By Paul Clark, James Stewart and Darlene Clark
Most of the news coverage of the immigration bill recently passed by the U.S. Senate has focused on initiatives that would strengthen border security, establish a guest worker program and provide a form of amnesty for undocumented immigrants. Virtually unnoticed in the bill was a provision that would make it easier for foreign nurses to immigrate and work in America's health care system.
The purpose of this provision, according to its authors, is to help reduce the nursing shortage currently facing our country by making it easier to recruit nurses from abroad. Unfortunately, this policy represents a band-aid approach to the serious nursing shortage we face and distracts employers and policy-makers from addressing the fundamental problems behind the shortage—the difficult working conditions nurses face every day on the job. In addition, recruiting nurses from less affluent nations that are grappling with their own shortage of nurses does great damage to developing countries' health care systems that struggle to provide even basic care to their citizens.
Anyone who has spent time in a hospital knows that registered nurses play a critical role in the provision of medical care. Nurses represent the single largest occupational group in health care and because of the extensive time they spend with patients, they are at the heart of the care delivery system.
In recent years, the U.S. health care system has faced a significant shortage of nurses. Hospitals, in particular, have been unable to find sufficient nurses to fill their needs. As of April, U.S. hospitals had 118,000 openings for RNs. The number of vacant positions is expected to grow to 275,000 by 2010, and to more than 800,000 by 2020.
Despite these numbers, we do not really have a shortage of qualified nurses. What we have is an insufficient number of nurses willing to work under the very difficult working conditions they face in our hospitals. In 2000, for example, there were nearly 500,000 nurses not working in health care; many more than would be needed to fill every position in every health care facility in this country. While some nurses choose to stay at home and raise families, others work in fields ranging from real estate to education to retail sales. In a great many cases, they do so because they believe current conditions in our hospitals prevent them from providing optimal, or even adequate, care to their patients.
Many observers believe this problem can be traced back to the implementation of managed care in the 1990s. Under this approach to health care, HMOs and insurance companies forced providers such as hospitals to continually cut costs. The hospitals, in turn, tried to squeeze more productivity from their nurses by reducing staffing levels and requiring fewer nurses to care for more patients. All too often, nurses argue, this understaffing has resulted in poorer care that, in the worst case scenario, puts patients at risk. Eventually, the day-to-day stress and guilt of working under these conditions caused nurses to begin leaving the health care field.
Unions, where they represent RNs, have made progress in addressing the issue of understaffing. However, in nonunion hospitals, nurses have little voice in decision making and must either continue to work short-staffed or leave. Many choose to leave.
And, of course, nurses leaving the workforce results in a chain reaction by increasing the shortage, which in turn, puts additional pressure on the nurses that remain, causing even more to leave.
Bringing nurses from abroad, or even educating more nurses here, without addressing the root causes of the nursing shortage, will have the same effect as sticking a finger into a leaky dike. It may help in the very short term, but in the long-term, disaster awaits. The focus on the recruitment of nurses from overseas further weakens the collective ability of nurses to seek improvements in working conditions. Immigrants are less likely to challenge employers because of their tenuous residency status. This willingness to accept employment on whatever terms are offered enables employers to place additional demands on the health care workforce, which will, in turn, accelerate the departure of domestic nurses from the profession.
In addition to diverting attention from a central cause of the nursing shortage, encouraging the immigration of overseas nurses does substantial damage to the health care systems of poorer countries. Virtually every developing country has a much more substantial shortage than we do. The latest available statistics indicate that in the United States there are 937 RNs for every 100,000 people. Among the nations from which we currently recruit, the Philippines has 169 nurses per 100,000 people; China has 105; Mexico, 90; and India, 80. In English-speaking African nations, the ratios are often even lower. For example, Zimbabwe has 72 nurses per 100,000 population and Liberia has 18.
Not only are these countries deprived of the services of valuable health care professionals when nurses emigrate, but since the education of nurses is funded by the government in these countries, poor nations also lose the investment they have made in the nurse workforce.
And, if we are serious about helping the developing world fight AIDs, malaria and other epidemics, we need to understand that no matter how much funding affluent countries pour into regions of the world where these diseases are rampant, our efforts cannot be effective if the health care professionals required to provide care are not in place.
So what should we do to address the nursing shortage? First, we need to stop poaching nurses from other countries as a means of reducing the shortage we face here. The immigration legislation now under consideration in Congress would have the opposite effect. Second, we must understand that while we need to get health care costs under control, saving money by cutting back on nurse staffing levels is counterproductive. Third, our health care system needs to treat nurses like the professionals they are by providing better pay and working conditions and by respecting their right to form unions. And fourth, we need to expand nursing education programs in the United States. If we make nursing an attractive and rewarding career and provide educational opportunities for people interested in the profession, it will attract the compassionate, concerned individuals we desperately need.
………….…………………….………….…………..
Paul Clark and James Stewart are faculty members at Penn State University's Department of Labor Studies and Industrial Relations and Darlene Clark is a faculty member in the School of Nursing at the university. They address the issue of nurse immigration and recruitment in more detail in “The Globalization of the Labor Market for Health-Care Professionals,” International Labor Review, volume 145, numbers 1-2, 2006, pp. 37-64, available at .
