By Megan Flaherty
Illustration by Malcolm Garris/PhotoDisc
March 15, 1999

The continuing shortage of American nurses is forcing healthcare recruiters to look to foreign-trained nurses on temporary visas to solve staffing problems. But such quick fixes may have unintended long-term consequences for the nursing profession, experts say.

"If a shortage is forming, the knee-jerk reaction is to recruit foreign nurses," said Eleanor Glaessel-Brown, PhD, a consultant at Journeylines in Boston. "This reaction is far from a long-term solution to the problem. You’re not developing a work force that’s there when you need it."

If it’s clear the nation is heading into a nursing shortage, employers and policy-makers will start clamoring for more foreign-trained nurses, agreed Cheryl Peterson, RN, senior policy fellow for international affairs at the American Nurses Association. However, it’s not enough to just allow more foreign-trained nurses to work in the United States, she said. "If we constantly pass legislation that provides short-term fixes to cycles of workforce demands, we never address the real problems."

Shortage strategy

Congress responded to the nation’s last major nursing shortage—in the late ’80s—by passing the Immigration Nursing Relief Act of 1989 to create a special temporary H-1A visa category for RNs. According to Ruth Samardick, a statistician with the U.S. Department of Labor, between 6,000 to 7,000 foreign-trained nurses were granted H-1A visas in each of the four fiscal years from 1992 to 1995.

Even at the height of the shortage, no more than 1 percent of the nurses working in the United States were foreign trained, according to the Department of Labor. Most of those foreign-trained

nurses came from the Philippines, Canada, Ireland, the United Kingdom, India, and China, Glaessel-Brown said.

Since the H-1A program ended in 1995, the number of foreign nurses working in the United States has dropped dramatically. But if another full-fledged nursing shortage transpires, there’s no doubt that

some employers and policy-makers will push for programs similar to the H-1A program, experts say.

NAFTA and the H-1B program

In the meantime, thousands of Canadian nurses are taking advantage of the North American Free Trade Agreement and filling staffing gaps in the United States. NAFTA allows nurses to come to the United States for a year at a time and then apply to renew their visas.

In 1994, 6,821 Canadian nurses came here under NAFTA, and in 1995, an additional 5,234. U.S. nurses can also work in Canada under the agreement, but only 56 U.S. nurses went to Canada to work in 1994, and 41 in 1995, Samardick said.

NAFTA also applies to Mexico, but Mexican nurses generally can’t work in the United States because their education and training is not comparable to that of U.S. nurses, said Barbara L. Nichols, MS, RN, FAAN, chief executive officer of the Commission of Graduates of Foreign Nursing Schools. The CGFNS ensures that foreign-trained nurses who apply for visas have clean backgrounds and meet educational, English-proficiency, and other criteria.

The final vehicle under which foreign-trained nurses can currently enter the United States on temporary visas is the H-1B program. The H-1B program allows nurses with the equivalent of a baccalaureate degree to work in the United States, as long as the position they fill requires a baccalaureate degree. In fiscal year 1997, the Department of Labor certified 736 job openings for H-1B visas, but there is no way of knowing how many of those positions were actually filled, Samardick said.

Lessons learned

Department of Labor studies from the H-1A era have shown that foreign-trained nurses did not take jobs away from U.S. nurses, Nichols said. Foreign nurses worked in urban underserved areas where many American nurses didn’t want to work. They also worked evening or night shifts and often in nursing homes, she said.

Glaessel-Brown interviewed many H-1A nurses in the early `90s, as well as American-trained nurses working side by side with them. "Foreign-trained nurses were by and large very well-trained and had a lot of experience," Glaessel-Brown said. Some communication problems existed, as well as transitional issues that needed to be worked out in terms of equipment and medication. "By and large they weren’t insurmountable problems," she said.

"It appears the presence of foreign nurses didn’t affect U.S. nurses’ wages or responsibilities for the most part," Glaessel-Brown said. "Generally, U.S.-born nurses were very happy to have the help. During the height of the shortage they were very overworked and overwhelmed. They were grateful to have trained foreign nurses come and share in the responsibilities." At the time, U.S.-born nurses felt more threatened by the increased use of unlicensed assistive personnel than by foreign-trained nurses, she said.

Long-term solutions

Regardless of the qualifications of foreign nurses, the only long-term solutions to nursing shortages are for healthcare employers to develop programs—including mentoring and career development—that will make U.S. nurses want to work for them, Peterson said.

If the healthcare industry looked ahead and paid more attention to increasing salaries, providing benefits, offering training, developing career ladders, and attracting young people into the profession, the U.S. nursing work force would stabilize, Glaessel-Brown said.

"The connotation is ‘We need nurses and let’s go get them [from other countries], and then when the demand drops, we can forget about this.’ It gives a harmful message to the profession that this is a disposable work force," Glaessel-Brown said.