Bridges or Barriers
Will new certification rules for foreign nurses protect patients or intensify staff shortages?

By Lorraine Steefel, RN, MSN, CTN
July 19, 2004

Every day, some 500 of 2,500 nurses at the Henry Ford Health System, Detroit, cross the Canadian border to work. A new ruling by the Department of Homeland Security (DHS) that requires visa certification for foreign nurses who work in the U.S. may change this for Henry Ford and other border facilities. Is the new ruling a hardship for foreign nurses, a serious patient safety concern, or a measure of patient protection?

As the transition period for this new ruling comes to an end, discussions about its merits and drawbacks are heating up.

The new view

“The law isn’t new,” says Phyllis Kritek, RN, PhD, FAAN, immediate past-president of the Board of Trustees of the Commission on Graduates of Foreign Nursing Schools (CGFNS). Kritek says that the Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA), aimed at controlling illegal immigration, dates back to 1996. What’s new is the final ruling that DHS made last year regarding how to carry out the IIRIRA.

Under the new rule, nonimmigrant nurses who enter the U.S. after the date of the ruling, July 26, 2003, but before July 26, 2004, would have a year from entry to produce a visa certificate from a DHS-approved agency, such as CGFNS. Nurses already here before the ruling date would have until July 26, 2004, to produce the certificate. After that, whenever nurses ask for an extension or leave and want to return to the U.S., they must have a certificate in hand. Previously under the Trade NAFTA, nonimmigrant nurses from Canada or Mexico who worked in the U.S. were exempt from visa certification.

Border sites

Canadian nurse Joyce Farrer, RN, MSN, ED, director at Henry Ford Hospital, Detroit, sees the new ruling as a hardship, voicing what many of her Canadian staff nurses ask: “Why go through the process especially after working in the states for years?”

“VisaScreen, the program that CGFNS initiated after IIRIRA was passed in 1996, is a long, often frustrating process,” says Farrer (see sidebar for more information).

At a time when U.S. health care facilities are recruiting in Canada because of the nursing shortage, it’s hard to understand the timing of a rule that might slow down foreign nurse recruitment or discourage Canadian nurses from coming here or staying.

“The new ruling doesn’t take into consideration the effect on the border states,” says Maureen Henson, SPHR, Henry Ford director of recruitment strategies. Henson believes that Canadian nurses who currently fortify border health care facilities, many of whom have worked in the U.S. for years, are caught short. “Hardest hit will be cities like Detroit, Buffalo, and Seattle,” she says.

Colleagues at facilities in southeastern Michigan are trying to assess the possible impact of the new ruling. At Henry Ford, where about 20% of nurses are Canadian, Henson estimates that the greatest impact would be in the ED, ICU, and OR. “Though confident that we would not close areas, we might have to redeploy staffing,” she says.

Heading off workforce woes

Hoping to leverage influence over the issue, Henry Ford and area colleagues mustered political support by writing to Michigan Gov. Jennifer Granholm and U.S. senators. They and nursing groups wrote to Secretary of Homeland Security Tom Ridge requesting an extension of the July deadline.

On behalf of the National Council of the State Boards of Nursing (NCSBN) president Donna Dorsey, RN, MS, FAAN, told Ridge that “10,000 to 15,000 nurses who have been licensed and practicing in the U.S. since 1997 will be unable to provide health care because of the retroactive implementation of the rule.”

Dorsey added, “This is a serious patient safety concern for our citizens based on the evidence of medical errors related to short staffing.”

The American Organization of Nurse Executives urged Ridge to delay the final rule for at least 18 months. CEO Pamela Thompson, RN, MS, FAAN, wrote that the screening is required of nurses currently employed by U.S. hospitals who have been viewed professionally competent by the state in which they practice.

In agreement with AONE, the American Hospital Association voiced its concern that certification is redundant for foreign health care workers currently licensed to work in a state who have passed a state licensing exam and for alien health care professionals educated in the U.S. The new rule “will exacerbate the current shortages and the impact on hospitals affected by this rule could be operational problems that result in the closure of beds and the inability to provide safe and quality nursing care,” according to the AHA.

The rule also applies to physical therapists, occupational therapists, speech-language pathologists, audiologists, medical technicians, medical laboratory technologists, and physician assistants.

Opposing views

“The ANA believes that to protect people seeking health care in the U.S., all foreign-educated nurses need to meet the basic screening requirements spelled out in this rule,” says Cheryl Peterson, RN, MS, senior policy analyst for the American Nurses Association.

The ANA acknowledges the difficulty it may cause for some Canadian nurses already in the U.S. However, the group opposes a delay, noting that the IIRIRA was originally passed in 1996.

“The DHS, concerned about how the new ruling would affect health care facilities, already granted a one-year transition period for nurses to start the certification process,” she says.

“The issue is protection of the public at a time of high mobility of nurses.”

CGFNS says its job is to protect the public by helping nurses meet U.S. expectations regarding competency. “The CGFNS is recognized by statute as a credentialing organization qualified to certify that foreign health care workers are competent to provide health care services to U.S. health care consumers,” says CGFNS CEO Barbara Nichols, RN, MS, DHL, FAAN. To facilitate VisaScreen certification, CGFNS implemented new technology upgrades. The CGFNS and the International Commission on Healthcare Professions cosponsored a series of educational forums about the new ruling in 12 major cities in the U.S. and Canada for recruiters, nurse executives, and other major stakeholders.

Canadian nurses may see a positive side to the issue. Though visa certification signals the end of reliance on U.S. endorsement (no exam) licenses, it also means that these nurses may be able to take advantage of employment opportunities previously denied to them. Some 80% of employment opportunities were never available to Canadian RNs who depended on endorsement states for employment options.1

Farrer says many of her staff at Henry Ford Hospital are in the VisaScreen process. “The hospital is supportive and is reimbursing nurses the $325 CGFNS application fee,” she says. As the July deadline approaches, Henson says that the Henry Ford Health System is preparing to implement contingency staffing plans, but the real concern is for the long-range effects.

Lorraine Steefel, RN, MSN, CTN, is a senior staff writer for Nursing Spectrum.

Reference
1. Canadian Nurses. Procare USA. Available at: www.procareusa.com/canadian-nurses. Accessed May 25, 2004.