern that the ICN principles are not identifiable in any of the country examples this paper explores. Not a single developed or developing country effort, including the Canadian experience, actually responds to these principles in a visible way. In fact, in a recent analysis of policy responses to global health human resources flows, improved domestic HHR self-sufficiency was described as “widely endorsed but not followed.”
RNAO’s position is that the individual human right to migrate is not in question. What is in question are HHR policies in wealthy countries such as Canada that target HHR from poor countries as a solution to domestically created nursing shortages. RNAO fully recognizes Canada’s nursing shortage, and, alongside others, is working diligently to resolve it. Local solutions are both necessary and possible. The Association has consistently argued that this is a Canadian problem, and it demands Canadian solutions. In a number of research and policy documents, briefing notes, and election platforms over the years, RNAO has spelled out critical policies that are essential to resolve this challenge. These policies are not only feasible but also desirable to raise the quality of care for, and the health status of, Canadians.
Some of these policies are well underway and the results are extremely positive. This is the case with Ontario’s actions in recent years to increase the number of nurses, to increase the proportion working full time, to guarantee full-time work for new graduates, and to expand roles for nurses. Still, as our recommendations suggest, much remains to be done both in Ontario and across the country, including:
- Ensuring that government and those health organizations funded by the government do not engage in international recruitment of nurses and other health professionals.
- Ensuring that internationally educated nurses who make Ontario their new home face no systemic barriers to practise their profession.
- Establishing permanent funding for existing upgrading and bridging programs for internationally educated nurses who make Ontario their new home.
- Strengthening local HHR capacity through:
Substantive investments in nursing education across the country, including infrastructure, faculty and nursing seats.
Continued investment in workplace health, including adequate workloads, employment arrangements that match nurses’ needs, professional opportunities, and best management practices.
Continued investments in patient safety and quality patient care, including continuity of care and care provider, best practices in clinical care, and improved interdisciplinary work.
The Association knows that these and other local solutions, designed to tackle the specific needs of jurisdictions and communities, will address the shortage of nursing and other health-care professionals. Trying to resolve our problems on the backs of other jurisdictions will only aggravate nursing shortages, including the one in Canada, on a global scale.
For complete text and references, please see the full version
of the RNAO Recruitment of Internationally Educated Nurses Policy Brief.