For more than a decade, the U.S. has faced a shortage of nurses to staff hospitals and nursing homes. While the current recession has encouraged some who had left the profession to return, about 100,000 positions remain unfilled. Experts say that if more is not done to entice people to enter the field - and to expand the U.S.'s nurse-training capacity - that number could triple or quadruple by 2025. President Barack Obama's goal of expanding health coverage to millions of the uninsured could also face additional hurdles if the supply of nurses can't meet the demand.
Some lawmakers are looking to the immigration pipeline as one means to raise staffing levels. In May, Representative Robert Wexler (D-Fla.) introduced a bill that would allow 20,000 additional nurses to enter the U.S. each year for the next three years as a temporary measure to fill the gap. If the bill doesn't pass on its own, lawmakers may include it in a comprehensive immigration reform package. Obama is slated to meet with congressional leaders on June 25 to discuss reforming U.S. immigration laws.
Hospital administrators such as William R. Moore in El Centro, Calif., a sparsely populated town 100 miles east of San Diego, see the Wexler bill as a potential life raft. Moore is chief human resources director at El Centro Regional Medical Center, a 135-bed public hospital that typically has 30 open positions for registered nurses (RNs). While it's hard to lure nurses from nearby big cities (San Diego is 100 miles west), Moore says he could quickly recruit dozens of eager, qualified nurses from the Philippines if the government allocated more visas. "All we want is temporary relief," says Moore. "Let us get a group of experienced RN hires from the Philippines, and we won't ask for more."
Obama begs to differ
Wexler's bill is opposed by labor unions, whose leaders say it would undermine efforts to produce a steady domestic workforce while sapping other nations' nurses. Obama has also expressed skepticism about the idea that the U.S. needs to import nurses, in particular because the U.S. unemployment rate continues to rise. "The notion that we would have to import nurses makes absolutely no sense," Obama said at a health-care forum in March. "There are a lot of people [in the U.S.] who would love to be in that helping profession, and yet we just aren't providing the resources to get them trained—that's something we've got to fix." The $787 billion economic stimulus bill included $500 million to address shortages of health workers in the U.S., with about $100 million to promote nursing and increase capacity at U.S. nurse-training schools.
The nursing shortage has a number of causes, including an aging workforce, difficult working conditions coupled with stagnating pay, and a lack of capacity at U.S. nursing schools. Peter I. Buerhaus, professor of nursing at Vanderbilt University Medical Center, says the recession has eased the nurse shortage in some areas of the U.S. as more Americans seek out the field's relative job security. Some hospitals also see less need for staff as more Americans lose health insurance and fewer people spend money on elective surgery and doctor visits. But Buerhaus estimates that by 2025 the nurse deficit will be twice as severe as the last major staffing shortage in the mid-1960s, after Congress passed the Medicare and Medicaid programs.
As openings have become more difficult to fill domestically, more foreign-born nurses have entered the workforce, most commonly through green cards that allow for permanent residency.
In 1994, 9% of the total registered nurse workforce was composed of foreign-born RNs; by 2008 that percentage had risen to 16.3%, or about 400,000 RNs, according to Buerhaus' research. Of those 400,000 nurses, about 10% had immigrated to the U.S. within the previous five years. About one-third of the increase in RNs from 2001 to 2008 was composed of foreign-born RNs.
Many U.S. nurses choosing not to work
The trend worries leaders of nurses' unions, who say importing workers can lower incentives to improve working conditions. Understaffing, mandatory overtime, and physically demanding work, such as lifting and bathing patients, take their toll. And while pay has risen in some regions to attract more nurses, in recent years it has flattened at the national level. That's why up to 500,000 registered nurses are choosing not to practice their profession—fully one-fifth of the current RN workforce of 2.5 million. Union leaders say the down economy is a chance to bring these nurses back into the field. "If unemployment is spiking, why do we need to bring in nurses from another country?" asks Ann Converso, president of United American Nurses, which represents 50,000 RNs. "We believe thousands and thousands of RNs would rejoin the profession if conditions improved." Converso says she doesn't oppose all overseas recruitment, but that lawmakers' focus should be on improving staffing ratios in hospitals to improve working conditions. "We have to again allow nurses to do what they do best: care for human beings," she says.
Mick Whitley, managing director of London-based global health-care staffing firm HCL International, says there's no need for alarm about foreign nurses. He points out that since 2006 it has become increasingly difficult for foreign-born nurses to obtain green cards to work in the U.S.; an applicant backlog has built up as annual quotas have been reached. "While patients in U.S. hospitals wait and suffer from a lack of sufficient care, experienced and caring internationally trained nurses who want to come here to help are also waiting [for a green card] for as long as seven years," says Whitley, a former nurse in the U.K. and Australia. "It's great that President Obama has committed more money to expanding health care, but the nurses that will be necessary to staff such expansions are nowhere to be found - at least not here, not yet."
Moore of El Centro Regional Medical Center says his hospital has been waiting for two years for 20 Philippine nurses he recruited to obtain visas. He says in the meantime he's unable to find talent in the area. "We're in the poorest and least literate county in California, right in the middle of the desert," says Moore. "We're not a destination for [American] nurses." Moore has had success hiring Philippine nurses, many of whom choose to stay and settle in El Centro. To them the U.S. "is the land of milk and honey, and the streets are paved in gold," says Moore. "They're not so particular."
Moore denies he wants to hire foreign-born talent to hold down wages. "We pay [a nurse] fresh out of school $28 an hour and $35-$40 with experience," he says.
One point everyone seems to agree on is that the U.S. needs more capacity to train nurses. Since 2002, enrollments at nursing schools have increased so much that up to 50,000 qualified applicants are turned away each year from training programs. The main problem is a lack of teaching staff at these schools. Dan Stultz, president of the Texas Hospital Assn., which represents more than 500 Texas hospitals, helped form the Texas Nursing Workforce Shortage Coalition to push for funding from the state legislature to boost capacity at Texas nursing schools. Stultz says the state has about 22,000 nurse vacancies now, and that the number could rise to 70,000 by 2020. Meanwhile, for the last five years, 8,000 to 12,000 nursing-student applicants have been denied places at training programs for lack of space. "We have qualified people that get accepted and can't attend," says Stultz. "We don't need more immigration; we need to increase capacity and grow our own workforce."