Recruitment of Foreign Nurses Helping Ease Nursing Shortage by Gina Shaw Since the late 1990s, frequent headlines have warned of a burgeoning nursing shortage in the United States. By the year 2020, 44 states and the District of Columbia will face a serious shortage of registered nurses, according to a July 2002 report from the Health Resources and Services Administration. Part of the reason for this is that nurses are retiring at a faster rate than new U.S. nursing school grads can replace them. On average, most nurses in the United States are in their 40s, with that average age expected to reach 45.4 by 2010, according to the American Nurses Association. As older nurses draw nearer to retirement age, the Bureau of Labor Statistics has projected that more than 1 million new and replacement nurses will be needed by 2012, yet the number of nurses sitting for the national licensing exam went down by 20 percent between 1995 and 2003. And a nursing shortage means more than just inconvenience, such as waiting longer to have an IV put in or a dressing changed. The Joint Commission on Accreditation of Healthcare Organizations has found that low nursing staff levels are a contributing factor in 24 percent of p atient death and injury cases. Who will fill the gap? For many hospitals, at least part of the answer lies outside the United States. Recruiting trained nurses from countries such as South Africa, Mexico and the Philippines has become a key staffing tool for hospitals confronting nursing shortages. There are now more than 90,000 foreign-trained nurses working in U.S. hospitals, accounting for about 4 percent of the nursing workforce, and more than 23,000 foreigners took the U.S. nurse licensing examination in 2003 (thatís up from about 20,000 in 2002). In early 2000, St. Louis-based SSM Health Care became one of many U.S. hospitals to send a nurse recruitment team to the Philippines. Nurses trained in the Philippines are particularly attractive candidates for U.S. hospitals because their training and preparation so closely mirror programs in this country. "The nurses in the Philippines are bachelorís-prepared RNs, and theyíre taught with an American curriculum," said Mary Jane Brecklin, SSMís recruitment and retention services coordinator. "While they donít have the same level of medical technology, their health care delivery system is organized in a very similar way to the U.S., so the change of work environment wouldnít be that much of a shock." SSMís four-nurse team spent five days in Cebu, interviewing 90 nurses. They offered positions to 59 of the candidates interviewedóall of whom accepted. But that wasnít the end of the story. Extensive international recruitment requirements eventually meant that only 39 of the 59 nurses Brecklin offered positions to were able to leap the immigration hurdles and come to the United States to practice. In fact, the 39th just arrived in St. Louis at the end of August. But just recruiting a few dozen new nurses from the Philippines, Africa or the Caribbean isnít the end of the nursing shortage dilemma, said Brecklin. "The real work started the minute we left the Philippines. This isnít like you or I accepting a position in the same city or another state," she pointed out. "These nurses are leaving their home, their family, their country of origin, to go halfway around the world to a country theyíve never been to." Hospitals that are successful in recruiting nurses internationally, Brecklin said, see hiring as only part of a much bigger effort to recruit and retain the new nurses. "We were starting from the ground up. Imagine bringing someone to Missouri in January who had never seen snow before," she said. "We developed task forces that focused on things like social integration and lifestyle integration." Although this may sound complicated, in some cases it might mean something as simple as staff members holding "apartment showers" to stock a new arrivalís home with unfamiliar needs like snow shovels. The program seems to be working. So far, every one of the nurses SSM recruited from the Philippines has remained on staff. "Itís been a good experience for us as an institution," said Brecklin. With the National Council Licensure Examination (NCLEX-RN)ówhich is required to practice as a registered nurse in the United Statesóset to be offered for the first time in three locations outside the United States (London, Seoul and Hong Kong) in January 2005, the influx of nurses from abroad seems likely to grow. But as these nurses flow to the United States (and to countries such as Britain, where foreign nurses make up some 8 percent of the workforce), what happens in the countries theyíve left behind? In the Caribbean, for example, the nursing vacancy rate hovers at around 35 percent, according to the Lillian Carter Center for International Nursing at Emory University in Atlanta. Even the Philippinesówhich has long been a primary source for international nurse recruitment, producing many more nurses than it needs in its own health care systemómay be reaching its limit. According to a recent article in Health Affairs, around 30,000 nursing positions in the Philippines remain unfilled, while 85 percent of Filipino nurses are working internationally. In 2001 alone, about a quarter of the nursing workforce in the Philippines left for work elsewhere. Whatís more, recruiting internationally may help to fill the nursing gap in the United States for the short term, but according to "Health Careís Human Crisis: The American Nursing Shortage," a report commissioned by the Robert Wood Johnson Foundation, itís just one of a number of temporary solutions that ultimately will not address the root problem. "We really need to improve and reinvent the profession," said one of the studyís authors, Edward OíNeil, professor of family and community medicine and dental public health, and director of the Center for the Health Professions at the University of California, San Francisco. "I donít want anybody thinking that this is the answer to the shortage. We need to focus more broadly on our institution, our community and our profession," agreed SSMís Brecklin. "For example, weíve put in place many retention-related initiatives and have worked diligently on improving our culture to be more welcoming and more flexible to meet our employeesí needs. The key is working in partnership with your employees." The Robert Wood Johnson report recommends the creation of an independent body, the National Forum to Advance Nursing, to do nothing less than change the culture of nursing in America. Its proposed goals include developing new models of nursing and health care provisions, advancing the study of nursingís contributions to health care outcomes and consumer satisfaction, reinventing work environments and nursing education to address the needs and values of those currently in the profession and appeal to a new generation of nurses, establishing a national nursing workforce measurement and data collection system, and creating a clearinghouse of effective strategies to advance cultural change within the nursing profession. "It would be easy and comfortable to look to the old answers and call for familiar responses such as monetary incentives, but they have not been working that well," said Dr. Steven A. Schroeder, former president and chief executive officer of the Robert Wood Johnson Foundation. "We must re-examine some of our long-held assumptions about the nursing profession and its position within the health care system." Gina Shaw is the medical writer for The Washington Diplomat.