The dilemma: International recruitment of nurses and midwives amid a global workforce shortage

International recruitment of nurses and midwives amid a global workforce shortage

Historic chronic underinvestment of nursing and midwifery, compounded by a global pandemic, has left a perilous shortage of the world’s largest health workforce.

The COVID-19 pandemic has worsened the already fragile state of the global nursing workforce, with the estimated global shortage of nurses and midwives at 30.6 million.

“Essentially the demand for nurses has outstripped supply. Many countries were experiencing shortages of nurses before COVID-19. The pandemic has further exposed these existing staffing gaps”, Adjunct Professor, WHO Collaborating Centre, University of Technology, Sydney, James Buchan told the ANMJ.

“It’s the great resignation – more nurses are retiring early, or working fewer hours or are moving to less demanding work – which is increasing the gap between supply and demand. On the back of that higher-income countries in the OECD are engaging in active international recruitment of other countries.

“What we are seeing is a chase for talent and there’s not enough to go around.”

The World Health Organization (WHO) has declared active recruitment of healthcare workers from less-resourced countries to meet the healthcare needs of well-resourced nations and its related migration as one of the greatest global threats in the 21st century.

Emigration rates for native-born nurses exceed 50% in 20 countries, which are mainly small islands in the Caribbean and the Pacific, according to the Organisation of Economic Co-operation and Development (OECD).

“There are Pacific Island countries where there are very small numbers of nurses and who are very vulnerable, even losing 10-20 nurses can have a significant impact on their health system,” Professor Buchan said.

According to the ICN report COVID-19 and the international supply of nurses, 550,000 foreign trained nurses are working across the 36 high-income OECD member countries (up from 460,000 in 2011). This includes 197,000 nurses in USA, 100,000 in the UK, 71,000 in Germany, and 53,000 in Australia.

“In the UK, recruiting nursing numbers is the highest it’s ever been since 1990 when we started collating the data. The NHS had 38,000 nurse vacancies before COVID which has grown to 45,000 – 10% or 1 in 10 RN vacancies in the NHS,” Professor Buchan said.

In June 2022, the Royal College of Nurses, UK, reported a ten-fold increase in nurse recruitment from ‘red list’ countries – those identified as having serious workforce challenges that must not be targeted for active recruitment. For example, 3,000 nurses from Nigeria, a red-list country, were registered in the UK last year.

The WHO Code of Practice framework on ethical recruitment, endorsed by all member states, outlines that high-income countries do not engage in large scale active recruitment of low-income countries.

However the Code is voluntary and the definition of ‘active’ is not clearly defined. In addition, the code was set out in 2010 before recruitment via social media.

“Country A may send out a message via social media that there are vacancies, and doesn’t target any country, so this is ‘not active’. It’s a very grey area,” Professor Buchan said.

At the May 2022 World Health Assembly, the ICN pleaded for governments to comply with the WHO Code of Practice and invest in nursing education with the aim of greater self-sufficiency in the supply of nurses.

ICN Chief Executive Officer Howard Catton said governments must address their own shortages by increasing the number of home-educated nurses and investing in retaining their current nurse workforce.

“It comes back to underinvestment in the nursing profession,” says Catton. “It is crucial that all countries train and retain more of their own nurses and implement ethical recruitment practices when they employ nurses from overseas.

“Career mobility is important for many nurses: it enables them to further their professional development, maximise their skills and qualifications, and fulfil their personal career goals.

“But there have been many cases of internationally educated nurses being poorly treated by their employers, and some countries that can ill-afford to lose their nurses have been left with insufficient numbers because of aggressive recruitment from overseas.”

The ICN calls on governments and employers to adopt appropriate policies when taking nurses from other countries.

Professor Buchan concurs. “It’s only fair those nurses have full information about the job they are coming to, the pay rates, and access to continuing development opportunities.

“It’s not something [recruitment] that ends the day the nurse gets off the plane. Careful consideration needs to be given to their settlement in the country, including what may be an unfamiliar culture, climate, and so on.”

In Australia, international recruitment has been a strategy regularly used to resolve workforce shortages. More recently, the government has been looking at lifting Australia’s skilled migrant cap by 35,000 per year up to 195,000.

ANMF’s policy on International recruitment of nurses and midwives clearly outlines that overseas recruitment must not be the primary strategy to overcome nursing and midwifery shortages in Australia.

“Governments must commit more resources for workforce planning, education and improving pay and conditions in order to attract and retain domestic nurses and midwives,” ANMF Federal Secretary Annie Butler said.

Policies should be adopted, both at country and international levels, to ensure nurse supply, says Professor Buchan. This includes by assessing and improving nurse workforce data, reviewing and expanding the capacity of the domestic nurse education system, assessing and improving retention of nurses and the attractiveness of nursing as a career, implementing policies to optimise the nursing workforce contribution, and monitoring and tracking nurse self-sufficiency.

“In the UK what is emerging is there is a high level of turnover of nurses in their 20s and early 30s not just pre-retirement in their 50s. We need to understand what is motivating them to leave.

“Safe staffing, workload, wellbeing, access to flexible hours and the ability to reduce their hours are at the core. We also need to ensure pay rates keep up with the cost of living,” Professor Buchan said.

“Pay and career structure that recognises and rewards nurses in advanced practice roles and nurse practitioners is also key. One of the problems is that nurses cannot scale up the career pathway. Many systems are under cost containment pressures with governments avoiding pay rises.”

In addition, workforce policies need to improve working conditions for women and to close gender gaps in leadership and pay, said Professor Buchan.

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