Patricia Pittman

U.S.-Based Recruitment of Foreign-Educated Nurses: Implications of an Emerging Industry

ObjectivesDespite an increase in the number of foreign-educated nurses (FENs) working in U.S. hospitals and nursing homes, very little is known about the industry that brought them here. Our objectives were to learn more about the size and scope of the international nurse recruitment industry, its business models, and the range of countries where companies actively recruit. Based on reports from focus groups of FENs in New York City, we also sought to identify some of the problems that have occurred in the areas of contracting and clinical orientation. MethodsWe used a combination of qualitative methods and secondary data sources, which included U.S.-based international nurse recruitment company Web sites, interviews with 20 executives from international nurse recruitment companies, two focus groups with FENs in New York City, and letters sent to the Philippine Nurses Association of America by FENs seeking legal advice. ResultsThrough a July 2007 Internet search, we found that at least 273 U.S. companies were actively recruiting FENs. While most such companies focused on the Philippines and India, about 20 companies were active in Africa. (A second search revealed that, as of January, at least 211 U.S. companies were actively recruiting FENs abroad.) Within the industry there is growing use of the staffing-agency model, which typically requires nurses to sign 18-to-36-month contracts and imposes high breach-of-contract fees. The focus group discussions with FENs in New York City revealed inadequate orientation programs and several types of labor abuses. ConclusionsConcerns about recruitment practices, which were expressed by many industry executives and FENs, reveal the need for accountability within the industry. KeywordsForeign-educated nurses, recruitment, migration, labor rights, voluntary code of conduct

Health insurance coverage in Central and Eastern Europe: Trends and challenges

Health insurance systems in Central and Eastern Europe have evolved in different ways from the centralized health systems inherited from the Soviet era, but there remain common trends and challenges in the region. Health spending is low in comparison to the spending of pre-2004 European Union members, but population aging, medical technology, economic growth, and heightened expectations will generate major spending pressures. Social health insurance is the dominant model in the region, but coverage is uneven. Key3reform issues include identifying ways to encourage additional investment in the health sector; and defining formal benefit packages, copayments, and the role of private insurance.

Residency programs for new nurse graduates: How widespread are they and what are the primary obstacles to further adoption?

OBJECTIVE: The objective of this study was to determine the prevalence of hospital RN residencies and the associated factors. BACKGROUND: The 2010 Institute of Medicine/Robert Wood Johnson Foundation report, The Future of Nursing: Leading Change, Advancing Health, recommends the adoption of nurse residency programs. METHODS: Members of the American Organization of Nurse Executives were surveyed, and covariates were identified. RESULTS: We found approximately 36.9% of all hospitals in our study offered a nurse residency in 2011. Associated covariates included not-for-profit status, midsize, and location in the South. Hospitals that offer residency programs were more likely to have other training programs. CONCLUSIONS: Findings suggest that residencies have been widely supported even in times of economic recession. It is important to track the expansion of these programs and to initiate research to examine the long-term impacts of residencies on nurse retention and clinical outcomes.

Immigration and contract problems experienced by foreign-educated nurses

More than 8% of employed RNs licensed since 2004 in the United States were educated overseas, yet little is known about the conditions of their recruitment or the impact of that experience on health care practice. This study assessed whether the labor rights of foreign-educated nurses were at risk during the latest period of high international recruitment: 2003 to 2007. Using consensus-based standards contained in the Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Health Professionals to the United States, this study found 50% of actively recruited foreign-educated nurses experienced a negative recruitment practice. The study also found that nurses educated in low-income countries and nurses with high contract breach fees, were significantly more likely to report such problems. If, as experts believe may occur, the nursing shortage in the United States returns around 2014, oversight of international recruitment will become critically important to delivering high-quality health care to Americans.

The changing roles of registered nurses in Pioneer Accountable Care Organizations

OBJECTIVES This study focuses on whether and how Pioneer Accountable Care Organization (ACO) leaders believe the deployment of the registered nurse workforce is changing in response to the shared savings incentives. METHODS Semistructured phone interviews with leaders from 18 of the original 32 Pioneer ACOs were conducted. RESULTS Narrative analysis suggests that all of the organizations are developing new and enhanced roles for registered nurses across the continuum of care. Overall, eight types of changes were reported: enhancement of roles, substitution, delegation, increased numbers of nurses, relocation of services, transfer of nurses from one setting to another, the use of liaison nurses across settings, and partnerships between nurses coordinating care in primary and acute care settings. CONCLUSIONS This exploratory study suggests that Pioneer ACO leaders believe that payment models are affecting the deployment of the health workforce and that these changes are, in turn, driving outcomes.

Community Health Centers Employ Diverse Staffing Patterns, Which Can Provide Productivity Lessons For Medical Practices

Community health centers are at the forefront of ambulatory care practices in their use of nonphysician clinicians and team-based primary care. We examined medical staffing patterns, the contributions of different types of staff to productivity, and the factors associated with staffing at community health centers across the United States. We identified four different staffing patterns: typical, high advanced-practice staff, high nursing staff, and high other medical staff. Overall, productivity per staff person was similar across the four staffing patterns. We found that physicians make the greatest contributions to productivity, but advanced-practice staff, nurses, and other medical staff also contribute. Patterns of community health center staffing are driven by numerous factors, including the concentration of clinicians in communities, nurse practitioner scope-of-practice laws, and patient characteristics such as insurance status. Our findings suggest that other group medical practices could incorporate more nonphysician staff without sacrificing productivity and thus profitability. However, the new staffing patterns that evolve may be affected by characteristics of the practice location or the types of patients served.

The future of nursing: monitoring the progress of recommended change in hospitals, nurse-led clinics, and home health and hospice agencies.

OBJECTIVE: The objective of this study was to assess the implementation of recommendations of the Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health. BACKGROUND: In 2010, the IOM made a series of recommendations aimed at transforming the role of nurses in healthcare delivery. METHODS: We conducted a multiyear survey, in 2011 and 2013, with nurse leaders who were members of the American Organization of Nurse Executives, the National Nursing Centers Consortium, or the Visiting Nurses Association of America. RESULTS: When comparing 2013 to 2011, we find progress in instituting the IOM’s recommendations in 3 areas: (1) raising the proportion of employed RNs with at least a bachelor’s degree; (2) expanding the proportion of healthcare institutions with nurse residency programs; and (3) offering opportunities for continuing nurse education CONCLUSIONS: Our findings suggest that healthcare organizations are transforming to support the recommendations of the IOM.

Original research: Perceptions of employment-based discrimination among newly arrived foreign-educated nurses

Objective To determine whether foreign-educated nurses (FENs) perceived they were treated equitably in the U.S. workplace during the last period of high international recruitment from 2003 to 2007. Background With experts predicting that isolated nursing shortages could return as soon as 2015, it is important to examine the lessons learned during the last period of high international recruitment in order to anticipate and address problems that may be endemic to such periods. In this baseline study, we asked FENs who were recruited to work in the United States between 2003 and 2007 about their hourly wages; clinical and cultural orientation to the United States; wages, benefits, and shift or unit assignments; and job satisfaction. Methods In 2008, we administered a survey to FENs who were issued VisaScreen certificates by the Commission on Graduates of Foreign Nursing Schools International between 2003 and 2007. We measured four outcomes of interest (hourly wages, job satisfaction, adequacy of orientation, and perceived discrimination) and conducted descriptive and regression analyses to determine if country of education and recruitment model were correlated with the outcomes. Results We found that 51% of respondents reported receiving insufficient orientation and 40% reported at least one discriminatory practice with regard to wages, benefits, or shift or unit assignments. FENs educated in low-income countries and those recruited by staffing agencies were significantly more likely than other FENs to report that they receive inequitable treatment compared with their U.S. counterparts. Conclusions These findings raise both practical and ethical concerns that should interest those striving to create positive health care workplace environments and to ensure staff retention. Health care leaders should take steps to ensure that FENs are, and perceive that they are, treated equitably.

Nursing workforce education, migration and the quality of health care: a global challenge

Throughout the world, the supply of skilled nurses is notoriously volatile, with major shifts into and out of the workforce as economies fluctuate. In the USA, Staiger et al . [1, 2] believe that the current surge in new registered nurse (RN) graduates will only partially alleviate future shortages. They predict that when the US unemployment rate drops to 6.5%, large numbers of nurses will retire or return to part time work leading to a return of regional shortages. They further suggest that the unprecedented expansion of health-care insurance coverage beginning in 2014 under the US Affordable Care Act of 2010 will likely increase the demand for nurses just as the supply is declining. Shifts in the US nursing labor market affect the nursing workforce in many other countries. Like many developed nations, during nursing shortages the USA turns to international recruitment. As the last 7-year nursing shortage began to wane, fully 12.2% of newly licensed nurses in 2007 were foreign educated, according to the National Council of State Boards of Nurses. During those years a major constraint on international recruitment was the country visa caps, which led to a backlog of nurses awaiting visas in countries like the Philippines and India. However, US immigration reform in 2013 may remove these caps enabling tens of thousands of foreign-educated nurses (FENs), who are already pre-approved for visas and waiting in the queue, to emigrate to migrate to the USA [3]. The volatility of the international demand for nurses likely has major implications for the quality of care in the USA and in sending nations. In destination countries, research to date clearly demonstrates that more nurses are better. Years of research has shown that lower nurse-to-patient staffing ratios …

Alternative Approaches to the Governance of Transnational Labor Recruitment

As globalization advances, the governance challenges relating to cross-border labor recruitment have also grown. Transnational companies that manage the employment-based migration process often take advantage of individuals seeking work abroad. While some states have implemented recruitment regulations, a combination of jurisdictional constraints and economic interests have limited states’ capacity and political will to take action. Supplemental strategies are emerging led by international organizations, non-governmental organizations (NGOs), labor unions, and corporate trade groups. This paper reviews the strengths and weaknesses of strategies led by each of these different types of actors and explores potential synergies among them.