‘Promises’ Without Positions: Who is Responsible for Supporting and Assisting Internationally Qualified Nurses When International Nurse Recruitment Goes Awry?

Abstract

Nursing is a highly mobile profession, one of the great things being that skills are internationally transferable, meaning nurses can generally move freely around the world and secure employment in a wide range of health and social service settings. Many nurses seek international experience, and we ourselves have both worked internationally in a diverse range of multi-national settings throughout our careers. We have both gained enormously from the richness of these experiences forming lasting connections and friendships within the international nursing community.

Nurses move countries for all sorts of reasons, and it is important to distinguish the differences between nurse migration and international nurse recruitment. These are related terms, in that they both refer to the international movement and employment of nurses, but there are also some crucial differences. Nurse migration refers to the movement of nurses from their home country to work in another country. This is self-initiated by individual nurses for a range of personal and professional factors, including seeking new professional opportunities as well as uniquely individual and family reasons such as prospects for improved living conditions, better pay, lifestyle aspirations and more.

In contrast, international nurse recruitment refers to a more systematised and targeted process whereby health organisations and governments actively seek and employ nurses from other countries to fill gaps in their own domestic nursing workforces. It generally involves inducements, guaranteed employment, and various support such as help with the logistics of visa, travel and licensing requirements. International recruitment has long been seen as a panacea by (mainly) Western countries to address nursing shortages, with many nurses recruited from low-to-middle-income countries (Sheehy, Crawford, and River 2024). Typically, it is cheaper, quicker and easier to address workforce issues through international recruitment, rather than systemically addressing and resourcing the root causes of nursing shortages. Recruitment of foreign nurses has been used to fill gaps in the generalist as well as the specialist-nursing workforce (Kurup et al. 2024; Sheehy, Crawford, and River 2024).

For many years, there have been concerns about the ethics of international nurse recruitment including pleas from the International Council of Nurses for governments to closely monitor and report their recruitment activities and to commit to improved investment in achieving self-sufficiency in their own nursing workforces (International Council of Nurses 2022). This is because many of the home countries from which nurses are recruited have a dire need for a strong nursing workforce of their own. These countries frequently spend a proportionately large amount of money educating health workers who are then recruited to much wealthier countries, leaving their home countries under-resourced, thus threatening the health of their own populations. The countries of origin often have significant health challenges but are unable to compete with wealthier nations who can afford to offer inducements to recruit nurses. Ensuring ethical recruitment practices is imperative. Many countries have committed to adhering to the WHO Code of Practice on International Recruitment of Health Personnel (2010) to invest in growing their own domestic workforce, prevent the exploitation of source countries and maintain global health equity (World Health Organization 2010).

New Zealand/Aotearoa is an island nation of 5.3 million people in the South Pacific. The population is made up of people from a range of backgrounds including Indigenous Māori (16.5%), Asians (15.1%) and non-Māori Pacific Islanders (8.1%) with most remaining census respondents confirming European descent. Indigenous Māori and Pacifica peoples are noted as the most youthful and fastest growing population cohort (Stats New Zealand 2024). New Zealand is a high-income country, as defined by the World Bank (2023) with advanced healthcare, education and infrastructure, and high levels of technological development and innovation (World Bank 2023). The importance of culturally aligned care, particularly for Indigenous people is well documented, however; like many other high-income countries, New Zealand has consistently relied on International recruitment as a means of providing an adequate nursing workforce in contrast to providing sufficient investment in its own domestic nursing pipeline (Brownie and Broman 2024).

New Zealand has the highest percentage of internationally qualified nurses (IQNs) among western nations rising from 27.25% in 2020 to 44.7% by June 2024 (New Zealand Nursing Council 2024). In the year to June 2023, 8748 IQN's were issued with a certificate to practice nursing in New Zealand, and in the year to June 20–24, 5321 IQN's were accredited to work as a nurse in New Zealand after undergoing competency assessment representing a 131% increase on the previous year (Miller 2024). However, New Zealand's nursing employment market has cooled, fuelled by the perfect storm of a globally difficult financial context, a financially challenged health sector (New Zealand Government 2024) and the recent unprecedented large-scale import of IQN's (New Zealand Nursing Council 2024).

The current situation has made it more difficult for both international and local domestically qualified graduate nurses to get work (Miller 2024; O'Dwyer 2024) potentially contributing to the increasing flow of domestically qualified nurses and new graduates migrating to Australia. In the 10 months to February 2024, 12% of New Zealand's active nursing workforce registered to work in Australia. Totalling 9000 or 900 per month over the 10-month period, the numbers had increased from 625 per month in the preceding 8-month period (Quinn 2024). Domestic graduates have the option of Trans-Tasman migration; however, this means further loss of a dwindling domestic resource along with dislocation from family and home for the outwardly migrating new graduates. But, for graduates facing job uncertainty (O'Dwyer 2024), this is a potentially unavoidable option if they wish to practice in the profession for which they have just qualified.

When newly migrated international nurses are unable to find employment, they are in a precarious situation, meaning that they may have to draw on the support of charities to help them to survive. Recently, Miller (2024) reported a leading charity being approached by an increased number of IQN's, ‘who are completely and utterly stuck with no prospect of moving forward… mostly they are supporting themselves with loans they have taken out, sometimes two loans… They can't afford to stay. They can't afford to go home’ (Miller 2024). Miller (2024) sought comment from the New Zealand Nurses Organisation (NZNO), who reportedly criticised the lack of adequate workforce planning which could have prevented these issues, asserting that while more nursing staff were needed in hospital wards across New Zealand, proposed budget cuts meant that more jobs were unlikely in the sector's current context. The sense of déjà vu is disheartening when looking back a decade to when immigration department adjustments were needed to stem the flow of IQN's into the country (O'Connor 2014). This raises a legitimate question as to what has gone wrong in the workforce planning processes and why nurses are caught in this recurring cycle of migration without work? In the current scenario, the immigration minister is quoted as saying that if an IQN cannot secure employment, ‘they should not be in New Zealand’ (Miller 2024) and yet close to 18,000 more IQNs have been recruited in the 21 months from September 2022 to June 2024 alone (New Zealand Nursing Council 2024).

It is simply unacceptable for governments and other agencies to actively undertake large-scale recruitment of IQN's into a situation of employment uncertainty, for nurses to traverse the challenges of migration and international certification only to find that adequate work is not available to sustain them. Obtaining international certification costs money and time. At every step of the way agencies are making money on the processes associated with recruitment, relocation and certification, all saying they take no responsibility for the end employment scenario. Immigration agents and departments, professional registration authorities and educational providers all benefit financially through receipt of monies gained via agency fees, immigration fees, costs associated with professional assessment of eligibility and fees charged by educational providers for the provision of competency assessment programs. Yet at the end of the process, we see nurses out of pocket and out of work. It is disturbing to hear of newly arrived nurses becoming driven into poverty, unable to return home and becoming dependent upon the third (voluntary sector) for survival, with a parallel lack of job opportunities for domestically qualified counterparts (Miller 2024) who have invested heavily in the acquisition of their nursing qualification.

The current reality is that international nurses seeking to practice in New Zealand are entering a system under pressure. Even though the Government 2024 budget allocation includes $3.44 billion for hospital and specialist services and $2.12 billion for primary, community and public health, monthly overspends have triggered a current review of staff appointment processes and replacement of the health governance board with a Ministerially appointed Commissioner (New Zealand Government 2024).

While international recruitment has been somewhat helpful in alleviating shortages, overseas nurses often face challenges in adapting to a new healthcare systems, cultures, and workplaces. The decision to move countries is a major one, involving considerable emotional and financial investment. Having moved countries more than once ourselves, we are personally familiar with the challenges associated with adjusting to practice in a new country, and all that involves. Evidence highlights that recertification to practice nursing in a new country can be an extremely stressful process (Högstedt et al. 2021). There is a raft of published papers outlining the many issues experienced by overseas qualified nurses transitioning to a new country, including experiences of racism and discrimination, communication challenges, orientation difficulties, homesickness and yearning for home, feeling devalued, dealing with differences, lack of meaningful support systems, isolation, deskilling, self-doubt and cultural shock (Pung and Goh 2017; Rajpoot et al. 2024; Sheehy, Crawford, and River 2024). Internationally educated nurses may experience cultural conflict in various areas of nursing practice (Balante, van den Broek, and White 2021). This is because cultural background influences and informs beliefs and attitudes about the way in which health care is delivered.

Kurup et al. (2024) have reported that IQNs face challenges in using their specialist skills due to restricted opportunities, financial limitations, and inadequately managed transition pathways. When IQN's are needed to compliment a domestic workforce, adequate support and orientation programs are essential to their successful integration into new countries and cultures. Employers and regulatory bodies can significantly enhance the professional assimilation and career advancement of IQNs by welcoming them into jobs which provide supportive orientation, offer tailored gap training, acknowledge specialised skills, and ensure job certainty (Kurup et al. 2024).

Nurses engaged through international recruitment processes are often commoditised and depersonalised, meaning that the emphasis of recruitment is primarily on acquiring a certain number of nurses for a certain price. The focus is often on bulk recruitment and so the unique characteristics and qualities of each nurse may be subordinated to the primary purpose of meeting numerical targets. Such recruitment frequently occurs in the absence of the valid data sets needed to properly inform nursing workforce planning (Brownie and Broman 2024). It must be remembered that these nurses are not just numbers—they are people. Every single IQN is a unique individual, with their own personal hopes and dreams, professional aspirations and family responsibilities.

The situation in New Zealand serves as an important case study highlighting the potential challenges associated with aggressive recruitment strategies when they are not accompanied by comprehensive workforce planning. This scenario underscores the critical need for a more nuanced approach to recruitment and workforce management. Additionally, it prompts reflection on the role and responsibilities of recruiting agencies in supporting IQNs who, upon arriving in a new country with the expectation of finding employment quickly, may encounter unforeseen difficulties in securing work. Many of these individuals face significant barriers, including lack of local networks and family support, and limited resources to return to their home country or to relocate to other regions where employment opportunities might be more accessible.

Poorly managed workforce planning, nurse recruitment and acculturation processes call into question the role and responsibility of employers, nurse leaders and professional regulators, particularly in the face of over-recruitment of IQN's. In the first instance, professional leaders and regulators should focus on the recommendations in the WHO Code of Practice on the International Recruitment of Health Personnel (World Health Organization 2010) by working with their governments prioritising investment in sustainable domestic workforce pipelines, engaging in ethical international recruitment processes and in preventing the exploitation of IQN's and their host countries.

The authors declare no conflicts of interest.