It might pale in comparison to America's appetite for foreign oil and other imports, but U.S. hospitals already are embroiled in a controversy over the growing consumption of another foreign resource: nurses.
The migration of foreign nurses to the U.S., in pursuit of better wages and living conditions, is being blamed in part for a severe shortage of healthcare services in some countries, especially in Africa and Southeast Asia, as more nurses leave their native countries for the promised land. They leave behind hospitals that, in some cases, scarcely have enough nurses to remain open, according to a World Health Organization report.
With more than 400,000 vacant nursing positions projected in the U.S. during the next 10 years, according to federal projections, recruiters are courting nurses in Asia, most notably the Philippines and India, as well as Africa-with some nations now barely able to provide many basic healthcare services because of depleted corps of nurses. In the U.S., 126,000 nurse openings were reported in 2001, or a 13% vacancy rate, according to the Washington-based American Nurses Association, a number that most experts say is only going to climb. But other countries informally reported much higher vacancy rates. Hospitals in countries throughout southern Africa reported vacancy rates of 30% in late 2002.
Proponents of international recruiting say the supply of well-trained nurses abroad is practically endless as nursing schools train students specifically to work in the U.S. Critics, however, believe the practice of bringing foreign nurses to America is merely a cosmetic fix at home and compounds shortages abroad.
The issue is "clearly devastating the healthcare infrastructure" in foreign countries as governments are forced to close hospitals because of a lack of nurses, says Joyce Thompson, a professor of community health nursing at Western Michigan University, Kalamazoo.
Thompson witnessed the exodus from Africa during the past 16 years in her former role as director of a Pennsylvania State University program promoting women's health in Uganda and Malawi. A combination of foreign recruitment and the HIV epidemic, which hasn't spared doctors and nurses, has "decimated" healthcare in Africa, she says.
"It's always difficult (to see) a resource-rich country that hasn't planned appropriately depend on lesser-developed countries to meet their needs," Thompson says.
According to a 2001 WHO report, nursing shortages were reported in many countries throughout the six regions worldwide monitored by the WHO's Global Advisory Group on Nursing and Midwifery, with emigration trends exacerbating the shortfalls. "Nurse migration from less developed to more developed countries is a growing problem that compounds the shortage issue and produces a disproportionately adverse impact on the developing countries with few economic resources," according to the report.
In Zambia, for instance, a major referral hospital that needs at least 1,500 nurses to operate efficiently has only 500 on staff, the report states. Ten years ago in Poland, more than 10,000 new nurses were being graduated annually from educational courses, a figure that fell to 3,000 in 2000. Meanwhile, vacancies in the Netherlands were expected to increase to 7,000 last year from 5,000 in 2000.
The foreign-nurse issue has caught the attention of the ANA, which is pushing the nursing community to examine the reasons behind U.S. shortages instead of depending on overseas labor to correct the problem.
In 2000, the latest year for which statistics are available, nearly 86,000 foreign-born nurses worked in the U.S., representing 4% of the nursing workforce, according to the federal Health Resources and Services Administration. Approximately 4,700 foreign nurses immigrate to the U.S. annually, according to the agency's data.
"We are taking a valuable resource from another country," says Cheryl Peterson, senior policy analyst for the ANA. "At the very least, we are exacerbating the problem of nurse shortages. The healthcare industry in the U.S. has used immigration as a means of addressing the nursing shortage." But that doesn't deal with the reasons why nurses in the U.S. are leaving the profession, she says.
Myra Carmon, president of the Georgia Nurses Association, also believes bringing foreign nurses to America is not solving the domestic nursing shortage. Her organization has signed on with the ANA in recognizing what she says are the adverse effects international migration will have on global healthcare quality.
"We just don't think foreign nurses are the answer," Carmon says. "It is robbing Peter to pay Paul. It does deplete the supply in other places. This is a drastic problem."
Some observers, however, see less altruism in the ANA's position.
K. Bruce Stickler, a healthcare labor lawyer with the Chicago firm Stickler and Nelson, says he believes the association's stance against the recruitment of foreign nurses is "disingenuous."
"This has absolutely nothing to do with their concern over the quality of healthcare in these countries," Stickler says. "It goes back to the economics of the issue." In many cases, foreign nurses have a harder work ethic and put in overtime when they arrive in the U.S., which could be the root of the ANA's opposition, he says.
"I would think the ANA would work to eliminate shortages," he says. "This is truly a smokescreen."
But recruiters find a willing audience when traveling overseas to nursing hotbeds such as the Philippines and India, and African nations such as Botswana and Namibia. They find nurses who are underpaid and looking to make it big in the U.S., recruiters say. Many send a large portion of their earnings back home to family members.
"These countries have to take into account the pay and conditions for the nurses" in their native countries, Peterson says. "There is a reason why these nurses are leaving."
Some recruiters are taking advantage of the situation by lying about wages and other benefits, Thompson contends. Nurses head to the U.S. with illusions of top-paying jobs but are unaware of the reality they face because of a "lack of ethics" among recruiters, Thompson says.
"These nurses haven't been given the full information," she says. In many cases, foreign nurses in the U.S. earn much lower wages than their American peers, she says.
But Carol Fueger, president of Nashville-based Bridge Staffing, says the nurses are coming to an ideal work environment. Foreign nurses' wages and benefits are competitive with new U.S. graduates and they soon make salaries reflective of their experience, she says. After learning U.S. clinical practices and different hospital methods, foreign nurses usually earn salaries comparable to their peers' after about a year in the U.S., she says.
"Nurses in these countries realize that if the conditions weren't right, they wouldn't leave," she says. "I don't think we are exploiting them. They come in at the entry level and very quickly assimilate."
Recruiters spend, on average, about $10,000 to bring a foreign nurse into the U.S., Fueger says. The costs stem from immigration processing fees, assistance to nurses studying for nursing exams and fees involved in verifying nurses' English-speaking efficiency and their educational backgrounds.
Using their visas
The focus on foreign nurses has peaked since the U.S. Immigration and Naturalization Service, now under the auspices of the Department of Homeland Security, gave the nurse-recruiting industry a boost last year by issuing clearer guidelines for using the H1-B visa for nurses.
The H1-B was originally created for high-tech workers with specialized skills who had four-year degrees in their fields. In the past, some nurses, such as nurse anesthetists, were able to come to the U.S. on the H1-B because of their specialized skills. But the federal government has provided guidance for recruiters that allow hospitals and recruiters to bring nurses without four-year degrees to live and work in the U.S. Hospitals act as sponsors for the foreign nurses and guarantee jobs. Nurses can count every three years of experience toward one academic year.
Recruiters who pay an extra $1,000 expedited-processing fee on top of the standard $1,100 fee could have nurses arrive in the U.S. within six weeks under the restated H1-B visa rules. Recruiters who don't pay the extra fees have to wait about six months before landing their nurses, still quicker than the previous 12- to 18-month waits.
Instead of becoming mired in immigration bureaucracy, recruiters will be able to focus on the nurses and make sure they have practical experience and can pass the English proficiency test. Experts say the easing of restrictions is likely to boost recruiting efforts because hospitals will be able to assess their staffing needs without concerns about long immigration waiting periods.
The less-restrictive policies have caught the attention of U.S. recruiters and hospitals looking to fill nursing vacancies.
Their first choice of recruitment is the Philippines, where nursing students are trained in English to land a job in the U.S. In a country where the primary export is foreign labor, recruiters make the pilgrimage with goals of hiring hundreds of nurses during a single visit. The curriculum is similar to the courses taught in U.S. nursing schools, leading to an easier adjustment for those recruited.
Fueger, who recruits about 100 nurses annually from the Philippines, defends the practice. Universities in the Philippines have prepared the nurses well for U.S. careers, she says. The country boasts 171 nursing schools and about 13,000 graduates annually, according to the Philippine Nurses Association of America, which works to promote the welfare of Filipino nurses in the U.S. The association estimates 250,000 nurses from the Philippines have relocated to the U.S. and the United Kingdom since the 1960s.
The Philippines is one country that does not see its nursing ranks depleted by U.S. recruiting because there is an ample supply, she says.
"They have educated more nurses than they can use in their country," Fueger says. "It becomes an acceptable alternative to areas that have vacancies. Somebody has to provide care. Until we have enough nurses, there has to be an alternative."
Carl Shusterman, a Los Angeles immigration lawyer who owns his own practice, says the recruiting trips are a big event in the Philippines, with teams of U.S. hospital representatives attending job fairs at local hotels. The nurses and government leaders know what is at stake--good-paying jobs in the U.S. and the ability for the nurses to send money back home, which boosts the local economy.
"They all want to come to the U.S.; the families are thrilled about it," Shusterman says. "It is a wonderful thing economically."
But the ANA's Peterson contends the constant recruitment in the Philippines is hurting that country's healthcare because the most experienced nurses are leaving the country. Other foreign countries besides the U.S. are looking for the best and brightest nurses the Philippines has to offer, she says. Ultimately, nurses who have a history of poor work performance and little education are left behind to work in local hospitals. "It is a true incidence of brain drain," she says. "They are recruiting the best-educated."
U.S. hospitals, as well as hospitals in the United Kingdom and Ireland, tend to overlook the fact they are depleting nurses from other countries, Peterson says.
St. Vincent's Medical Center, a 528-bed hospital in Jacksonville, Fla., is one of many U.S. hospitals that has recently turned to recruiting in the Philippines. Executives hope the efforts will help offset the facility's 5.4% vacancy rate for registered nurses. The hospital wants to tap into the foreign market at a time when the average age of nurses nationwide is 46 and rising.
"Knowing that most registered nurses move away from the bedside, we want to be prepared with additional recruitment pools," says Jan Lipsky, vice president of organizational effectiveness at St. Vincent's. "We don't want to compete with other hospitals in Jacksonville."
The hospital, which employs 600 registered nurses, has about 40 job offers on the table for Philippine nurses. Another 10 Filipino student nurses receive assistance annually through St. Vincent's affiliation with Daughters of Charity schools in the Philippines, says Lipsky, who oversees recruitment efforts. Those students will fill a pipeline for St. Vincent's.
Lipsky defends her decision to head overseas for staffing needs. She sees the Philippines as a reliable source for nurses. After beginning the recruiting process three years ago, Lipsky anticipates seeing her first Filipino nurse at St. Vincent's in June.
"Their ability to produce more nurses is there," she says. "We are hearing there is a surplus. I do not feel we are creating a depletion of nurses in the Philippines."
Lipsky says she gets a general sense of appreciation from the country's representatives. "The Philippine government looks at recruitment of nurses in a positive light," she says. "It is a good link financially because the nurses are sending money home. There is a real comfort level with this link."
Mark Morales, vice president of planning and placement at Texas Health Resources, Arlington, agrees and called foreign recruitment a "key strategy" at his 13-hospital system. His system employs 3,000 nurses and currently has a 10% nursing vacancy rate. He anticipates bringing 150 nurses from the Philippines to his system in the second quarter, the end result of a process that began two years ago. The system needed to look overseas to help fill the vacant positions, he says.
"The Philippines produces so many graduates that they are just everywhere," Morales says. "It has almost become an industry. We felt confident we didn't go in and rob Peter to pay Paul."
Even as recruiters and hospitals cast their nets overseas for competent nurses, they are pushing for changes in the U.S. to ensure a larger pool of homegrown candidates. Everybody agrees steps must be taken to bolster the nursing ranks locally.
A workforce-planning program that takes a comprehensive census of how many nurses are employed in the U.S. and the number of vacancies would be a good start to determine the industry's needs, Peterson says. "It would lead us to a sensible policy in how many nurses we should be recruiting," she says.
Experts say the industry could get a boost if the image of nursing were portrayed more positively and if there were better global planning. The work starts at U.S. nursing schools. Efforts to hire more faculty members and persuade more students to enroll in nursing school would be just the beginning, Morales says.
Peterson advocates capping the number of nurses the U.S. brings into the country annually. She also says the U.S. should reciprocate by providing educational funding to the nations exporting their nurses to America.
Shusterman says he believes U.S. hospitals will continue to look at the Philippines and other countries for nurses because those countries' supply helps meet the demand. But hospitals should not look at foreign recruitment as the long-term answer, he says.
"It has been a safety valve because hospitals can go somewhere besides U.S. nursing schools," he says. "I don't think we are going to take every last nurse from the Philippines. They will open more and more nursing schools. But if the amount of nursing schools stays static, then there will be a problem."
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