Recruitment of internationally trained nurses: Time for a global model for shared responsibility

The World Health Organization (WHO) has highlighted an estimated shortfall of about 6 million nurses worldwide (Organization, 2020). This nursing shortage threatens the quality, effectiveness, and sustainability of health care systems and is expected to increase post-COVID, particularly in low- and middle-income countries (Aluttis et al., 2014; Buchan & Catton, 2020; Shaffer et al., 2020). The global mobility of nurses and associated recruitment competition compounds this problem (Aluttis et al., 2014; Buchan & Catton, 2020; Shaffer et al., 2020), and low-income countries may be disproportionally impacted by nurses migrating for better opportunities (Rolle Sands et al., 2020; Shaffer et al., 2020). Generally, health care professionals, especially nurses and physicians, are highly mobile and global. A deeper understanding of global health workforce mobility is necessary to mitigate shortages and ensure adequately staffed health care systems. This paper explores current global trends in nurse mobility and offers insights into challenges and solutions to ensure adequate staffing and mitigate shortages in the post-COVID era. Targeted action is needed to address nursing shortages. However, existing initiatives focus on importing talent rather than overarching strategies or long-term solutions. The United Arab Emirates relies on international nurses (approximately 96% of the nursing workforce) (Al-Yateem et al., 2020) and is currently recruiting more nurses to support health care delivery. Other countries also depend on international recruitment. For example, 14.5% of nurses working in the United Kingdom in 2019 were from outside the country (mostly from India and the Philippines), and this proportion is growing steadily (Royal College of Nursing - UK, 2020). In the United States, around 5% of RNs are foreign-trained, with many from the Philippines, Canada, and India (U.S. Department of Health and Human Services, 2018), while around 8.9% of the Canadian nursing workforce (Government of Canada, 2021), 17.7% of RNs in Australia, and 14% of currently registered nurses and midwives in Ireland were trained overseas. Despite benefits for individuals, professional groups, and health systems, international recruitment remains insufficient to address current nursing deficits. There is also limited information on the impact of international recruitment on source countries. Given the persisting global nursing shortages and pandemic-related health workforce pressures, international nurse recruitment may increase in many countries. This may have catastrophic consequences for health care systems in developing countries, which should be assessed and collectively addressed by all parties concerned. International dialogue is necessary to coordinate and regulate the recruitment of nurses from developing countries—where they are greatly needed. COVID-19 highlighted the importance of international collaboration and the equitable distribution of resources between rich and developing countries. Typically, nurses move from developing to developed countries (Aluttis et al., 2014; Rolle Sands et al., 2020), which is driven by nurses seeking better personal and professional lives (Alameddine et al., 2020),(Davda et al., 2018). However, health care systems in source countries cannot compensate for lost nurses (Emanuel-Frith, 2018). In addition, remaining nurses often face higher patient–nurse ratios and increased workloads, which may compromise the quality of services provided. There are also concerns regarding the impact of foreign-trained nurses on the quality of health care services in destination countries. The movement of skilled, qualified nurses (e.g., those who work in intensive/critical care units, operating theatres, and emergency rooms; Lorenzo et al., 2007, Yan, 2006) from developing to developed countries results in a brain drain and leaves less skilled nurses to deliver nursing services. Furthermore, it depletes the pool of senior and experienced nurses in critical, specialized, leadership, and academic positions in source countries (Alameddine et al., 2017). This brain drain has also escalated into a “brain waste.” For example, many doctors in the Philippines have retrained as nurses/nurse medics to pursue employment in Western countries (Khaliq et al., 2008); many of these doctors had ≥10 years' experience or specialty training (Khaliq et al., 2008). Southeast Asia and Africa have significant shortages of health workers, especially nurses and midwives (International Center on Nurse Migration, 2018), but many nurses are recruited internationally from these countries. Both the Philippines and India have very low nurse to population ratios (0.24 and 0.34 nurses/1000 population, respectively) (Statistics, 2022). In comparison, the top nurse importing countries, including Australia, Ireland, the United Kingdom, and New Zealand, have much higher ratios (12.57, 12.4, 8.42, and 11.15 nurses/1000 population, respectively) (Statistics;, 2022; WHO-The Global Health Observatory, 2018). However, recruitment of nurses from India and the Philippines continues. This is commercially driven and yields significant profits for stakeholders in the education, training, and exporting process (Khadria, 2007). Unfortunately, economic returns from such migration do not reach the source country's health care system (Efendi et al., 2017; Rolle Sands et al., 2020). International recruitment is expected to continue, as the WHO estimated an additional 9 million nurses and midwives are needed for all countries to reach Sustainable Development Goal 3 (health and well-being) by 2030 (International Center on Nurse Migration, 2018). However, it is likely that richer countries will continue to attract nurses to the detriment of source countries. The COVID-19 pandemic emphasized nurses' importance in maintaining well-performing and resilient health systems and exposed the risks associated with staffing and skills shortages (Kuhlmann et al., 2021; Zapata et al., 2021), especially as nurses continued to provide all essential health services. The effects of the pandemic were magnified in areas with nursing shortages; more suffering was endured, and more lives were lost. The leading health care workforce exporters were among the countries that experienced shortages of staff to fight the pandemic (Kuhlmann et al., 2021, Zapata et al., 2021). Nurse migration raises ethical issues, including its impact on health care systems in source (often developing) countries, the responsibilities of destination countries, and effect on nurse employment in destination countries. Other issues are nurses' rights to travel and advance their careers, developing countries' right to retain nurses they educate, discrimination against migrant nurses, and the value of remittances migrant nurses send home (O'Connor, 2016). Additional global concerns are the shortage and migration of nursing faculty, which has resulted in international competition to attract nursing faculty (Thompson et al., 2014). Nursing faculty migration can impact a country's ability to secure an adequate, stable, and high-quality nursing workforce (Thompson et al., 2014). Developed countries can play an important role in exchanging nursing knowledge and innovations with developing countries. As migrating nurses contribute to developments in destination countries (e.g., educational models, technological innovations), destination countries should reward these contributions by supporting source countries in acquiring the latest developments. This support can be through direct training and scholars from developed countries visiting developing countries and building capacity, or through opportunities for faculty/leaders from developing countries to visit developed countries, participate in professional development activities, and gain exposure to current developments. Finding and developing senior nursing researchers and educators are major challenges for developing countries. International faculty exchange programs and mentoring faculty in developing countries would allow junior scholars to learn and grow with experienced Western mentors. Important avenues for such exchanges include joint postgraduate programs and national training programs for nurse executives and leaders (Harrowing et al., 2010; Shultz & Aiken, 2010; Xu, 2012). Another important strategy is for nursing education institutions to engage with the global nursing community, which will develop the capacity of nursing scholars/institutions, facilitate knowledge transfer, and improve the visibility of institutions/scholars internationally. This could be achieved by exchange programs, shared postgraduate programs, collaborating in conferences and research, and supporting publications from developing countries. Facilitating publications in high-quality peer-reviewed international journals is essential given the importance of such publications in securing research grants, promotion, and institutional visibility. This will help developing countries retain faculty and develop capacity, thereby positively influencing the nursing profession (Xu, 2012). Ethical considerations when working toward these objectives include avoiding ethnocentrism and maintaining cultural awareness, sensitivity, mutuality, and respect. It is also essential that source and destination countries acknowledge they are in a joint effort with shared goals and objectives (Andrews & Fargotstein, 1986; Furuta et al., 2003; Xu, 2012). Without local and international nursing workforce management and migration policy changes, the global maldistribution of nurses may be exacerbated. Source countries face crises in nursing capacity and are unable to ensure adequate health care access for their populations. Balancing domestic health workforce needs, employment, and training opportunities for international nurses while acknowledging nurses' right to migrate are challenges for both source and destination countries. The current scenario puts low-income countries at risk and threatens global efforts to achieve universal health coverage. The global nursing migration pattern has sparked international debate about the consequences for health care systems worldwide, including questions about sustainability, justice, and global social accountability. It has also highlighted the need to share responsibility globally and work collaboratively to address the situation. Nursing and health care authorities in destination countries need to consider health service challenges and ethical issues in source countries. Nursing faculty migration also requires urgent investigation to support health system stability. Nursing management should develop innovative strategies to attract more new nurses and train and retain nurses locally. Nursing professionals worldwide, especially in developed countries, should collaborate to develop their fellow nurses and the nursing profession internationally.

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