National nursing home trade associations call for increased immigration as key to solving their shortages in nursing staff. See LeadingAge’s recommendations to the Senate here, American Health Care Association’s letter to CMS Administrator here, and Center Alert here. Not true.
A new article in Health Affairs, “Why International Recruitment Won’t Solve The US Nursing Staffing Crisis,” recognizes that recruiting internationally educated nurses (IENs) “will not, . . . , solve the underlying problem of poor management practices that result in high nurse turnover rates and contribute to the current staffing crisis” in the United States. It suggests that to believe IENs “would accept the same subpar working conditions that are causing US-trained nurses to leave clinical practice in US health systems is offensive . . . [and] has deep roots in racism, xenophobia, and sexism.” Moreover, the potential pool of IENs is about 8,663, a small fraction of the estimated 203,200 nursing vacancies nationwide. The authors suggest that nursing facilities improve working conditions to retain current workers.
The article identifies multiple challenges that show why reliance on IENs to relieve nursing shortages makes little sense. First, it elaborates on issues of racism, xenophobia, and sexism:
It is racist and xenophobic to assume that IENs—most of whom belong to racial and ethnic minoritized groups and have different heritage from US nurses—would tolerate substandard working conditions because they are “foreigners.” It is sexist to assume that immigrant women, who constitute the majority of IENs, would accept poor working conditions when their US counterparts would not. Nurses, regardless of their countries of origin, quit their jobs because they have been mistreated and undervalued. Given the persistent anti-immigrant sentiment in news headlines, which frequently depict a society that is openly hostile to immigrants mainly from racial and ethnic minoritized groups, why would they choose to work in such a country?
Next, the article describes structural barriers that make hiring IENs difficult:
- Less than half the IENs are passing nursing licensure examinations, compared to 86% of U.S. trained bachelor degree graduates.
- Getting a work visa or employer-based green card requires IENs to have a bachelor’s degree. This requirement reduces the potential pool of IENs to 8,663.
- Even though providers are exempt from conducting a “test of the labor market” before hiring registered nurses and physical therapists, the green card process for IENs takes from one to six years.
- “Unethical recruiters” have used “punitive multiyear contracts” that violate U.S. employment law. A federal judge in New York held that a facility violated the Trafficking Victims Protection Act because of the liquidated damages provision in the nurses’ contracts. See discussion of Paguirigan v. Prompt Nursing Employment Agency LLC in this Alert.
The article makes five recommendations:
- rewarding health care organizations with high retention rates for U.S. workers;
- designating nursing as a Science, Technology, Engineering, and Mathematics (STEM) field in order to make it easier for IENs to qualify for an H-1B visa;
- focusing international recruitment on populations speaking languages other than English, in order to reflect local patient populations in the U.S.;
- requiring organizations that hire IENs ‘to have culturally humble transitional education programs to support nurses during their first two years of work in the U.S.;”
- leveraging the skills of as many as 20,000 “‘hidden’” IENs who already reside in the U.S. but have not become credentialled here.
The article concludes that although IENs are vital to the health care system in the United States, they are not a sustainable solution: “It is like trying to use a Band-Aid to stop a hemorrhaging wound – it may provide temporary relief, but it will not work in the long run.” Instead, the article recommends focusing on “retaining the existing workforce while also creating more equitable and accessible pathways to employment for IENs.”
May 18, 2023 – T. Edelman