global reach of the nursing shortage: The American Nurses Association questions the ethics of luring foreign-educated nurses to the United States, The

Trossman, Susan

It's no secret that there's a nurse-staffing crisis in the United States. An American Hospital Association (AHA) survey of 715 hospitals conducted in spring 2001 revealed that there were as many as 126,000 unfilled registered nurse positions nationwide.

But the RN shortfall in this country is only part of the story. The International Council of Nurses (ICN), a federation of 125 nursing organizations, compiled the following statistics in 2001 to demonstrate the global reach of the nursing shortage. The Netherlands, for example, is predicting a shortage of 7,000 nurses in 2002. Canada will need at least 10,000 nursing graduates each year through 2011 to meet its future needs but is currently graduating only about half that number. A major hospital in Zambia now has only a third of the 1,500 nurses it requires to function effectively. And England reported that approximately 22,000 full-time-equivalent positions nationwide were unfilled as of March 2000.

The international shortage often goes unrecognized in the United States. In what the American Nurses Association believes is a short-sighted approach to meeting staffing needs, U.S. health care facilities-individually and in coalition-continue to urge state and federal lawmakers to ease restrictions in both state regulations and U.S. immigration law to allow a greater influx of foreign-educated nurses into this country. The ANA opposes these proposed changes to immigration law as well as the aggressive recruitment of foreign-trained nurses on both ethical and practical grounds, as do other nursing organizations. At its December 2001 Workforce Forum meeting, the ICN leadership informed ANA representatives that it was close to releasing guidelines that address the ethics of international recruiting during a global shortage.

Robbing Peter to Pay Paul?

"The ANA is not anti-immigration. We believe every qualified nurse has the right to seek employment in the United States, just as we believe U.S. nurses should have the same opportunity to practice in any other country of their choice," said ANA president Mary Foley, MS, RN. "What we object to is the practice of luring highly skilled nurses from South Africa, India, and other countries that depend greatly on these health care practitioners' skills and talents, to work in health care facilities here."

Virginia Nurses Association (VNA) member Rebecca Rice, EdD, MPH, RN, agrees, saying that the United States is pivotal when it comes to the shifting of the worldwide nursing workforce, primarily because higher wages are offered here.

"When we have a nursing shortage and ease our immigration laws, what we're doing is stealing nurses from other countries," said Rice, chairperson of the Legislative Coalition of Virginia Nurses. "What happens in those countries when the brain drain occurs?"

The ANA also is concerned about the exploitation of foreign-educated nurses once they begin working in health care facilities that have sub-standard working conditions. Many employers know that foreign-educated nurses will not speak up about poor working conditions or unfair treatment.

While testifying about the nursing shortage before the U.S. House of Representatives Committee on Health, Education, Labor, and Pensions, Foley cited several examples of problems that occurred when employers used immigrant nurses. In one case, the Immigration and Naturalization Service-Chicago District issued a $1.29 million fine against a health care management company that fraudulently obtained 225 visas to employ Filipino nurses as lower-paid nurse's aides instead of as registered nurses.

And finally, the ANA believes that bringing in foreign nurses doesn't address the underlying problem that drives shortages-nurses' deteriorating working conditions.

"Registered nurses are leaving hospitals in droves because they are forced to work long hours and short staffed," Foley said. "The ANA and its constituent member associations [CMAs] are more than willing to work with the hospital industry to improve working conditions and stabilize the nursing workforce."

The Foreign-Educated Nurse Pool

According to Cheryl Peterson, MSN, RN, senior policy fellow in the American Nurses Association's practice department, there are three main ways that foreign-educated nurses can get permission to enter the United States to practice: permanent visas, for those who want to become residents of the United States; temporary visas, for those who are here to work only for a specified time; and under negotiated trade agreements, such as the North American Free Trade Agreement.

The H-1C visa, for example, is a temporary visa that is specific to nursing; however, the number of these visas made available each year is limited to 500 and those who enter the United States with such a visa can practice only within designated health professional-shortage areas. Only 14 hospitals nationwide currently meet the Department of Labor's requirements for these visas.

The Philippines and Canada account for the largest number of foreign-educated nurses entering this country. Nurses from the United Kingdom, Ireland, and India also practice here in substantial numbers. Peterson added that currently, the INS does not have the ability to accurately count and monitor the number of nurses coming into the country, so it is very difficult to get accurate data on the number of foreign-educated nurses practicing here.

To be eligible to practice in the United States, foreign-educated nurses entering on temporary or permanent employment-based visas must go through a screening process, which includes a predictor examination that forecasts their likely performance on the National Council of State Boards of Nursing's licensure examination (NCLEX), English proficiency testing, a review of the nurse's educational preparation comparing it with the standard U.S. curriculum, and a check of the nurse's license in her home country to ensure that it's valid and unencumbered.

Legislative Efforts

On the national front, the ANA is fighting passage of the Rural and Urban Health Care Act of 2001 (S 1259 and HR 2705). This legislation would dramatically expand the existing H-1C temporary nursing visa program established in 1999 and strip away workplace protections for foreign-educated nurses that the ANA fought to include in the original law.

In South Carolina, nurses are fighting a bill that would allow Canadian nurses to practice in the state without having to pass the NCLEX. "The Canadian nurse bill is a tricky bit of business," said South Carolina Nurses Association (SCNA) executive director Judith Thompson. "The hospital administrators who pushed their senators to introduce the bill are in a world of hurt. They can't hold on to their staff, because hospitals in neighboring Charlotte, North Carolina, have better pay scales."

The SCNA and the state board of nursing both object to the legislation on several counts and have testified against its passage at two state hearings, she said.

In Virginia, an effort is underway to allow nurses from Canada to become licensed in the state simply by endorsement, according to VNA executive director Jan Marshall Johnson, MS, RN. The VNA previously was successful in changing a legislative measure that would have allowed foreign-educated nurses to work in nursing homes without a license for 180 days. Instead, they can work only 90 days, the same as new U.S. nurse graduates.

Other Strategies

As a member of the ICN, the ANA helped develop that organization's soon-to-be released ethical guidelines on international recruitment. Closer to home, the ANA has been promoting its stance on immigration law to members of Congress, the Bush administration, and the American Hospital Association, which all support the increased employment of foreign-educated nurses. Foley is a member of the AHA Workforce Committee that's currently developing recommendations to address the nursing shortage.

The American Nurses Association has been lobbying for the passage of one federal bill that would ban mandatory overtime and another that would ensure continued funding for the Nurse Education Act, by which awards are granted to students willing to practice in designated shortage areas. Further, the ANA has been working with its State Nursing Associations to push health care facilities to adopt the ANA's "Principles for Nurse Staffing," which are aimed at ensuring high-quality patient care.

The ANA also backs the implementation of 16 recommendations developed by a 1988 presidential task force to counter the nursing shortage. They include strategies such as collecting better data on the economic contribution nurses make to health care facilities and giving nurses a voice in governing their workplaces.

"The health care industry must stop its laissez-faire approach to planning its staffing needs now and in the future," Foley said. "We don't want more nurses to leave the profession in frustration or have young people refuse to consider nursing as a viable career. We also don't want to take nurses away from countries that are struggling to provide care to their own people. Consumers of health care and nurses worldwide deserve better."

by Susan Trossman, RN

Susan Trossman, RN is the senior reporter for the" American Nurse", a bi-monthly newsletter of current nursing trends and issues provided free to all dues paying members of the American Nurses Association / Nevada Nurses Association.

Copyright Nevada Nurses Association Feb 2003
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