TERCERA FASE: Establecimiento de las zonas de valor (Implementación de Qgis

For more than fifty years hospitals in the United States have been importing nurses from abroad (Brush, Sochalski & Berger, 2004; Polsky, Ross, Brush & Sochalski, 2007). In 2004 it was estimated that four percent of the 2.7 million Registered nurses in the United States were foreign trained (Aiken, Buchan, Sochalski, Nichols & Powell, 2004; Xu & Kwak, 2007). This equates to approximately 90,000 nurses. In 2007 a study was undertaken by Xu & Kwak where characteristics of internationally educated nurses [IEN’s] were compared to US educated nurses. Secondary analysis databases from the National Sample of Registered Nurses between 1977 and 2000 found that the average age for IEN’s was 43.7 years which is fairly consistent with all nurses. Twenty six percent of IEN’s came from the Pacific region and were located mostly in urban areas. They also found that the IEN’s were prepared at a higher educational level, more likely to hold more than one job and worked longer hours. Most IEN’s were direct care providers and many worked in Intensive Care Units.

The National Center for Health Workforce Analysis (2010) sends a survey out every four years to a small percentage, approximately one to two percent, of actively licensed nurses in each state of the United States. Part of this survey shows the characteristics and employment of IEN’s. The 2008 survey estimated the number of IEN’s in the United States had increased to over 165,000; 5.4 percent of the current United States registered nurse population. Over a quarter of these nurses had received

their United States nursing license after 2004 however most nurses did not get this US license till four or more years after completing their initial RN training in their own country. A third of the IEN’s were very experienced, having at least ten years of nursing post graduation behind them. Much like the study by Xu and Kwak (2007) found, the nurses were more likely to work in a hospital setting fulltime. Almost 50 percent of the IEN’s were from the Philippines with the second highest percentage, 12 percent, from Canada. India and the United Kingdom were a distant third and fourth. Almost two thirds of the IEN’s were located in California, New York, Florida or Texas.

Polsky, Ross, Brush and Sochalski (2007) maintain the number of foreign born nurses employed in the US grew four times faster than the number of US born nurses during the ten years between 1990 and 2000. In 1990, they noted there were

approximately 113,000 foreign trained nurses and ten years later there were 181, 000. In the same period of time while the majority of the nurses were from Asia, notably the Philippines, the number of Canadian nurses doubled and African nurses tripled (Polsky et al., 2007). Other authors estimate the number of foreign trained nurses in the US now to be closer to 330,000; 12 percent of the nursing workforce (Dumont & Zurn, 2007).

Certainly recent migration inflow figures show a trend towards increasing

diversification of source countries for nurses (Dumont & Zurn, 2007). While decades ago most of the nurse migrants were from Canada and the UK, since the 1960’s there has been a switch in recruitment to the Philippines and other Asian countries (Bach, 2003). More recently there has been a further diversification of source countries. India and the Philippines are still the main countries that supply the US with nurses but there is a definite increase in flow from smaller countries (Dumont & Zurn, 2007). Brush (2008) agrees, citing increased numbers of Chinese, Indian, Arabic, Nigerian, Korean and Kenyan nurses.

In a study for the California Board of Registered Nursing, Spetz, Keane and Herrera (2011) explored the composition of nurses working in California. Out of a potential pool of over 350,000 California certified nurses, a stratified random survey was sent to 10,000 nurses. Of the 6224 nurses that responded to the survey, a response rate of 62 percent, they found that 23 percent were educated outside of the USA. This was a significant increase from previous surveys done since 1990 when 13 percent were foreign trained.

Graph One: Percentage of foreign trained nurses in California

Data from Spetz, Keane & Herrera (2011): California Board of Registered Nursing survey,

This considerable increase in the number of nurses immigrating to the US is driven by a significant nurse shortage. Buchan, Parkin and Sochalski (2003) report the shortfall of US nurses is due to a 40 percent increased demand for nurses with only a six percent increase in supply. This demand for nurses has led to the expansion of organised international nurse recruitment (Aiken, Buchan, Sochalski, Nichols & Powell, 2004; Brush, Sochalski & Berger, 2004; Ross, Polsky & Sochalski, 2005). In 2007 there were 273 United States companies actively recruiting nurses mostly from developing

countries (Pittman, Folsom & Bass, 2010). Fifty percent of foreign nurses are thought to use these recruiting agencies (Pittman, Folsom & Bass, 2010). Significant ‘pull’ factors such as free travel, licensure and room and board coupled with extensive learning and practice opportunities appeal to foreign nurses particularly those from developing countries looking for a better way of life (Brush et al., 2004; Ross et al., 2005).

Prior to 1990 the flow of migrants was predominantly based on familial

connections with a smaller percentage employment based so as not to harm US workers (Lowell, 2001). Lowell notes that the Immigration Act of 1990 increased the overall number of permanent migrants and tripled the number of employment based

admissions while making the transition from temporary to permanent migrant easier. Yearly approximately 65,000 professional workers, which include nurses, may enter on a H1B visa with a six year maximum stay while additional workers from Canada and Mexico are able to easily migrate with the advent of the North American Free Trade Agreement Act (Lowell, 2001).

0 5 10 15 20 25 1990 1993 1997 2004 2006 2008 2010

More recent stringent requirements for licensure and restrictive immigration policies particularly in the last ten years have made it more difficult to enter the US to work as a nurse (Aiken, Buchan, Sochalski, Nichols & Powell, 2004). To ensure safe patient care 80 percent of the US State nursing boards require a Commission Graduate Foreign Nursing Schools (CGFNS) certificate prior to applying to take their state board exams (Davis & Nichols, 2004). This certificate ensures home country credentials are reviewed and a qualifying exam certifies English proficiency and nursing knowledge and proficiency (Brush, Sochalski & Berger, 2004; Singh & Sochan, 2010). It has been proven to be a good predictor of the likelihood that a foreign nurse will pass the State RN

Licensing Board exams (Bach, 2003; Davis & Nichols, 2004).