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Is Recruiting Foreign Nurses the Answer?

Vol. 1 •Issue 5 • Page 22
Is Recruiting Foreign Nurses the Answer?

The scope of the nursing shortage has changed the rhetoric surrounding the practice

By Timothy A. Mercer

Photoilustrations by Tom Centola

With the shortage of nurses worsening across the United States, many health care providers are stepping up their recruitment efforts on foreign shores. The practice is not new. But it is being viewed differently in the context of the current nursing shortage – considered an international dilemma.

In the United States, concerns over the shortage have politicians scrutinizing immigration policy in an effort to make the passage of foreign nurses into the country less burdensome. But many are concerned that foreign recruitment is a shortsighted solution that might have a negative effect domestically and abroad. Finding a way to respect individual labor rights while not contributing to the current staffing dilemma has proven to be a difficult task.


Foreign recruitment is an important tool for some facilities, according to Alain Bois, RN, nurse manager of the children/adolescent psychiatric services at Northern Maine Medical Center in Fort Kent. A native of New Brunswick, Canada, Bois said the facility's close proximity to the Canadian border has helped it weather the nursing shortage thus far.

"We have felt the nursing shortage, but we have not felt it as much as we might have because of the Canadian nurses," he said. "We are very close to the border, and we have many nurses who still reside in Canada and work here.

"It has been a good crutch for us," Bois said, " because we are very remote, and usually people who graduate from the local nursing program want to go to a bigger city. So it is hard to attract nurses graduating from the nursing schools."

Judy Jones, MS, RN, vice president for nursing administration at Parkland Memorial Hospital in Dallas, said her facility recruited foreign nurses during the nursing shortage of the late 1980s. And although one might expect some reticence from American nurses working in facilities where foreign recruitment is practiced, Jones said she has not experienced any backlash.

"Acclimating new nurses is the real issue," she said. "Our nurses are always happy to see new nurses, and they welcome helping hands. What we have found is that the new nurses need time to settle in. Support groups are needed; a buddy is needed; they have to purchase everything from scratch. They really start out in the negative as far as possessions go, and transportation is often an issue as well."

However, despite Jones' experiences, a recent unscientific online spot survey by ADVANCE for Nurses revealed that many American nurses do not support foreign recruitment. Nearly 60 percent of the respondents said they unequivocally are against recruiting nurses from outside the United States, with or without a nursing shortage.

Bois said there has been some hostility toward his "angels" from the Great White North. "When I started here there was a campaign to get a union in the hospital, and that was the time that I felt that the most, the coldness between the Canadian nurses and the American nurses," he said. The common perception in such cases, Bois surmised, is that foreign nurses are coming in to take jobs from American nurses. "But that is not it at all," Bois said. "They are simply stepping up to the plate because no one else will."


Hospitals dealing with the national shortage of qualified nurses are literally scouring the earth to find the talent they need to maintain necessary staffing numbers. A report in the May 4 edition of the Atlanta Business Chronicle stated that Tenet Healthcare Corp. hopes to recruit nurses from Northern Ireland to help staff hospitals in the Southeast.

But hospitals that have turned to foreign recruitment are running into immigration hurdles that did not exist during the last nursing shortage, in the late 1980s. In May, hospital CEOs testified before a Senate subcommittee on behalf of the American Hospital Association (AHA) regarding the flexibility of immigration policies in the United States. Specifically, health care providers want Congress to reinstate the H-1A visa program, which would enable foreign nurses to work temporarily in the United States.

Carla Luggiero, JD, RN, the AHA's senior associate director for federal relations, said the H-1A program was a pilot program that ended in 1995, and it was the favored method for recruiting foreign nurses. The H-1C visa, which she said was established after the H-1A, is too restrictive and limits the number of nurses who can come in under its wing and what hospitals they go to. And most immigration tools open to hospitals today take too long for facilities that need help in the short term, Luggiero said.

"We can help ease the situation in some hospitals through foreign recruitment," Luggiero said, "particularly those facilities that are having problems, like rural hospitals and inner city hospitals."

Parkland's Judy Jones says another visa available to nurse recruiters, the H1-B, is problematic as well. "One of the things is that the people coming in under the H-1B have to have is a bachelor's degree. But that is not a minimum requirement for staff positions at many facilities, and staff positions are the hardest to fill right now."


But changes to the management of health care systems worldwide have complicated foreign nurse recruitment. Bois said he is starting to see the pool of nursing talent in Canada shrink a bit. Ten years ago, changes in the government's funding of health care restricted entry-level nursing jobs in Canada, he said, sending many Canadian nurses to the States. Now, a reinvigorated health care system has Canadian hospitals hiring again. And since Canada, like the United States, is facing an ongoing shortage, facilities like Northern Maine Medical Center are seeing less interest from nurses looking to emigrate.

And that is perhaps the primary difference between this shortage and the shortage of the late 1980s. This time around, the crisis is a global health issue. A recent study by the University of Pennsylvania suggests that nursing around the world has been hit hard by cost-cutting initiatives. A team of researchers conducted surveys of 13,471 acute-care hospital nurses in the United States; 17,450 in Canada; 5,006 in England; 4,721 in Scotland; and 2,681 in Germany during 1998 and 1999. They found that despite differences in health care delivery systems, all countries were dealing with many of the same issues, including a lack of nursing satisfaction and concern about providing quality patient care.

"It was striking the same types of problems in countries that have very different health care systems," said Sean Clarke, PhD, RN, assistant professor at the University of Pennsylvania and associate director for the Center of Health Outcomes and Policy Research.

"No matter what country you look at, where there have been active efforts to rein in the cost of hospital care, nursing has borne the brunt of those cost-cutting efforts. And what it translates into is nurses in all these countries are showing similar levels of dissatisfaction, "concern about staffing and the responsiveness of administrators to reports of problems, concern about quality of care, and burnout levels."

The study found:

• As many as half of the registered nurses reported a decline in the quality of patient care provided in their hospital within the previous year and no more than one-third judged the care provided on their units as excellent.

• Two-thirds of nurses say there aren't enough nurses in their hospitals to provide adequate quality of care to patients.

• In four of the five countries, including the United States, approximately 40 percent of the hospital nurses reported being dissatisfied with their current jobs; the comparable statistic for professional workers in the United States at large is 10 percent.

• Burnout levels are high and significant numbers (at least one in five of all nurses and one in three nurses under 30) indicated they intended to leave their jobs within the next year.

These types of statistics have led to criticism of the techniques used by health care professionals to retain new nurses, including foreign recruitment. Specifically, concerns have been raised as to whether foreign recruitment actually masks the larger problems facing health care providers – the need to change the work environment of the typical RN.

Immigration lawyers representing hospitals and recruitment firms are pushing for opening up immigration policies, Dr. Clarke said, but there are ongoing debates between advocates of increased immigration, people against such a move (largely nurses' unions and representatives from the countries themselves) and lawmakers.

"Those in favor of allowing more foreign-trained nurses in say yes, we can use as many nurses as are willing to come, while those against warn that bringing nurses from other countries is a band-aid solution with potentially negative consequences both for the countries who are losing them and in the long run, for North American hospitals.

"I think we have to look at what is making hospitals such noxious places to work, to put it bluntly, and remedy those problems so that all nurses working in hospitals – whether they trained here or abroad – will stay, instead of looking for the easy fix."

Others agree, including the International Council of Nurses, which issued a position paper addressing some of its concerns regarding recruitment policies. "Massive recruitment campaigns for foreign nurses have been initiated by some governments and private agencies," according to the statement. "These campaigns delay effective local measures that would improve recruitment, retention and long-term human resource planning.

The policy statement also states that some recruitment agencies follow "unethical methods of work that prevent informed decision-making on the part of the recruited nurse." It goes on to state, "discriminatory treatment [e.g. pay, working conditions] may occur between national and foreign nurses and between foreign nurses from different countries."

Indeed, there seems to be reason for concern in this regard. In August, Reuters Health reported on a case highlighted by England's Royal College of Nursing involving five Filipino nurses. The nurses reportedly signed contracts with a nursing home before coming to the UK last year. But upon their arrival, the nursing home changed their employment contract and slashed their initial salaries.

The RCN also told Reuters it has come across cases of foreign nurses being threatened with deportation or legal action if they broke their contracts, and some nurses reportedly were asked to pay large sums of money to recruitment agencies in return for jobs.


Other emerging economic trends make the current shortage stand out from past staffing dilemmas. A background paper written for the International Council of Nurses in Switzerland by Per Godtland Kristensen, international secretary for the Norwegian Nurses Association, suggests that current migratory trends of nurses could create new ethical dilemmas regarding nursing recruitment. Kristensen maintains that increased professional migration raises concerns about the discrepancies between individual labor rights and ethical practices in a global economy.

"Employment migration is not a modern phenomenon," he said. "People all over the world, including nurses, have been migrating in search of work for ages – inside countries and across borders. What is new is that employment migration seems to be on the increase, at least as far as professionals, including nurses, are concerned."

Globalization and the emergence of regional trade agreements are fueling this change in professional migration, Kristensen said. "We have been used to imports and exports of material goods for generations. Now we experience a new development: The import and export of services, regulated by the World Trade Organization's General Agreement on Trade in Services."

Kristensen goes on to identify three driving forces behind movement or migration: individual choice, exchange programs and active recruitment. It is the last of these factors, he said, that when abused poses a threat to stabilized health care across the globe.

"I think we all agree that the individual choice has to be respected," he said. "I think we also agree that exchange programs are of mutual benefit É Neither shall I oppose employers' rights to recruit nurses from other countries. But the right to recruit does not mean that a country should recruit aggressively. That is a fairly new trend, and it does not reflect any fair competition."

This trend tends to benefit richer nations at the expense of poorer nations, Kristensen said, a situation that is likely to worsen given a climate of globalization.

"This trend is likely to grow in line with developments of the General Agreement on Trade in Services. It is not likely to create a "win-win" situation. The wealthier countries will gain, while the poorer countries will lose. Massive recruitment is likely to increase the burden in many countries, which already have a problem. In some countries it will even come on top of a decreasing nursing work force É"


Most of those familiar with the current nursing shortage agree that foreign nurse recruitment is not going to go away, nor should it. But they also agree that it should not be considered a solution to the shortage, the roots of which are buried in the dirt of management policies and rising patient acuity.

While the AHA and others continue to push for continued easing of immigration restrictions, Luggiero said they know they are pushing for a short-term solution. "We need both a short-term and long-term approach," Luggiero said.

The ICN puts the aegis for change squarely on management and health care officials, as well as government. "Management and compensation practices greatly affect the severity of nursing shortages, particularly in health institutions," according to a position statement.

Also, "In many countries, the career structures for nurses are inappropriate. Some governments have failed to address the identified problems relating to hours of work, ongoing education, re-entry programmes, staffing levels, attitudes of administrators, security, housing and day care services."

Jones of Parkland categorized foreign recruitment as a tool to help cope with current conditions. "There are some things in nursing we need to address," she said. "Salaries are going up, but the working conditions for nurses in hospitals remain an issue. So I think that foreign recruitment is most specifically a tool to help us manage in the shortage."

But the sobering results of the University of Pennsylvania's study suggest that the problems hospitals face could get worse before they get better, Dr. Clarke said.

"[The Center's] position is that foreign nurses can help meet some needs in the short term but in the long term, we need to attend to the fundamental climate issues in hospitals and assist nurse leaders in addressing them," he said.

"Nurses' concerns are fundamentally about the quality of care, the impact on the patients – not just themselves," Dr. Clarke said. "And I think nurses fundamentally know what kind of resources are needed in a hospital, and where you get into trouble is when management for various reasons can't or won't respond to what nurses believe is necessary."

Timothy A. Mercer is assistant editor at ADVANCE.


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