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 preapproved 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 save lives [4]. In the poorest sending nations, exploratory research suggests that massive out-migration has had a negative impact on quality [5, 6]. On the other hand, some nations, such as the Philippines and India, purposely overproduce nurses with the intent of promoting migration and increasing remittances. Understanding the impact of this ‘export model’ on quality of care in sending nations is a complex research challenge that has yet to be seriously undertaken. Returning to the question of how international nurse recruitment affects the quality of care in the USA, Felber and Aiken’s study in the period of 2006–07 is the first to examine the impact of additional FENs under varied conditions. Their study offers a point of departure for research on the relationship between international recruitment patterns and the quality of care in the USA and in other countries. The authors find that among hospitals with inadequate nurse staffing ratios, high reliance on FENs, in particular over 25% FENs on staff, is associated with higher rates of mortality and failure to rescue. They offer as one possible explanation that hospitals with adequate staffing ratios are better able to supervise FENs. As with all research that attempts to associate a certain class of worker with outcomes, it is especially important to be cautious about policy conclusions in advance of fully understanding the causal pathways that may be at play. The key challenge of this study is potential sample bias, be that at the level of hospital variation, including management styles, or the FEN population itself. We know, for example, that FENs are not a monolithic group. Indeed, it is possible that the circumstances of their recruitment and integration into the USA could be an even more important factor than the fact that they were born in, and received their nursing education, in a country other than the USA. Since the central independent variable of this study is ‘foreign educated’, let us begin with variation in nursing education among countries. The conceptual model assumes that nursing education in Canada, Philippines, India, South Korea and Jamaica, just to name a few of the countries that account for a high level of nurse migration, may be radically different from that in the USA. Interestingly, however, when the authors controlled for being Canadian, they found no effect on their results. Since the Canadian’s nursing education system is probably the most similar to the USA [7], the question arises as to whether other specific countries should be included in the model. Or perhaps something else is driving the observed differences. I would argue that ‘time in the Unites States’ could be a critical variable for at least two reasons. First, based on the American Community Survey, we know that more than two-thirds of foreign-born nurses that entered the USA after age 21 are US citizens [8]. Presumably FENs who are US citizens are different from those who recently arrived; they are likely to be better acclimated to the US health-care system, and differences in culture and language are likely mitigated.