Running head: COSTS AND BENEFITS OF IMPORTING FOREIGN NURSES

The Costs and Benefits of Importing Foreign Nurses:

Which One is Outweighing?
Sewon Lee
University of Saint Mary

COSTS AND BENEFITS OF IMPORTING FOREIGN NURSES

Abstract
Today, many countries in the world, including the United States are still facing a nursing
shortage. Throughout the history, global recruitment was used as the main way of dealing with
the problem. This paper looks at the benefits and issues derived from the global recruitment of
nurses in various perspectives, such as monetary, psychological, and ethical aspects. One might
not agree with the statement saying the global recruitments flaws seem to outweigh its benefits,
but one thing is very clear that nurses have to remember their responsibility of taking care of the
global society.

COSTS AND BENEFITS OF IMPORTING FOREIGN NURSES

The Costs and Benefits of Importing Nurses

During the last decade, there has been a huge shortage of nurses internationally due to the
factors such as aging of the workforce and increased demand for health care services. As one of
those countries, United States has been trying to resolve the issue by importing foreign nurses.
Proving that, the number of immigrated nurses in U.S. has been gradually increasing since 1998.
In 2000, there were approximately 150 million nurses who migrated to other countries, and it
increased to 231.5 million in 2013 (Squires, Ojemeni, & Jones, 2016). While it helped U.S.
significantly reaching the increased health care demand, it also posed various cultural, ethical,
and political problems not only to the importing country, U.S., but also the exporting countries.
In addition to that, lots of current research suggest that U.S. will still be facing the same issue by
2025 (Delucas, 2014), meaning U.S. might have to continue importing foreign nurses, which will
further intensify these import derivative issues U.S. is having right now. By evaluating costs and
benefits of importing foreign nurses, U.S. and the global society can find out if the benefits are
indeed outweighing the costs, and thus, take the most appropriate actions.
One of the most significant benefits and probably the main purpose of importing foreign
nurses in the U.S. is meeting the high demand and providing health care services for the rapidly
growing population. In the 1980s, many hospitals in the U.S. had to close due to the lack of
nurses. In fact, 76% of the hospitals in U.S. were looking for more nurses (Jurado & Pacquiao,
2015). Thousands of foreign nurses were added to that field, filling the vacancy. If it were not for
the foreign nurses, the U.S. health care system might have gone through an extreme healthcare
crisis. That is why the U.S. government helped the foreign nurses stay and be protected by laws
and regulations. For example, the Immigration Nurse Relief Act of 1989 helped to recruit more

COSTS AND BENEFITS OF IMPORTING FOREIGN NURSES

foreign nurses and to make them stay in the U.S. by giving them a chance to become a
permanent resident under certain requirements (Jurado & Pacquio, 2015).
It sounds almost obvious to state that the importing country benefits from this trade.
Then, how about the exporting country? Do they gain anything in return? The answer to the
question is yes. There are some benefits for the exporting country, even though it might not
necessarily be as valuable as those of the importing countries. Among the benefits, one can say
money is the most valuable gain. This can be seen in the case of immigration of Filipino nurses
in 1950. Nationwide financial profits due to the emigration of nurses were so high that it was
strongly supported by the Filipino government; they were praised by the government as
ambassadors whose works contributed to paying off Philippines national debt (Jurado &
Pacquiao, 2015). This financial benefit is also significant at an individual family level. A research
done in Lesotho, another nurse exporting country, shows that many emigrated nurses saw the
higher income as a main driving force behind their decision of immigration. This is typical
because the importing countrys money value is greater than the exporting countrys money. With
the money, those nurses are able to support their family at home, afford their childrens
education, and build and renovate their house (Ntlale & Duma, 2012).
Another benefit that made nurses immigrate to U.S is closely related to how nurses were
treated and viewed in their home country. Usually, in developing countries, nurses are treated
poorly with little or no respect and appreciation. For example, Filipino nurses often work
overtime but do not get paid for that. They also do not get a good benefit like a hospital provided
health insurance (Jurado & Pacquiao, 2015). On top of that, the research done by Ntlale & Duma
states that Filipino nurses work in a stressful environment, and they are exposed to many
communicable diseases. This can be also seen in Lesotho; nurses in Lesotho were constantly

COSTS AND BENEFITS OF IMPORTING FOREIGN NURSES

concerned for their safety from HIV, AIDS, and Tuberculosis. Additionally, their hospitals do not
have enough or appropriate personal protective equipment (Ntlale & Duma, 2012). So, moving
to a country where their works are appreciated and practicing in a safe environment must have
been very appealing to those nurses. Looking at this from another perspective, this shouldve
been helpful for developing countries to realize how they were mistreating their nurses, and thus,
trying to figure out ways for improvements.
Of course, there are many costs accompanying with these benefits. From the exporting
countrys perspective, one of the possible main costs is losing nurses. Those developing countries
are not exporting nurses because they have too many. Ironically, they are the ones who need
nurses the most. In 2006, The World Health Organization Report stated that there were 1123
nurses in Lesotho, and they need 700 more. This resulted in delayed implementation of its
national health campaign which was about HIV testing and counseling (Ntlale & Duma, 2012).
Other nurse exporting countries like Canada, Philippines and India are having the same issue.
Then, from where do Canada and Philippines supply their nurses? The answer is surprising. They
get their nurses from countries that are less developed than they are. ...Canada from the United
Kingdom; the United Kingdom from India, South Africa, and Jamaica, and South Africa from
Ghana (Delucas, 2014). It appears to be a food chain: the chain where only the highest class is
benefiting. And, it never ends. The real question is, however, where does Ghana get their nurses
from? The answer is nowhere.
This leads to the most important aspect of this nursing importation, some ethical issues.
The quality of healthcare systems is constantly reduced due to the lack of nurses. While the
importing countries are meeting their high healthcare demand, the exporting countries cannot.
This is ironical because they are the ones who really need more nurses due to their critical health

COSTS AND BENEFITS OF IMPORTING FOREIGN NURSES

risks. Proving that, a research shows 36 out of the total number of 57 African countries face the
nursing shortages. These African countries have only 3% healthcare workforce and 1% economic
resource of the world. With this little resources, nurses of the exporting countries have to deal
with more critical health problems. As a result, their health care system collapses; their mortality
and morbidity rates are soaring. What is worse is that there is no improvement in the healthcare
system due to lack of investments. As a result, the quality of health care is extremely low. The
outbreak of Rotaviruses is a great example for this. Rotaviruses cause at least 500,000 children
younger than 5 years old every year in developing countries (Delucas, 2014).
The lack of investments leads to an even greater nursing shortage with what researchers
call a brain drainage. Since the exporting countries have less money to provide an affordable and
good quality of nursing education, there are fewer nursing students, thus fewer nurses. In the
Philippines, this was even more aggravated when their government strongly supported exporting
the current and new nurses to other countries. Interestingly, in the Philippines, the rate of medical
enrollment also went down. That was because many medical students and currently working
physicians decided to become a nurse and migrate to the U.S. According to a study, among rural
areas, up to 80% of physicians change their vocation to a nurse (Delucas, 2014). This is literally
the definition of brain drainage in action. And it is clear that without the proper number of
intellectuals, the future of healthcare systems of exporting countries cannot be bright. All these
problems might not be as troublesome as the ones in a developing country if those happened in a
developed country. Thats because there is a huge difference in the perception and roles of nurses
in the two countries. Unlike in developed countries, nurses of the developing countries have
more control and scope of practice even including some of the physicians. In fact, those nurses
are usually the primary health care provider instead of physicians, thus taking nurses away from

COSTS AND BENEFITS OF IMPORTING FOREIGN NURSES

those countries is as same as taking everything from their healthcare system. (Delucas, 2014).
Looking at those facts, it seems like global recruitment has more flaws than its benefits.
Even if there are more benefits than flaws, people will notice that it is just ethically not wrong to
do. More and more people come to realize that over the time, and people started to work on
raising the awareness of importing nurses in U.S. and globally. Many health organizations started
to establish some new rules and regulations that could moderate the situation. For example, in
1946, the World Health Organization (WHO) developed the global code of practice on
international recruitment of health personnel, which advocates for the right to health of everyone
and every country (Delucas 2014). This was a new advancement compare to its original nursing
code of ethics that was focused on the four core elements, such as, advocacy, responsibility,
accountability, and confidentiality. The global code of practice promotes a voluntary, ethical
practices of importing nurses (Potter, Perry, Stockert & Hall 2012). The main emphasis of this
code is focused on making a health care system sustainable; so, that the need for global
recruitment is naturally decreased, and especially not to recruit from the developing countries
(Squires at al., 2016). Another change the U.S. has implemented lies in the board exam. Every
three year, the contents and structures of the professional nursing licensure exam are changed
with the purpose of decreasing in the pass rate for international nurses, even though this has a
downside of lowering the pass rate for local nurses in the United States. On top of this, the
number of work visas available to international nurses has been decreased, and making it even
harder, there was a new language competency test added to the original requirements for work
visas (Squires at al., 2016).
Likewise, the American Nurses Associations (ANA) developed a statement regarding the
responsibility of nurses; nurses are not only to care for individuals but also to care about the

COSTS AND BENEFITS OF IMPORTING FOREIGN NURSES

global health issues such as lack of resources and health care access (Delucas, 2014). The author
of the book named, Fundamentals of Nursing also talks about the importance of knowledge for
nurses regarding the global healthcare society. In the book, it says that healthcare leaders should
be aware of what is going on around the world, and thats the reason why the International
Council of Nurses (ICN) was created (Potter at al., 2012). ICN focuses on three main areas:
professional practice, regulation, and socio-economic welfare. For improvement of each area,
ICN hosts global forums, conduct research, and publish journals that can be shared by global
health communities. There are special networks set up for HIV-AIDs or responding to disasters.
One of the innovative actions of ICN includes telenursing network in response to its increased
need. They also celebrate the international nursing day (International Council of Nurses, 2015).
Thanks to the ICN, more nurses are able to communicate with nurses from other countries and
share the knowledge of ongoing issues and possible solutions.
In conclusion, the nursing shortage cannot be approached by just the global recruitment.
Even though it is solving the problem to a certain degree and has some benefits such as financial
gain to the family and home country of the migrating nurses, it poses too many problems to the
home country and importing country. When nurses in the developing countries leave, more
nurses and even physicians leave, which leaves nothing behind and making the country brain
drainage. At this point, it is not about benefits or costs anymore; it becomes a problem of ethics.
Organizations like ANA and WHO have created new rules and regulations in order to promote a
sustainable health care system in the United States, and they emphasized nurses responsibility
not just to their home country but also to the global society. Since the U.S. is still facing the
problem of a nursing shortage and it will be continued in the future, it is important to find some
feasible and effective solutions as soon as possible.

COSTS AND BENEFITS OF IMPORTING FOREIGN NURSES

References
Delucas, A. C. (2014). Foreign nurse recruitment: Global risk. Nursing Ethics, 21(1), 76-85.
doi:10.1177/0969733013486798
International Council of Nurses. (2015). ICN NETWORKS. Retrieved from
http://www.icn.ch/networks/icn-networks/
Jurado, L. M., & Pacquiao, D. F. (2015). Historical Analysis of Filipino Nurse Migration to the
US. Journal of Nursing Practice Applications & Reviews of Research, 5(1), 4-18.
doi:10.13178/jnparr.2015.0501.1303
Ntlale, M.E & Duma, S.E., 2012, The costs and benefits of nurse migration on families: A
Lesotho experience, Curationis 13(1), Art. 13, 8 pages. http://dx.doi.org/10.4102/
curationis.v34i1.13
Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2012). Fundamentals of Nursing. St. Louise,
MO.: Mosby Elsevier.
Squires, A., Ojemeni, M. T., & Jones, S. (2016). Exploring longitudinal shifts in international
nurse migration to the United States between 2003 and 2013 through a random effects
panel data analysis. Human Resources For Health, 1411-21. doi:10.1186/s12960-0160118-7

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10

Appendix
I.

II.

III.

IV.

V.

INTRODUCTION
A.
Historical background behind the lack of nurses
1.
International shortage
2.
Attributing factors in the United States
B.
The reason why we need to assess the costs and benefits
1.
Cultural, ethical, political issues
2.
Its never-ending
BENEFITS OF IMPORTING FOREIGN NURSES
A.
Benefits to the importing country - Satisfying the demand
a)
The U.S. hospitals closing in 1980s
b)
The Immigration Nurse Relief Act
B.
Benefits to the exporting country
1.
Pulling factor - Financial Gain
a)
National level - Filipino nurses in 1950
b)
Individual level - Lesotho case
2.
Pushing factors
a)
How nurses are treated in developing countries
(1)
Public perception
(2)
Overtime pay
(3)
Poor benefits
b)
Working environment in developing countries
(1)
Prevalent communicable diseases
(2)
Insufficient Personal Protective Equipment
COSTS OF IMPORTING FOREIGN NURSES
A.
Costs to the exporting countries
1.
Losing nurses
a)
Lesotho case
b)
The global food chain
2.
Losing other health care professionals
B.
Costs to the importing countries
1.
Team work at a hospital
a)
Language barriers
b)
Different practices
2.
Patient Safety
ETHICAL ISSUES
A.
WHO global code of practice on the international recruitment of health personnel
B.
Nursing Code of Ethics by American Nurses Association
C.
Brain drain in developing countries: they rely on charities
RESOLUTION - Exploring options
1.
Self-sufficiency and sustainability
2.
Efforts of International Governmental Organization