NRSE4570_M4_Shaffer_et_al_2019_The_Role_of_Nurses_in_Advancing_the_Objectives.pdf

The Role of Nurses inAdvancing the Objectives of theGlobal Compacts for Migrationand on Refugees

Franklin Shaffer, EdD, RN, FAAN, FFNMRCSI;Mukul Bakhshi, JD; Niamh Farrell, MA;Thomas Álvarez, BA

Nurses and other health care professionals are in a unique position to shift the paradigm aroundmigration debates. As caregivers and advocates for patients and other providers, nurses are crucialto the health and well-being of individuals, families, and communities. This is especially true formigrants, including increasingly vulnerable refugee populations around the world. As negotiationssurrounding the Global Compact for Migration and Global Compact on Refugees come to a close,nurses’ roles are becoming more apparent. Nurses are facilitators of migration and can help ensurethat the benefits of migration are maximized and the challenges are mitigated. Often, nurses aremigrants themselves. Leveraging nurses’ knowledge, experience, talents, and compassion is cru-cial for attaining the objectives of both the Global Compact for Migration and the Global Compacton Refugees. Nurses are large contributors to the United Nations’ 2030 Agenda for SustainableDevelopment and its 17 Sustainable Development Goals. The global nursing workforce has enor-mous potential to advance the achievement of these goals and objectives. In a world that appearsto be increasingly xenophobic and hostile to migrants, nurses stand out as professionals who canchange the narrative while providing compassionate care for the most vulnerable. Key words:advocacy, Global Compact, migration, refugees, sustainable development, United Nations

NURSES AND THE GLOBAL COMPACTSFOR MIGRATION AND REFUGEES

Nurses and other health care profession-als are looking to amplify their voices in avariety of policy discussions. Many do thisthrough their professional organizations. His-torically, nursing organizations have been ap-prehensive about wading into broader policy

Author Affiliations: CGFNS International, Inc,Philadelphia, Pennsylvania (Dr Shaffer, Ms Farrell,and Mr Álvarez); and CGFNS Alliance for EthicalInternational Recruitment Practices, Philadelphia,Pennsylvania (Dr Bakhshi).

The authors declare no conflict of interest.

Correspondence: Franklin Shaffer, EdD, RN, FAAN,FFNMRCSI, CGFNS International, Inc., 3600 Market St.,Ste. 400, Philadelphia, PA 19104 ([email protected]).

DOI: 10.1097/NAQ.0000000000000328

debates, as nursing advocacy has traditionallycentered on patients and providers.1 How-ever, these organizations have begun to lever-age the credibility of—and public trust in—their profession. The relatively large numberof nurses, combined with their considerableexpertise, allows them to speak powerfullyon a variety of issues that influence their abil-ity to adequately address the health needs ofpatients. One way to do this is through sup-port of the Global Compact for Safe, Orderly,and Regular Migration and the Global Com-pact on Refugees, discussed later in this arti-cle. The migration-related issues addressed inthese compacts impact the very core of healthcare professionals’ work.

Organizations across the globe are advocat-ing on behalf of both providers and thosethey serve. The Salvation Army, Eurocarers

Nurses in Advancing Global Compacts for Migration and on Refugees 11

(an organization that focuses on those whocare for others in Europe, both as unpaid andpaid caregivers), and a consortium of 14 otherEuropean organizations have released a state-ment lauding the Global Compact as an “op-portunity to commit to reforms and policiesthat provide social protection and sustainableand quality domestic and care services forthose needing care, and decent work for thoseworking in the sector.”2 In the United States,the American Nurses Association has not spo-ken directly on the Global Compact but hasstated, “The Code of Ethics for Nurses withInterpretive Statements calls on all nurses toalways act to preserve the human rights of vul-nerable groups such as children, women andrefugees.”3 The American Nurses Associationhas also cited that Code in a statement oppos-ing the US policy toward migrants and asylumseekers that led to the separation of parentsfrom their children.4

Nurses can leverage their favorable pub-lic perception to shift the paradigm aroundmigration debates. Globally, many destinationcountries have highly politically charged en-vironments around immigration policy. Wor-ries about loss of national identity, jobs be-ing “stolen” by migrants, and crime haveprompted increasingly xenophobic rhetoricalong with the election of officials who fa-vor restrictive immigration policies. However,most countries are more welcoming of nursesand other health care providers. Even as coun-tries have generally moved against support-ing immigration, the skills of foreign nursesand health care professionals are still soughtafter.5

This phenomenon is not new—the globalneed for health care workers makes them pre-ferred migrants. Even when the US Congresswas acting to restrict immigration through theIllegal Immigration Reform and Immigrant Re-sponsibility Act of 1996, nurses were kept ona shortlist of occupations with an assumedshortage,6 who would therefore be eligiblefor migration to the United States. Currently,while the Trump Administration has targetedcategories of immigrants, such as those whoare undocumented or under the H1-B pro-

gram for rule changes, it has not spokenabout reducing the number of visas in thevisa categories that include most nurses. Re-cently, in the United Kingdom, where con-cerns about migration were a motivation forthe vote that the United Kingdom leave the Eu-ropean Union (known informally as “Brexit”),the British Home Office exempted doctorsand nurses from the cap placed on the num-ber of skilled workers who could immigrateto the United Kingdom.7 By highlighting theimportance of health care professionals to sys-tems and patients, the polarizing immigrationrhetoric that paints migrants as criminals andjob stealers can be mitigated, allowing for amore reasoned discussion of how to lever-age migration to strengthen the economiesof both origin and destination countries.

REFUGEES AND MIGRANTS

International migrants include people whocross borders to live in another country forany reason. Refugees are a subset of thatgroup. According to Dilip Ratha8 at the WorldBank, there are 262 million migrants world-wide, including 19 million to 24 millionrefugees. The United Nations High Commis-sioner for Refugees states,

Under international law, refugees are persons out-side their countries of origin who are in need ofinternational protection because of a serious threatto their lives, physical integrity, or freedom in theircountry of origin as a result of persecution, armedconflict, violence, or serious public disorder.9 (p1)

Many migrants who do not meet the stan-dards for refugee status leave countries oftheir own volition. Others are displaced be-cause of unfavorable circumstances such asdrought, natural disaster, or poor economicopportunities. Migrants, both refugees andothers, require certain protections and are en-titled to universal human rights. This issueis becoming even more urgent, because un-der some scenarios (eg, climate change), thenumber of migrants could more than triple to875 million by 2050.8 The Global Compact forMigration and the Global Compact on

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Refugees outline these protections and pro-vide pathways for more organized, stable, andsafer migration for both groups.

THE GLOBAL COMPACTS

The Global Compact for Safe, Orderly, andRegular Migration and the Global Compacton Refugees stem from the 2016 UN GeneralAssembly Resolution 71/1, New York Dec-laration for Refugees and Migrants.10 TheNew York Declaration states that, althoughrefugees are a subset of the larger migrantpopulation, the 2 groups are distinct. TheNew York Declaration contains commitmentsto refugees and nonforcibly displaced mi-grants (together); commitments to migrants(only); and commitments to refugees (only).It also contains 2 annexes that serve as thefoundations for the 2 Compacts. Annex Ioutlines a Comprehensive Refugee ResponseFramework (CRRF). The CRRF explains thatthe United Nations High Commissioner forRefugees is responsible for creating a com-pact specifically for refugees, with the CRRFat its core, as well as programs of action thatcan be implemented around the world. An-nex II contains the basis for the Global Com-pact for Migration that will “set out a range ofprinciples, commitments and understandingsamong Member States regarding internationalmigration in all its dimensions.”10(p1)

The Global Compact for Migration is signif-icant because it is the first international com-pact of its kind to specifically address migra-tion. The Compact emphasizes “common un-derstanding, shared responsibilities and unityof purpose,” aiming “to facilitate safe, orderlyand regular migration, while reducing theincidence and impact of irregular migrationthrough international cooperation . . . .”11(p1)

Bi- and multilateral agreements betweencountries about how to achieve this aim arecritical. However, civil society, academia, andother stakeholders also play an important rolein helping migrants thrive in their currentsituations. The Global Compact for Migrationstresses the importance of migrant empower-ment and its impact on inclusion and stability.

It also identifies the immense potential mi-grants possess, which can be used to attainthe Sustainable Development Goals (SDGs).11

The cofacilitators of the Global Compactfor Migration (the Permanent Missions of Mex-ico and Switzerland to the United Nations)outlined 23 objectives and commitments thatmust be attained for safe, orderly, and regularmigration. These include—but are not limitedto—supporting vulnerable groups withinmigrant populations, identifying and fightinghuman trafficking, improving migrant identi-fication and documentation, combating xeno-phobia, and tapping into migrants’ skills andresources to help improve stability, achievesustainability, and provide a much-neededsense of purpose.10 While the New YorkDeclaration was adopted by all United Na-tions member states, the Global Compact forMigration is not legally binding.12 Its effortswere hampered when the United States with-drew from the Compact in December 2017,stating that it interfered with its sovereigntyand domestic immigration policy.13

Refugees, a particularly vulnerable popula-tion, have historically received internationalprotections. This began on a global scale withthe 1951 United Nations Convention Relat-ing to the Status of Refugees. The Conven-tion was born out of the atrocities and massdisplacement caused by World War II. It ex-plains what determines refugee status, out-lines refugee rights, and explicitly states thata refugee should not be forced to return toa place where his or her life is endangered(nonrefoulement).14 It applied only to thosedisplaced by violence or persecution withinEurope before January 1, 1951. The 1967 Pro-tocol Relating to the Status of Refugees ex-panded the scope of the 1951 Convention torefugees around the world and from all timeperiods.15

The Global Compact on Refugees has 4main objectives: “Ease the pressure on hostcountries; enhance refugee self-reliance; ex-pand access to third-country solutions; andsupport conditions in countries of originfor return in safety and dignity.”12 As pre-viously noted, the CRRF forms the basis

Nurses in Advancing Global Compacts for Migration and on Refugees 13

of the Global Compact on Refugees. Accord-ing to the CRRF, in the New York Decla-ration, “Through a comprehensive refugeeresponse based on the principles of inter-national cooperation and on burden- andresponsibility-sharing, we are better able toprotect and assist host States and communi-ties involved.”10(p1) Similar to the Global Com-pact for Migration, the Global Compact onRefugees emphasizes the importance of pro-tecting vulnerable populations, promoting so-cial inclusion and cohesion, and encouragingrefugee empowerment toward achieving theSDGs. It also emphasizes “burden-sharing” be-tween states, civil society groups, academia,and other relevant stakeholders.16

WORK OF HEALTH CAREORGANIZATIONS TO ADVANCEFAIR RECRUITMENT

Objective 6 of the Global Compact for Mi-gration seeks to “facilitate fair and ethical re-cruitment and safeguard conditions that en-sure decent work.” The health care sectorhas been at the forefront of efforts to en-sure ethical recruitment. In 2008, a multi-stakeholder task force including recruiters,employers, unions, nurse representative orga-nizations, and credential evaluation organiza-tions established a code of standards of prac-tice to ensure that recruitment of internationalhealth care workers is ethical. From its incep-tion, the Code has been administered by theAlliance for Ethical International RecruitmentPractices, now a division of CGFNS Interna-tional, Inc. It was updated as the Health CareCode for Ethical International Recruitment& Employment Practices in 2016.17 The Codewas designed to set best practices to ame-liorate contract and other problems rampantduring the 2003-2007 boom years for the re-cruitment of foreign-educated nurses (FENs)to the United States.18

The Alliance Code preceded the devel-opment of the World Health Organization’s(WHO’s) 2010 Code of Global Practice onthe International Recruitment of Health CarePersonnel, which provides voluntary guid-

ance for member states. Members promiseto report on their progress on following thisguidance every 3 years.

The two codes support each other and work sym-biotically, with the WHO Code articulating globalprinciples and a framework for international aware-ness and cooperation, and the Alliance Code pro-viding detailed guidance to individuals and com-panies operating in the healthcare recruitmentsector.19 (p1)

The Global Compact for Migration con-tains a number of objectives and priorities.Objective 1 cites the need for data as thebasis of evidence-based policies. The Inter-national Centre on Nurse Migration, createdby CGFNS and the International Council ofNurses, represents an effort to aggregate re-search in this sector.20 While these volun-tary initiatives have had challenges in gainingtraction, they provide guidance as the UnitedNations, regional cooperatives, and individualcountries seek to promote fair and ethical re-cruitment at both the national and grassrootslevels.

NURSING CONTRIBUTIONS TO THEGLOBAL COMPACT FOR MIGRATIONOBJECTIVES

Nurses play a critical role in achieving thegoals and objectives of the Global Compactfor Migration. Migrant nurses “address andreduce vulnerabilities in migration” (objec-tive 7).11 Migrant populations are largely com-posed of women and children, many of whomneed medical attention.21 These groups arealso at a greater risk for gender-based vio-lence and harassment. Certain cultural normsoften prevent women from reporting violenceand seeking help, particularly if the authorityfigure is male. Nurses can help bridge this gap.As the majority of nurses are female, womenof vulnerable populations who experience vi-olence, harassment, or need medical attentioncan find refuge in a female nurse. As a re-sult, nurses are key to advancing objective 10:“Prevent and combat trafficking in persons inthe context of international migration.”11(p1)

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With proper education, nurses can identifyand stop trafficking, in addition to providingmedical care.22

Migrant nurse contributions are perhapsmost apparent in objectives 15 and 16. Objec-tive 15 discusses “Provid[ing] basic servicesfor migrants.” This portion of the Compactstates that the following is supremely impor-tant: “Promote the implementation of the rec-ommendations of the WHO Framework of Pri-orities and Guiding Principles to Promote theHealth of Refugees and Migrants.”11(p1) Thesepriorities are not achievable without nurses,particularly priority 1: “Advocate mainstream-ing refugee and migrant health in the global,regional and country agendas and contin-gency planning.”23(p1)

Objective 16 seeks to “empower migrantsand societies to realize full inclusion and so-cial cohesion.”11(p1) Migrant participation inthe labor force provides a myriad of benefitsfor the migrant, the migrant community, andthe host country. Migrant nurses contributeto the health and well-being of the migrantand host communities. Healthy migrants arebetter able to work and provide for their fam-ilies. More migrants in the labor force lead toincreased interaction and cohesion betweenthe migrants and host country and potentiallyincrease the economic activity of the hostcountry. The theme of the 2030 Agenda forSustainable Development is “leave no one

behind”; migrant nurses are crucial in thisfight.24

SUSTAINABLE DEVELOPMENT GOALS

The 2030 Agenda for Sustainable Develop-ment outlines 17 specific goals (SDGs) thatthe United Nations has set for the world toreach by 2030. The SDGs were promulgatedin 2015, replacing the Millennium Develop-ment Goals. As indicated in the Figure, theSDGs cover almost every facet of life from“Clean Water and Sanitation” to “Peace, Jus-tice and Strong Institutions.”24(p1) The SDGsand the Global Compacts go hand in hand.The Global Compact for Migration seeks to“empower migrants to become full membersof our societies, highlight their positive con-tribution, and promote social cohesion.”11(p1)

The Global Compact on Refugees seeks to pro-mote self-reliance and equitable burden- andresponsibility-sharing.16 Both Compacts viewmigrant talents and experiences as resourcesthat can be utilized to achieve the SDGs.

NURSING AND THE SUSTAINABLEDEVELOPMENT GOALS

Just as nurses have the potential to achievemany of the Global Compact for Migration’sand the Global Compact on Refugees’ objec-tives, they and their organizations have the

Figure. The Sustainable Development Goals are part of the 2030 Agenda for Sustainable Development,as promulgated by the United Nations.

Nurses in Advancing Global Compacts for Migration and on Refugees 15

potential to help achieve the SDGs.26 Nurs-ing’s most obvious contribution to the SDGsis through “Goal 3: Good Health and WellBeing.” This goal seeks to “ensure healthylives and promote well-being for all at allages.”24(p1) As health care providers, nursesare on the front lines of community healthand primary care. They are also available asfamily planning consultants, advocates for ma-ternal health, and health educators. Nurses’work helps achieve other SDGs as well. Ahealthy population is better equipped to at-tend school, experience reduced inequalities,and focus on SDGs such as achieving “Sustain-able Cities and Communities.”24(p1)

Nursing also promotes gender equity (goal5).24 Nursing is a female-dominated profes-sion. Furthermore, nursing is one of the fewprofessions women are encouraged to pur-sue, as opposed to remaining in the home aswives and mothers. Female nurses are rolemodels for younger generations of women.While nursing is not a well-respected profes-sion in many parts of the world, it is essen-tial for quality health care. Nurses in thesecountries not only provide extremely impor-tant health care but also serve as beacons offemale empowerment.

Nursing is fundamental to the SDGs as awhole. Poverty cannot be eradicated withouthealth care providers. Hunger cannot be sus-tainably eliminated without nutritional educa-tion. Sustainable cities will not develop with-out a strong, healthy workforce. A healthyworkforce leads to the achievement of SDGs,such as caring for life below water and lifeon land. Development is impossible withouthealth. Good health leads to better workers,and increased stability, which reduces thepush to migrate.

NURSES AS FACILITATORSFOR MIGRATION

Nurses are on the front lines in servingthe world’s most vulnerable populations, in-cluding refugees and migrants. As previouslynoted, there are an estimated 262 millioninternational migrants, an increase from

155 million in 2000.8 Women represent 48%of all international migrants.27 Refugee andmigrant populations possess a unique set ofmedical needs. A report on refugee patientoutcomes in Geneva, Switzerland, found thatlanguage barriers and cultural differences be-tween patients and practitioners negativelyimpact the health deliverance outcomes.28

This study found that adequate (interpretive)language services are associated with a higherand more accurate reporting of medical his-tory, past trauma, and mental illness, as wellas an increased level of psychological refer-rals. Similarly, when asylum seekers perceivedtheir communication with nurses to be good,they reported 2 to 3 times as many symptomsas when they rated their communication tobe poor.28

Migrants around the world, particularlywomen and children, are more susceptible toabuses such as extortion, sexual and physi-cal assault, and human trafficking. As previ-ously noted, nurses can help mitigate theseabuses, particularly human trafficking, in sup-port of objective 10. In the case of hu-man trafficking, the nursing profession is in-volved in its prevention throughout the carecontinuum—from initial discovery and identi-fication to intervention and finally to restora-tion of health.29 Nurses are often the firstto encounter victims of human trafficking,whether they are able to identify them or not.In the United States, for example, traffickingvictims often do not speak English, are not fa-miliar with American culture, and are not inthe position to ask for help. In many cases,they are threatened with physical or sexualviolence should they disobey the demands oftheir traffickers.29 The same can be said for mi-grants and refugees who are victims of sexualor physical abuse and extortion. In general,migrants and refugees are incredibly vulner-able and are likely to underplay the abusesthey may have experienced because of fear ofrepercussion or even deportation.

With proper training, nurses can recognizethe unseen and nuanced signs of human traf-ficking and other abuses and then work toaddress them. In an interview with Nursing

16 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2019

Administration Quarterly, Kimberly Will-iams, Program Coordinator for Spiritual Careat Baylor St Luke’s Hospital, offered some ex-amples of red flags that may signal humantrafficking. These include bruising, illness, ortrauma caused by past negligence, a patient’sinability to answer common questions, and apatient’s lack of identification.22 While it canbe painful and traumatizing for a patient to dis-cuss experiences of abuse, nurses are profes-sionally positioned and possess the emotionalsensitivity to identify and treat these victims.

NURSES AS MIGRANTS THEMSELVES

Since its inception, the nursing profes-sion has crossed borders to deliver nursingcare.30 Western nursing methods have beenexported from the developed to the devel-oping world since the 1800s.31 Americanmissionaries shared their nursing practiceswith Korea and China,32 as did British citi-zens with colonies throughout the world.33

During the World War II era, the UnitedStates introduced Western-style nursing meth-ods to the Philippines, which, in turn, becamethe global leader for creating and exportingnurses internationally.34

While international migration continues tointensify, international nurse migration in-creases in tandem. Globally, the demand fornurses has reached unprecedented heightsbecause of factors that include aging pop-ulations, increased health coverage, and in-creases in chronic diseases worldwide. To ad-dress these challenges, many countries arerelying more heavily on nurse migration tofill vacancies and address demand. Nurse mi-grants are highly skilled and have more re-sources and means to migrate than lower-skilled workers. In the United States, FENsmake up between 6% and 15% of the RNworkforce and women represent 83% of thisnumber.35,36 FENs make up an estimated 7.9%of the nursing workforce in Canada, 15.2%in the United Kingdom, 18.3% in Australia,and 26.7% in New Zealand.37 As discussed ear-lier, these nurses are pivotal to advancing the

objectives of the Global Compacts and the2030 Agenda for Sustainable Development.

NURSES AS REFUGEES

While highly skilled workers such as nursesare often the first to migrate in situations ofconflict or natural disaster, they are not al-ways able to migrate. Some become forciblydisplaced and forced to flee their countries,along with other refugees. The case of thesenurse refugees is a topic that has become in-creasingly visible in discussions surroundingrefugees around the globe. Global discoursesurrounding refugees does not typically recog-nize nurses for the educational or professionalcompetencies that they possess. The narrativearound refugees and displaced persons needsto evolve to highlight their skill sets and theirsocial and economic potential. The skills ofnurse refugees should be better leveraged tofurther advance the goals and objectives ofthe Global Compacts. Nurse refugees possessthe cultural, linguistic, and experiential skillsets to serve refugee populations, especiallyin populations from their countries of origin.

The Global Compact on Refugees empha-sizes refugee self-reliance and burden- andresponsibility-sharing, which are particularlypertinent for refugee nurses. The Compactstates that strengthening local capabilities iscritical. Refugee nurses should be particularlyvaluable in serving other refugees in theircommunities. However, because of host coun-try restrictions, refugee nurses experience in-creased difficulty finding employment, evenwith organizations that serve their popula-tions and communities. CGFNS International,Inc, has developed a policy for refugee nursesseeking employment and the dignity of re-turning to the work of caregiving. CGFNS canhelp reconstruct their credentials for evalua-tion purposes when original documentationmay not be available.

The Global Compact on Refugees also liststhe protections refugees require during dif-ferent stages of migration.16 Nurses are nec-essary at each of these stages, particularlyat reception and admission. Refugee nurses

Nurses in Advancing Global Compacts for Migration and on Refugees 17

stationed at the reception/admission pointcan be a comfort to new arrivals and can pro-vide care with a personal sense of understand-ing and compassion born of their own expe-riences. Vulnerable populations have uniquehealth disorders and conditions and requirespecific health care needs. Refugee popula-tions may be more inclined to receive carefrom a fellow refugee health care provider.Often, noncommunicable diseases, such asmental health disorders, are the leading healthissues facing refugee communities. In mostcases, cultural and linguistic competency iskey to delivering adequate care to these pop-ulations. A refugee nurse would be more qual-ified and appropriate to care for refugee pop-ulations than local or foreign volunteer healthworkers. Apart from gains to patient caredelivery, tapping into this labor pool wouldbring desired economic benefits, includingrelief to strained health workforces in hostcountries.

CONCLUSION

The Compacts described in this article arean attempt to holistically address the chal-lenges and opportunities of migration, givencurrent global realities. Nurses have a keyrole to play in advancing these objectivesin a world where migration will continueto rapidly increase. Nurses are migrants indemand and can help shift the often toxicrhetoric around migration issues. They are atthe front lines in helping migrant and refugeepopulations escape poverty or oppressionand then integrate into their new countries.Nurses can use this opportunity and their piv-otal role to advance the core objectives ofthe profession’s advocacy—to support nursesand protect their patients—by ensuring thatnurses’ expertise is embedded in efforts to ap-ply the principles of these United Nations’ ini-tiatives on the ground in both migrant sourceand destination countries.

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