International Nurse Market: Supply Trends and Market Influences Marcia R. Faller, RN, BSN Mimi Hua Published by AMN Healthcare November 2006 This service brief examines the cause and directional flow of current and prospective international nurse migration trends and the role nurse recruitment companies play as intermediaries to facilitate those trends. Areas examined include volume and source countries of international nurses into the United States, migratory trends and international nurse recruitment companies.
EXECUTIVE SUMMARY Volume and Source Country Though reporting methods are limited, we can examine testing numbers, state licensing registrations and U.S. government census data to provide an overview of foreign-trained nurses working and/or immigrating into America. The sample survey of RNs conducted by the U.S. Department of Health and Human Services in 2004 estimates that approximately 3.5% of practicing RNs in the U.S. (equaling 100,791 RNs) are foreign educated. The results of the 2004 survey are consistent with an earlier HHS survey in 2000 finding that 3.7% of practicing RNs (nearly 100,000 RNs) were educated internationally. The 2004 survey also found that 50.2% of these foreign-trained nurses were educated in the Philippines, 20.2% in Canada, 8.4% in the U.K., 2.3% in Nigeria, 1.5% in Ireland, 1.3% in India, 1.2% in Hong Kong, 1.1% in Jamaica, 1.0% in Israel and South Korea and 12% in all other countries (each with less than 1.0%). The NCLEX exam is another indicator for estimating the number of foreign-educated nurses entering the U.S. NCLEX is the exam that must be taken an passed prior to a nurse receiving a license to practice as an RN in the U.S. In the first two quarters of 2006, 9,226 internationallyeducated RNs were calculated to have passed the NCLEX (representing 15% of all those passing). Since 1998, the pass rate of foreign-educated NCLEX candidates has steadily grown from approximately 27% to almost 50% in 2006. Based on the growth of foreign-educated NCLEX passers in the last ten years, we believe that the proportion of foreign-educated nurses to U.S-educated nurses will continue to increase for the foreseeable future. Migratory Trends Nursing shortages in developed countries such as the U.S., the Netherlands, the U.K., and Ireland have fostered increased migration of foreign-educated nurses. In the United States, individual employers, primarily acute care healthcare facilities, are driving international nurse recruitment. In contrast, the U.K. Department of Health, rather than the individual employer, developed the U.K. s explicit national policy to meet the National Health Services staffing growth targets via international nurses. Concerns have arisen over the migratory flow of nurses from developing countries to developed countries. Primarily, there is a question of whether this results in a brain drain effect in the source countries and what working conditions the migrant nurses face during transitions. The foremost cause for nurse migration from developing countries is economic gain. International Nurse Recruitment Agencies Validating the estimated size and market share of international nurse staffing companies is particularly difficult due to the lack of publicly available information. Additionally, the geographic playing field of nurse recruitment agencies can vary from a single region, to a single country to multiple countries. These companies vary in size and in their geographic specialties. The result is a highly fragmented market for international nurse recruitment. Further in-depth research is necessary to obtain a clearer understanding of market size and share. November 2006 Page 2 of 12
INTRODUCTION Foreign-educated nurses contribute significantly to the U.S. nursing workforce. Traditionally they have augmented the workforce during periods of shortage, providing care in hospitals and long-term care facilities in the United States. Nursing in the U.S. offers both challenges and opportunities to nurses educated outside the U.S. Motivation to meet the challenges of migration is high, and the story of the international nurse in the U.S. workforce is generally one of perseverance not only in obtaining a visa and a state license, but in adjusting to living and working in the United States. Globalization and international mobility are expected to continue into the next decade and beyond as nurses educated outside of the United States continue to have a significant impact on the U.S. nursing workforce. Since the migration of nurses across international borders and their assimilation into the U.S. workforce enables nursing to broaden its perspective and increase its diversity, the successful adaptation of international nurses to U.S. nursing practice is critical. 1 Process and Requirements Nurses who decide to immigrate cannot simply apply for U.S. employment there are many steps to the immigration process. Once the decision is made to immigrate, the nurse must obtain an occupational visa to enter the U.S. A common method for international nurses entering the U.S. is via a permanent visa known as a green card. One of the conditions for obtaining a permanent visa is that nurses must have their educational and licensure documents reviewed by the Commission on Graduates of Foreign Nursing Schools (CGFNS). This review protects the public by ensuring that all documents are valid, that their foreign nursing licenses are unencumbered, and that the education is comparable to that of a nurse educated in the U.S. Nursing education programs vary throughout the world. Entry requirements differ, as do curriculum and program length. For example, basic nursing education in the Philippines is at the baccalaureate level. There are few baccalaureate programs in Mexico and the majority of nurses in Mexico receive their nursing education at the secondary school level. Nursing and high school courses are combined, and students enter the program after nine years of schooling usually at age 14. This education is more comparable to that of a practical (LPN/LVN) nurse in the U.S. rather than a registered nurse. International nurses must also complete a screening program and demonstrate proficiency in written and spoken English to obtain their visa. Passing the CGFNS Qualifying Examination (which predicts success on the U.S. licensure examination) is one step in the process that helps to demonstrate that they have mastered the necessary requirements to practice nursing in this country. Proficiency in written and spoken English is demonstrated by passing either the Test of English as a Foreign Language (TOEFL), the Test for English for International Communication (TOEIC), or the International English Language Testing System (IELTS). Foreign educated 1 Davis, Catherine R. and Barbara L. Nichols. Foreign-Educated Nurses and the Changing U.S. Nursing Workforce. Nursing Administration Quarterly. 2002. 26(2):43-51. http:/www.intlnursemigration.org/download/foreigneducatednurses_2002_davis.pdf November 2006 Page 3 of 12
nurses from some English speaking countries are excluded from the requirement to demonstrate this proficiency. Once screening is completed, nurses are interviewed at the U.S. embassy or consulate in their home country or at an immigration center in the U.S. to assure that all visa requirements are met. This process can take anywhere from six months to two years, depending on the nurse s country of emigration. At any point in the process, foreign educated nurses may take and must pass the NCLEX exam, a comprehensive multiple choice exam, to be employed as a nurse in the U.S. Foreign-educated nurses must apply for U.S. licensure in the state where they intend to work. Each state sets its own requirements for licensure. While some states will extend reciprocity to selected international nurses (Canadian educated nurses are a good example) most states require international nurses to take the U.S. licensure examination and the NCLEX exam. This can be a daunting task for nurses educated outside of North America since they are more familiar with essay examinations than multiple choice tests. Only after state licensure is achieved can the international nurse begin U.S. employment. 2 VOLUME Registration and licensing of individual nurses is the responsibility of the state-level nurse registration boards. Each one operates independently, making it difficult to obtain a complete accounting of foreign nurses in the United States. This accounting may be further complicated by up to 15% of foreign nurses having multiple registrations across different states. 3 2000 Survey One national data source consisting of a sample survey of RNs conducted every four years on behalf of the U.S. Department of Health and Human Services reported in 2000 that there were nearly 100,000 foreign trained, U.S. licensed RNs working in the United States, which is approximately 3.7% of the U.S. nursing population. Among the foreign-trained nurses, 86% were working in nursing and 3% were working in other fields, including other health-related occupations. The mean age of foreign-trained nurses 45.4 years for all RNs and 43.8 years for those working in nursing was comparable to those who were U.S.-trained. The dominance of foreign nurse recruitment efforts for hospitals is reflected in their distribution across practice settings: 72% reported working in hospitals (compared with 59% of U.S. trained RNs), followed by 9% in nursing homes and 8% in public health. Of the 26,506 foreign nurses applying for U.S. RN licensure in the last half of the 1990s, 11 countries or areas represent 86% of the applicants as follows: Philippines (32.6%); Canada (22.0%); Africa (7.4%) mainly Nigeria and South Africa; Korea (7.1%); India (5.8%); U.K. (4.4%); Russia (2.2%); Australia (1.3%); China (1.3%); Poland (1.0%); and Jamaica (0.7%). 4 By 2000, the percentages had shifted: the Philippines (43%), Canada (16%), United Kingdom (8%) and India (10%) were the main countries of origin for foreign-educated nurses. 2 Davis, Catherine R. Foreign-Educated Nurses and the Changing U.S. Nursing Workforce. 3 Buchan, James et al. International Nurse Mobility: Trends and Policy Implications. World Health Organization, Geneva. 2003. http://www.icn.ch/int_nurse_mobility%20final.pdf 4 Ibid. November 2006 Page 4 of 12
Preliminary Results from 2004 Survey The 2004 survey estimates that 3.5% (100,791) of the RNs practicing in the United States received their basic nursing education outside the United States, not including the 0.3% (an estimated 9,687) who received their initial nursing education in Guam, Puerto Rico, the U.S. Virgin Islands or in unspecified States and territories. This percentage was about the same as in the 2000 survey. Based on the 2004 survey data, an estimated 5.3% of RNs practicing in a hospital setting are foreign-educated nurses. The countries where the highest proportion of these RNs received their education were: Philippines (50.2%) and Canada (20.2%). A much smaller percent of RNs received their basic nursing education in other countries such as the United Kingdom (8.4%), followed at a distance by Nigeria (2.3%), Ireland (1.5%), India (1.3%), Hong Kong (1.2%), Jamaica (1.1%), Israel (1.0%) and South Korea (1.0%). An additional 12% of RNs received their training in 47 other countries. 5 Source: U.S. Department of Health and Human Services Foreign-educated nurses combined were listed throughout all 50 States and the District of Columbia as the location of their principal nursing position in the 2004 survey. The five states estimated to have the largest percentage of foreign-educated RNs were: California (25.5%), Florida (9.6%), New York (9.3%), Texas (6.7%), and New Jersey (6.1%). An additional 10.8% of foreign-educated RNs did not indicate a state for their principal nursing position. Although their initial nursing education was outside the United States, over half of the foreigneducated RNs were estimated to have baccalaureate or higher degrees (59.9%) and 2% had doctorate degrees. Over 2% (an estimated 2,446) of foreign-educated nurses in the 2004 survey were Advanced Practice Nurses, of whom 65.8% were Nurse Practitioners, 13.1% were Clinical Nurse Specialists, 11.1% were Nurse Practitioner/Clinical Nurse Specialists and 10% were Nurse Managers. Not surprisingly, 68.5% of foreign-educated RNs speak at least one language other than English, most often Filipino (47.9% of foreign educated RNs). Over half of the foreign-educated nurses 5 U.S. Department of Health and Human Services. Preliminary Findings: 2004 National Sample Survey of Registered Nurses. March 2004. http://bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htm November 2006 Page 5 of 12
(54.7%) speak only one language other than English, 12.1% speak two languages, and 1.6% speak three or more languages. A significant number (4.3%) speak Spanish and an almost equal number speak French or an Asian language other than Filipino (3.7% and 3.6%, respectively). Similarly, the ethnic background of foreign-educated RNs differs from that of the general RN population. Over 50% are non-hispanic Asian/Pacific Islanders, including Filipinos, 31.3% are non-hispanic White, 6.7% are non-hispanic Black, and 2.1% are estimated to be Hispanic. In addition, the ethnic background of 9.2% of the foreign-educated nurses was unspecified. 6 NCLEX As Predictor As international nurses must pass the NCLEX exam to practice as an RN in the U.S., the NCLEX is another indicator for estimating the total number of foreign-educated nurses entering the United States annually and their originating countries. It should also be noted that some hospitals and staffing companies have significantly higher pass rates for foreign-trained nurses due to extensive preparation for the NCLEX exam. The tables below contain 2006 information current through Q2. 7 6 U.S. Department of Health and Human Services. Preliminary Findings: 2004 National Sample Survey of Registered Nurses. March 2004. http://bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htm. 7 National Council of State Boards of Nursing. NCLEX Statistics Fact Sheet. June 2006. http://www.ncsbn.org/pdfs/nclex_stats_fact_sheet.pdf November 2006 Page 6 of 12
Source: National Council of State Boards of Nursing November 2006 Page 7 of 12
TRENDS Developed countries such as the U.S., the Netherlands, the U.K., and Ireland have become more active in the international recruitment of nurses. While some recruitment is from one developed country to another (e.g., Canada to the U.S.), the volume of nurse recruitment from a developing country to a developed country is more significant as indicated by the 2004 Department of Health and Human Services survey. Different destination countries will have different mixes of source country nurses. For example, the U.K. and the U.S. are recruiting significant portions of international nurses from low income countries. In contrast, Norway recruits primarily from high or high middle income countries. 8 One should also note the existence of transition countries. These are countries where nurses first migrate to in order to increase clinical and language skills before migrating to a final destination country. This migratory pattern compounds the difficulty in accurately tracking foreign educated nurses. Inflow of international nurses to UK, Norway, Ireland, Victoria State (Australia) and USA with source countries defined by World Bank classifications The key driver in the current growth in nurse migration is active recruitment by some developed countries attempting to address their nursing shortages. The number of source countries from which international nurses are recruited has increased steadily over the years. The U.K. has an explicit national policy developed by its Department of Health to achieve the National Health Services staffing growth targets via international nurse recruitment. In the United States, individual employers are driving international nurse recruitment. The entity driving nurse migration for each country will influence its number of foreign-educated nurses, the level of difficulty for such nurses to migrate and its work environment for the foreign-educated nurses. 8 Buchan, James et al. International Migration of Nurses: Trends and Policy Implications. International Council of Nurses. 2005. http://www.icn.ch/global/issue5migration.pdf November 2006 Page 8 of 12
From the nurses perspective, the primary driver of migration in many developing countries is economic gain. There is widespread consensus that nurses migrate in search of incentives that usually fall within three categories: Improved learning and practice opportunities Better quality of life, pay and working conditions, and/or Personal safety. 9 When considering international migration, there is a delicate balance to be maintained between the human and labor rights of the individual and a collective concern for the health of the exporting nation s population. There is consensus in the literature that trade globalization and the growing lack of skilled labor in rich countries may accelerate a brain drain effect for some time to come. Brain drain occurs when trained and talented individuals emigrate to other nations or jurisdictions due to conflicts, lack of opportunity, or health hazards where they are living. Their departure leaves a gap in human capital in their own country, draining it of resources. The success of interventions to support the positive impact of international migration depends on the level of socio-economic and technological development in each country and a long-term strategy commitment by professional and political leaders. 10 A number of international trade agreements exist that further facilitate international migration through reciprocity. An example of a bilateral mutual recognition is the Trans-Tasman agreement, which enables nurses from Australia and New Zealand to practice in either country. An example of a multilateral agreement is the Directives in the European Union (EU), which enables a qualified registered nurse in one EU country to move to and work in another EU country. The entry of 10 new countries to the EU in May 2004 has made it easier for qualified nurses in these countries to migrate to Western Europe. On the opposite spectrum, changes in the visa requirements (VisaScreen) in the U.S. now require Canadian nurses to complete a VisaScreen where they previously were exempt under NAFTA from the VisaScreen requirement and from taking the licensing exam. 11 The pros and cons of international migration are summarized below: INTERNATIONAL NURSE MIGRATION PROS CONS Educational opportunities Improved quality of life Brain and/or skills drain Cultural sensitivity/competence in care Personal and occupational safety Professional practice opportunities Closure of health facilities due to nursing shortages in a given area Trans-cultural nursing workforce (e.g., racial and ethnic diversity) Better working conditions Global economic development Overwork of nurses practising in depleted areas Sustained maintenance and development of family members in the country of origin Stimulation of nurse-friendly recruitment and contract conditions Loss of national economic investment in HR development Vulnerable status of migrants Improved knowledge base and brain gain Source: International Council of Nurses Personal development Potentially abusive recruitment and employment practices 9 International Council of Nurses. Career Moves and Migrations: Critical Questions. 2002. http://www.icn.ch/careermovesmigangl.pdf 10 Ibid. 11 Buchan, James et al. International Migration of Nurses: Trends and Policy Implications. November 2006 Page 9 of 12
The supply of nurses is also dictating the directional migration of international nurses. Some countries have a surplus of nurses. For example, according to an International Council of Nurses overview paper published in 2000, 44% of licensed nurses in Taiwan were not employed in nursing. 12 In part, this surplus is due to employment patterns and to strategies to educate workers in high-demand occupations. A few western countries, including Spain, Finland and Germany, have also reported a surplus of nurses. In contrast, a supply shortage is far more common for the rest of the world. It is important to note that shortages are estimated based on demand that is supported by what people need and are willing to fund. For example, China, India and Pakistan reported 99, 45, and 34 nurses per 100,000 people respectively, whereas the U.S. reported 972 nurses per 100,000 people. Therefore, a country might report a supply surplus based on its target nurse-to-patient ratio when the surplus would not exist with a higher nurse-to-patient ratio. International mobility of nurses will continue to be a critical issue because global trade in professional services affects the economic value of registered nurses' services, regardless of whether they work in the U.S. or abroad. INTERNATIONAL NURSE RECRUITMENT COMPANIES International recruitment agency models vary (international; single country assisting in nurse export; single country assisting in nurse import) and also function in different ways. Agencies that are international recruit nurses from multiple countries and place them in multiple countries. Those that belong to the single country assisting in outflow model specialize in placing one country s nurses in one or more other countries. The single country assisting in inflow model is the exact opposite where the agency recruits nurses from multiple countries and place them within one country. In some cases, the agency is the initiator; in other cases, it is the facilitator and has a supporting role. 13 Models of recruitment agency involvement in the international movement of nurses Recruitment model Agency provided Agency led Agency facilitated Main features Agency actively recruits nurses on their own behalf for placement in other countries. Employer appoints an agency to identify a source country. Agency takes lead on recruitment, selection and placement, with some input from employer. Employer works in active partnership with agency to identify a source country. Employer is directly involved in selection process, which is facilitated by agency. Employer led Employer uses its own resources to identify a source country, select, recruit and place nurses, and deal with registration and permit issues, etc. Source: International Council of Nurses 12 Baumann, Andrea et al. The International Nursing Labour Market. The Nursing Sector Study Corporation. 2004. http://www.construirelavenir.ca/e/study/phase1/reports/11e_intl_nursing_labour_market.pdf#search=%22internati onal%20nursing%20market%22 13 Buchan, James et al. International Nurse Mobility: Trends and Policy Implications. World Health Organization, Geneva. 2003. http://www.icn.ch/int_nurse_mobility%20final.pdf November 2006 Page 10 of 12
In addition, recruitment agencies act as intermediaries in the process and play a significant role in international recruitment. They often have expert knowledge in recruitment, licensure, education, immigration, and assimilation issues. Agencies both stimulate and ease the process of migration for individual nurses. At times, there have also been reports of unethical behaviors on the part of the agencies and international conventions have been formed to protect the international nurse. 14 While there have been unethical behaviors reported for some agencies, ideally, an international nurse recruitment company offers a number of benefits beyond a competitive wage. Benefits offered may include medical and dental insurance, life insurance, retirement savings package, professional liability insurance, continuing education access, housing assistance, travel reimbursement, NCLEX-RN exam preparation, and cultural acclimation assistance. Agencies may offer one or more of these benefits; their goal should be to aid in the international nurses transition to a foreign country. Validating the estimated size and market share of international nurse staffing companies is difficult due to the lack of publicly available information. Additionally, the geographic playing field of recruiters can vary from a single region to single country to multiple countries. These companies vary in size in their geographic specialties. The result is a highly fragmented market for international nurse recruitment. CONCLUSION Foreign educated nurses are a significant portion of the worldwide nursing workforce. In the United States in particular, expected future nursing shortages will continue to create a pull for international nurses to meet the shortfall. Economic factors continue to make it attractive for foreign educated nurses to find host countries. International nurse recruitment companies are poised to help meet nursing shortages while providing a professionally and economically rewarding work experience for foreign-educated nurses. Marcia R. Faller, RN, BSN, is the Chief Nursing Officer and Executive Vice President, Operations and Mimi Hua is an Operations Analyst in AMN s San Diego office. Copyright 2006 AMN Healthcare. All rights reserved. 14 Buchan, James et al. International Nurse Mobility: Trends and Policy Implications. World Health Organization, Geneva. 2003. http://www.icn.ch/int_nurse_mobility%20final.pdf November 2006 Page 11 of 12
ABOUT AMN HEALTHCARE, INC. AMN Healthcare, the nation's largest provider of superior quality healthcare professionals for temporary and permanent positions, is your total solutions partner for all your clinical staffing needs. Combining nursing, physician and allied health staffing resources, AMN Healthcare offers healthcare staffing across a broad continuum of specialties and assignment lengths. With over 21 years' experience delivering exceptional service and quality, AMN Healthcare is the healthcare staffing industry leader. Based in San Diego, California, with offices in Dallas, Texas; Denver, Colorado; Ft. Lauderdale, Florida; Savannah, Georgia; Atlanta, Georgia; Salt Lake City, Utah; Irvine, California; and Charlotte, North Carolina, AMN Healthcare has built a reputation of excellence on its unique ability to provide thousands of nationally and internationally trained high-quality healthcare professionals. Through its international division, O'Grady Peyton International, the company also has offices in England, Ireland, Australia, Singapore and other overseas locations. AMN Healthcare's nursing and allied divisions are certified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), earning the Gold Seal of approval for the second year in a row. JCAHO Certification acknowledges AMN Healthcare's compliance with the Joint Commission's national set of consensusbased quality standards. CONTACT INFORMATION Marcia Faller, RN, BSN Chief Nursing Officer and Executive VP AMN Healthcare, Inc. 12400 High Bluff Drive San Diego, CA 92130 (800) 282-0300 (toll-free) staffing@amnhealthcare.com November 2006 Page 12 of 12