Nursing Shortage in the United States

Literature Review

            The current nursing shortage has stirred significant interest among healthcare professionals and there are several researches on different aspects of the problem. Relevant studies investigating this health crisis are presented here to provide vital information concerning the shortage of nursing staff in different areas of health care delivery. Similar studies involving nursing shortages in the past are also reviewed in order to draw correlations with the recent shortage. These studies help identify the important factors affecting the decrease in nurses working in different hospitals throughout the country as well as the different strategies employed by various agencies to address the problem. Finally, the implications of these strategies in relation to the quality of patient care and patient outcomes are discussed based on the results of the reviewed literature.

The shortage of qualified candidates available for nursing staffs is a worldwide issue; however, today’s challenges to fill the ever increasing void appear to be more dramatic than in previous years. The U.S., like the rest of the world, is experiencing a severe shortage of nurses. There exists an abundance of literature concerning the shortage of nurses and the possible, and perhaps necessary, solutions to be implemented to address this complex issue.  Sincere efforts are required in order to focus on the issue of recruitment and retention of healthcare professionals.

Historical Perspectives

The first schools of nursing in the United States were created during the Civil War because of difficulty in finding enough adequately trained nurses to provide patient care (Donahue, 1985). Shortage of nurses was again created by the dramatic growth spurred increased by the “Hill-Burton Act in 1946 and advanced medical care during the World War II (Andrews & Dziegielewski, 2005). The first time Federal funds were made available to increase the supply of nurses after passing ‘The Nurse Training Act’ of 1964 (Nurse Training Act, 1964). Since then demand for more health care, nurses, and therefore fund and labor resources followed by the cyclic shortages in each decade.

Nursing shortages have been cyclical events during the 1970s, 1980s, and early 1990s (Knox, Irving, & Gharrity, 2001). The Nursing discipline has witnessed two decades of decreased enrollments of students in schools of nursing. For example, in the 1980’s, there existed a marked decrease in nursing program enrollments, which led to decreases in faculty position (Brendtro and Hegge, 2000). When enrollment rebounded in the early 1990’s, many programs were not able to recruit full-time faculty and clinical staff nurses, since they found other opportunities and positions in nursing and other professions (Hinshaw, 2001).

In 1998, hospitals across the U.S. began to encounter a shortage of registered nurses (RNs) in various hospital departments. Initially, the shortage was experienced mainly in the intensive care units and operating rooms. However, by 2000, the shortage spread to the general medical wards and other surgical units (Buerhaus, Staiger, & Auerbach, 2000; Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2005). This was reflected by a 2000 survey conducted by the U.S. Department of Health and Human Services (DOHHS), which found that there was a shortage of 110,000 full-time-equivalent (FTE) registered nurses (RNs) during that year.  By 2005, the nursing shortage remained, despite an 8 percent increase in the number of licensed RNs between 2000 and 2004, which was estimated to 2.9 million RNs and an increase in employment of nurses to more than 83 percent of active RNs (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2005). It is projected that the shortage will continue to grow to approximately 275,000 RNs by 2010 and will almost triple this figure to 800,000 FTE RNs by 2020 (DOHHS, 2002). The Bureau of Labor Statistics, however, predicted that in 2012, the U.S. would be in need of more than 1.1 million new RNs in order to meet the increasing demand for health care (2004).

            These projections may vary among different studies but the increasing trend of the shortage is clear and there is no sign that the shortage will end anytime soon. Already, different facets of health care delivery are affected. In 2001, the national average hospital RN vacancy rate was estimated at 13% and nearly one-fifth of hospitals reported vacancy rates averaging over 20% (AHA, 2001). Studies indicated that varying rates of job vacancy for nurses in different hospital departments were reported, with the highest rate including those in medical and surgical care (16.3%), critical care (15.5%), and emergency care (15.2%) (Andrews, 2005; AHA, 2006). At the current rate of the nursing shortage, it is estimated that by 2020, there will be 400,000 RNs vacancies in hospitals (Murray, 2002). Health care delivery outside the hospitals such as nursing homes and other home health care providers are not spared from the shortage. According to General Accounting Office (GAO) report in 2001, nationwide serious staff vacancy rates (average about 10.2%) exist in hospitals, nursing homes, and home health care agencies (American Organization of Nurse Executives (AONE), 2002).

Factors Affecting Nursing Shortage

            A broad variety of factors have been identified which lead to the shortage of nurses in the U.S. These include an aging population, the educational system, nurse satisfaction, increased professional opportunities outside of nursing, and changes within the healthcare delivery system (AHA, 2002; Hart, 2001; Kimball et. al., 2002; and Buerhaus, 2000). These factors can be grouped into two main factors. First, there is the decrease in enrollment of students into nursing schools, which curtailed the supply of new nursing graduates to the constantly growing demand for qualified nurses. The second factor is the increasing turnover rate of staff nurses hospitals and other health care facilities due to growing number of registered nurses leaving the profession for various reasons. Different issues surround each of these two main factors and different strategies have been used to address these issues to resolve the nursing shortage.

Decreasing Enrollment Rates in Nursing Schools

There are several factors that influenced the decline of nursing school enrollment. The low unemployment rate and increasing career opportunities to women are among these factors (Murray, 2002; Nevidjon, 2001). Historically, nurses were predominately females who were unable to exercise autonomy over their education because of a lack of political and financial resources, and because of their male counterparts in medicine and hospital administration (Manley, 1995). Although the Council on Graduate Medical Education (COGME, 1996) had projected a nearly eight-fold increase in women entering the medical profession between 1970 and 2010, the number of those entering nursing is declining.  Fewer female candidates have been choosing the role of nurse or educator over the past decade as other professional opportunities (e.g. lawyer, doctor, engineers) have become more available to females (Booth, 2002).  The study by Staiger, Auerbach, and Buerhaus (2000) revealed that over the last 20 years, women graduating from high school were 30% to 40% less likely to pick nursing as a career than women who graduated in the 1960s and 1970s.

            The nursing shortages in the past also lead to more opportunities for nurses in various positions in nursing and other professions, which decreased the number of faculty nurses. In the early 1990’s, despite a rebound in nursing enrollment, many programs were not able to recruit full-time faculty and clinical staff nurses (Hinshaw, 2001). This appear to also hold true at present as the number of nurses pursuing an associate degree in nursing has increased by 13% but only 29% of graduates receive their basic nursing education in baccalaureate programs (Andrews, 2005). According to the American Association of Colleges of Nursing’s (AACN) website, a recent survey indicates that enrollment in entry-level baccalaureate nursing programs has increased by 5.0 percent from 2005 to 2006.  Although this is encouraging, surveyed nursing colleges and universities also reported that they have turned away more than 32,000 qualified applicants, primarily due to a shortage of nurse educators. This is alarming for the AACN as the nursing shortage is expected to intensify in the next few years, the supply of new nurses will have to come from somewhere outside the nursing colleges in the U.S.

            The current nursing shortage can also be traced to events of the 1990’s, as many healthcare futurists then were predicting that intensified managed care programs will eventually lead to a reduction in the number of hospital beds (Nevisdjon, 2001). The Pew Health Professions Commission published a series of reports with recommendations to reduce the number of nursing education programs by 10-20%, due to the advent of managed care (Andrews, 2005; Schwirian, 1998). Managed care also discouraged hospital admissions for all but the most seriously ill patients, and Medicare tighten the controls on spending on hospital services.  This made it difficult to meet the payroll demands associated with maintaining an adequate workforce (AHA, 2001). During 1994-1997, RN employment, which had shown accelerated growth since 1983, slowed by almost a half (Andrews, 2005).

Increasing Turnover Rates of Nurses

Nursing turnover remains a financial concern to public as well as private institutions, and impact on staff morale and working practices of the organization (Cavanagh & Coffin, 1992). Although turnover rates in the USA have stabilized due to recent economic conditions, RN turnover remains problematic in many countries (Fisher, Hinson, & Deets, 1994). Many researchers agree that turnover disrupts the input/throughput/output cycle of organizational production, problem of organizational control, dislocation costs for training and team building reduces production efficiency. On the other hand, turnover rate at moderate levels infuses “new blood,” introduces fresh ideas, and keeps the organization from becoming stagnant (Alexander, Bloom, & Nuchols, 1994, p. 505). Nursing turnover may affect production efficiency in several areas such as cost of recruiting and orienting replacement nurses, cost of recruiting agency nurses, reduced efficiency of team-based care on patient care units, and administrative costs of supervising new nurses (Alexander, 1994).  Two factors consistently surface as reasons for turnover among hospital nurses: dissatisfaction with working conditions and compensation (Andrews & Dziegielewski, 2005; Chandra, 2003; Upenieks, 2006).

Job dissatisfaction. According to Hart (2001), the top reason (56%) nurses leave patient care (besides retirement), is to seek a job that is less stressful and less physically demanding.  This study found that about 68% of nurses working in the field reported low morale in the workplace, and 55% of them indicated job dissatisfaction as a primary reason for changing careers. Furthermore, 53% of the currently employed nurses and 70% of nurses who had considered leaving were dissatisfied with lack of input on decisions which affected them.

Further research on job satisfaction indicated that career stage was one of the key factors for job satisfaction and dissatisfaction (Andrews, 2005).  Over 60% of nurses reported that they were dissatisfied with the very little difference in the pay scale of RNs with more experience compared to those with less experience.  The lack of reward for experience gave skilled nurses little justification to stay on the job, leading them to change their position to gain a higher salary in another facility or occupation (Reineck & Furino, 2005).

A U.K. study which included 462 nurses and 162 allied health professionals has shown that there are high level of satisfaction for both nurses and allied health professionals taking on innovative roles in the workplace (Collins et al., 2000). The key contributors were increased freedom and autonomy, being able to manage their own caseloads, and increased responsibility. These are regarded as features of an exemplary workplace in the nursing literature (Upenieks, 2005). Appropriate training was also related to job satisfaction, probably by enhancing perceptions of confidence and control (Collins et al., 2000). Other factors associated with job satisfaction were integration into the professional groups, collegial relationships, and heightened prospects for career advancement. Despite the positive impact of the expanded professional roles, a small but significant proportion of nurses expressed a desire to change careers if possible. This dissatisfaction was typically related to job stress and inadequate compensation in relation to the increased responsibilities. Thus the innovative roles produced mixed results, contributing to factors that both increase and undermine job satisfaction and commitment.

Among both current and former nurses, understaffing was identified as being the biggest problem of increasing stress and overwork, forcing them to leave the profession for better careers (Hart, 2001). For every patient over a 4:1 ratio, the odds of nursing burnout increased by 23% and job dissatisfaction by 15%, both of which lead to higher turnover rates and an increased shortage of nurses (Atencio, Cohen, & Gorenberg, 2003).

A 2002 report issued by the Joint Commission on Accreditation of Health Care Organizations (JCAHCO) stated that three-quarters of nurses want staffing increases, along with decreased in paperwork and administrative tasks (Atencio et al., 2003). Garretson (2004) considers inadequate staffing a major cause of low morale among hospital RNs. She argues that, “lack of morale is, and will continue to be, a driving force in nurses’ decisions to leave the profession” (p. 34). Inadequate staffing undermines nurses’ ability to provide high quality patient care. This situation is self-perpetuating since it intensifies staffing problems and patient issues and drives morale even lower.

To assess the extent of the problem, Garretson (2004) conducted a review of research from Europe and North America. The review produced both quantitative and qualitative evidence strongly supporting the need to increase hospital nurse-patient ratios. The comments of young nurses suggest that they entered the profession with idealism yet were quickly becoming disillusioned by the realities of excessive workloads and rapid turnover. Veteran nurses decry a dramatic decline in care quality. Based on the composite picture, Garretson drew four major conclusions. First, increasing the number of patients a nurse cares for on each shift raises the risk for poor patient outcomes, nursing errors, and lengthier hospital stays. Second, inadequate staffing ratios may be a major reason for low morale thus a more favorable nurse-patient ratio may facilitate better recruitment and retention. Third, a number of states are considering mandating designated nurse-patient ratios using minimum rather than maximum rates. Finally, while decreasing the number of RNs may seem cost-efficient, in the long run it may raise expenses due to turnover costs and patient complications and extended hospital stays.

Massachusetts is of the states that seek to mandate nurse-patient ratios. A 2005 survey of Massachusetts physicians sponsored by the Massachusetts Nurses Association disclosed that 82% of doctors agree that nurse understaffing undermines care quality (Atkinson, 2005). Reinforcing the severity of the problem, 78% of the respondents considered RN staffing levels in hospitals inadequate. Furthermore, 20% of the sample implicated nurses’ are being burdened with too many patients as a direct cause of patient deaths.

Roughly three-quarters of the physicians (74%) favored legislation mandating minimum nurse-patient ratios (Atkinson, 2005). More than 60% viewed such action as cost effective in simultaneously reducing the costs of nurse turnover and patient complications. Research into staffing levels and patient infection rates support that claim. In addition, one study reported that approximately one-third of former hospital patients and their families felt that care quality was compromised to at least some extent by a lack of available RNs.

Representatives of Massachusetts RNs (including a state legislator who is also a nurse) emphasize that nurses are the cornerstones of quality hospital care (Atkinson, 2005). It is interesting to note that Massachusetts actually has the highest proportion of nurses of any state in the U.S. (Garretson, 2004). However, only 40% are engaged in providing direct bedside care, a situation attributed to unwillingness to work in a setting where their professional contributions are unrecognized. Chandra (2003) declares that, “understaffing nursing professionals has created an environment where nurses are at times overworked and underpaid, a lethal combination in any profession” (p. 34).

Upenieks (2005) cites the need for resourceful, savvy nurse managers who know how to secure needed supplies and resources even with fiscal constraints. Nurses’ perceptions of managers play a key role in job satisfaction and intentions to stay with the organization (Kleinman, 2004; Ribelin, 2003). In a Nevada study, managers’ behaviors, specifically, ineffectiveness and lack of support and concern were cited as the number one cause of nurses’ decisions to leave acute care facilities (Cline, Reilly, & Moore, 2003). There is consensus that it is ultimately more cost-effective to address the underlying causes of staffing shortages than to rely primarily on short-term solutions.

According to HRSA report, between 1996 and 2000 nearly 175,000 nurses left the licensure pool; and those who are licensed and not employed in nursing grew from 52,000 to 490,000 with more nurses than ever before living the profession within the first 4 years after graduation (S0chalski, 2002; Andrews, 2005). The net outcome is a national vacancy rate growth of 126,000 nurses who is anticipated to exceed supply by over 800,000 by year 2020 (AHA, 2001; HRSA, 2002). Managers are faced with challenges of the failure of past efforts to attract a diverse workforce such increase recruitment with improved compensation packages (Dower et. al. 2001).

Looking at the nurse workforce one may wonder why nursing profession is challenged by a shortage since the workforce pool is comprised with 80% practicing nurses out of 2.8 million registered nurses in the US; 95% of these nurses are female; 12% are from minority group; 59% work in hospitals; 32.3% have baccalaureate degrees, 7.3% have master’s degrees, and 0.6% holds doctorates (Donely, 2005). Among African-Americans only 4.9% of a population that is measured as 12.2% of the general population practice nursing, Hispanics just 2% out of a population percentage of 11.4% seek nursing as a career; and 6% are men out of the 2.7 million nurses in the United States (HRSA, 2001). Representation of these under-represented populations severely limits on recruiting the pool of nurses from which future nurses might be secured (AHA, 2002). Thus changing the composition of the nursing workforce and the addressing the dissatisfaction of practicing nurses which contribute to the shortage of nursing will help in the recruitment and retention of qualified experienced nurses in the organization and profession of nursing.

            Inadequte compensation. Inadequate pay is an important factor in nurses’ decisions to seek employment in more lucrative health care settings than hospitals (Chandra, 2003). Flexible benefits that are congruent with nurses’ lifestyle preferences can be excellent incentives for retaining nurses (Spetz & Adams, 2006). Educational benefits provide dual advantages by facilitating the retention of nurses, while enabling them to gain knowledge and skills that benefit the organization. While recognizing that well-designed benefits packages are valuable for recruiting and retaining nurse, Spetz and Adams conclude that a positive work environment carries more weight in retaining staff nurses than salary and benefits. Other sources take a similar stance (Chandra, 2003; Runy, 2006; Upenieks, 2005).

            Much research and literature since 1990 indicates that many employers consider staff as an expense when nurses were seeking autonomy, salaries, flexible schedules, credibility, and professional respect to retain in the workforce. Nurses, midwives, and other healthcare professionals around the world are leaving the healthcare system due to underpay, hazardous working conditions, lack of career development as well as some professional status and autonomy (Booth, 2002). Organizations that gave attentions to the employee market and understand what employees were seeking from the work environment had a better chance to recruit and retain top talent, particularly when the unemployment was low (Nevidjon, 2001).

            Aging population. Another cause for the increased turnover is the aging population of the nurse workflow. Approximately one third of the nursing workforce is over age 50, and the average age of full-time nursing faculty is 49 (Nevidjon, 2001). According to the United States Department of Health and Human Services Administration (2002), a national survey of RNs indicated that in 1983, half of the RN workforce was under 35, compared to 31.7% in 2000.  According to the report, this percentage was expected to reduce to only 22% by 2002. A more recent survey showed that only 8 percent of RNs were under the age of 30, compared with 25 percent in 1980.  While the average age of RNs have increased to 46.8 years, which the highest average age since 1980, the percentage of RNs who are 50 years of age or older have also increased to over 41 percent compared to the 33 percent in 2000 and 25 percent in 1980 (DOHHS, 2006).

Recruitment and Retention of International Nurses

In response to the current nursing shortage, many health care facilities in the U.S. are exploring different strategies to remedy the problem. One of those strategies is the recruitment and employment of trained overseas. Considerable efforts have been undertaken by many health institutions to lure and retain foreign nurses to meet the increasing demand for qualified nurses in hospitals and other health care facilities. Although the strategy is obviously not new, it has become far more aggressive and organized in recent years. There has been a proliferation of for-profit agencies for the recruitment and employment of international nurses as well as a widening scope of countries sending trained nurses abroad. This strategy appears to be a short-term approach to resolving the nursing shortage as the migration of foreign nurses to the U.S. in the past fluctuated according to the nursing demand at that time. However, since 1998, despite the increasing number of U.S. trained nurses, the proportion of foreign nurses joining the U.S. nurse workforce is steadily expanding (Brush, Sochalski & Berger 2004). This is an indication that the demand for nurses is still far from being meet and that current strategies to boost up the domestic supply of nurses have not been productive enough to foil the shortage. As this recruitment strategy continue to gain strong support from health care institutions and health policy makers, there are economical and ethical issues that are raised against it. These issues need to be addressed in order to establish the recruitment of foreign nurses as a sustainable step to resolve the current nursing shortage.

Recruitment of International Nurses

According to Brush and Berger (2000 as cited in Brush & Berger, 2004), the U.S. has been recruiting foreign nurses to alleviate nursing shortages for the past fifty years. However, prior to the current shortage, the fraction of foreign nurses in the U.S. nurse workforce has not exceeded 5 percent (Brush & Berger, 2004). In 2003, this fraction has increased to 14 percent. The Philippines has been the primary donor of foreign nurses to the U.S. as well as to other recruiting countries. Filipinos represented more than half of the international graduates taking the National Council Licensing Examination for Registered Nurses (NCLEX-RN) in 2001 (Brush et al., 2004).  In the 1980’s, Filipino nurses accounted for 75 percent of all foreign nurses working in the U.S. (U.S. General Accounting Office, 1989 as cited in Brush & Berger, 2004). This percentage declined as nurse from other countries such as Canada, the U.K, India, Korea, and Nigeria also began to contributed to the U.S nurse workforce (Brush & Berger, 2004). The remaining proportion of international nurses came from countries that were recent arrivals to the U.S. RN workforce. While some proportion of U.S. nurses come from the U.K., the U.K. surpasses the U.S. as an aggressive recruiter of international nurses (Buchan & Sochalski, 2004). The migration of Canadian nurses to the U.S. may be partially due to the rampant downsizing and restructuring of Canadian hospitals in the late 1980s and 1990s (Armstrong-Stassen & Cameron, 2003).

Foreign nurses working in the U.S are employed in different health care settings. Most of them work in hospitals while some work in public and community health care. Analogous to their American counterparts, the proportion of foreign nurses working in hospitals has steadily gone down, from 79.9% in 1997 to 71.5% in 2003 (Brush et al., 2004). Growing proportions of nurses, both U.S.- and foreign-trained, are seeking employment in nursing homes or long-term care facilities, public and community health centers, and ambulatory care facilities. The trend of the foreign nurses recruitment into these health care settings is similar to U.S.-trained nurses, however, there has been a preferential increase in the number of foreign nurses working in nursing homes (Brush & Berger, 2004).

Cost of recruiting foreign nurses. Based on the 2004 report by the U.S. Department of Labor, the median annual earnings for registered nurses in 2002 was $48,090;  the average annual income for nurses working in hospitals and nursing homes where there are foreign nurse was $49,190 and $43,850, respectively (as cited in Brush & Berger, 2004). However, hospitals have to pay additional fees to recruiting agencies so many of them agree that hiring foreign nurses initially cost higher than hiring domestic nurse. On the other hand, the current shortage of domestic nurses have led them to hire temporary staff to fill in at their facilities which significantly cost a lot more than recruiting foreign nurses (Brush & Berger, 2004). According to an ad by an online recruiting agency, Wehavenurses.com, a recruiting hospital can save up to 43 percent of staffing cost by directly hiring nurses rather than using the services of temporary staffing agencies (Wehavenurses.com). Hiring a temporary nurse for a period of three years will cost $156,473.50 more than directly recruiting a nurse for the same period. Therefore, directly hiring 10 nurses will save the hospital $1,564,735.00 for three years. This illustrates how recruiting foreign nurses may be cost-effective in the long run.

Nursing agencies such as Global Healthcare also offer full refund of the recruitment fee to the recruiting hospital if a new nurse recruit fails to continue working for three months. Foreign nurses also sign two- to three-year work contract with the hiring institution and a partial refund is given to the recruiting hospital in case the recruited nurses fell short of their contract This protects the hiring hospital from retention problems and additional cost due to increased turnover of hospital nurses (Brush & Berger, 2004).

Immigration and assimilation of foreign nurses. According to Dumpel and the Joint Nursing Practice Commission (JNPC), there are transitional issues that hospitals have to bear which may translate to additional cost when recruiting foreign nurses (2005). Citing a study conducted by the National Council of State Boards of Nursing (NCSBN) in 2002, they reported that the complex immigration process to be undergone by international nurses and the different factors influencing the smooth transition of foreign nurses into the U.S. workforce are some of the barriers that recruiting hospitals have to go through. The study was done by sending out a  survey to 400 random hospitals in the U.S. which revealed that the lengthy process for the immigration of foreign nurses as well as the frequent changes to the requirements and regulations for immigration have been one of the major challenges in recruiting international nurses. Other problems that were cited included language barriers, cultural and social differences, competency level differences and arrangements in living settings (Dumpel & JNPC, 2005).

The JNPC Subcommittee identified methods that can ease the transition and assimilation of international nurses into the U.S nurse workforce. The subcommittee suggested that international nurses may work in other capacities aside from nursing. This will allow hospital employers to hire international nurses who have not yet passed the U.S. nursing licensure examination as unlicensed hospital personnel. This is particularly helpful as amidst the upsurge in foreign recruitment, the U.S. State Department announced in November 2006 all “employment-based” visas used to recruit foreign nurses and physical therapists were filled and no additional visas would be issued while the visas were being processed (AHA, 2006). To many health care administrators, the cap on visas for nurses was seen as a serious setback to addressing staff shortages. The AHA argues that the current shortage warrants expansion of visas for nurses, emphasizing that hospitals cannot meet health care demands without a continuing influx of foreign nurses. One administrator stated that, “international nurses are an excellent source of well-equipped and dedicated caregivers,” adding that staffing needs cannot be met without international nurses (p. 3). Several congressional representatives are supporting legislation to remove nurses and physical therapists from the visa caps since the Labor Department has classified them as “shortage occupations” (AHA, 2006, p. 1). The intense response to the cap on international nurse recruitment not only underscores the importance of foreign nurses to the U.S. health care system, but even more significant, the severity of the present shortage of RNs.

The employment of international nurses into position related to nursing will also help foreign nurses become more familiar with the health care system and give them a chance to become more comfortable with the work environment. International nurses may have more duties delegated to them as healthcare workers from their own country, especially in those countries where there are also shortages in other allied healthcare professions like doctors. This method is crucial in introducing to the foreign nurses the limits of their nursing practice and their responsibilities to their patients as U.S. nurses (Dumpel & JNPC, 2005).

The language barrier is one of the more difficult and significant factors international nurses have to overcome. It is crucial for international nurses to communicate effectively, both in speaking and in writing, especially when using medical terminology since patient safety is at risk because of medical errors caused by a communication barrier. This is why passing the English proficiency test remains the measure of nursing competence along with passing the U.S. nursing licensure examinations (Brush & Berger, 2004). The majority of the respondents to the NCSBN survey identified the language barrier as one of the major obstacles to the integration of foreign nurses in the U.S. healthcare system. This was illustrated by the relative ease of transition of international nurses whose native language is English into the U.S. nurse workforce according to the survey (Dumpel & JNPC, 2005). The JNPC Subcommittee suggested that setting up language classes would alleviate the communication barrier. This will help foreign nurses develop communication skills including medical terminology, abbreviations, colloquial terms and medications. Foreign nurses will have to learn these skills before they can competently assume nursing roles and responsibilities (Dumpel & JNPC, 2005).

Hospital employers can also use volunteers to act as mentors and preceptors to prospective international nurses to provide support to them even while they are still in their home country. The volunteers can assist international nurses adjust to the new culture upon their arrival in the United States and introduce them to other recruits from their own country. The volunteers should preferably be international nurses also and together they can make up support groups where they provide support for each other and discuss concerns about differences in their culture and work environment. This is important since differences in culture may compromise patient safety. For instance, foreign nurses from some cultures may be reluctant to ask question fearing it might be rude to do so or it might be embarrassing for them to let others know they did not understand (Dumpel & JNPC, 2005). The Sierra Health Services in Las Vegas, Nevada, which faces a critical nursing shortage due to its rapid growth, has adopted an innovative strategic plan for long-range recruitment and retention grounded in an apprenticeship paradigm and relies heavily on mentorship (Smith, 2006). Although still in the early stages, the model is expanding to other health care professions. Mentors are overwhelmingly positive and the fluid recruitment techniques have broken down cultural barriers for students and novice nurses.

Gerrish and Griffith (2003) observed that the foreign nurses’ interpersonal relationship with their mentors was a key contributor to their perceptions of the workplace environment. U.S. nurses view mentoring programs for new graduates as an effective retention strategy (Buerhaus et al., 2005a). Drawing on Hale’s definition, Block et al. (2005) define nurse mentorship as a relationship between two nurses “formed on the basis of mutual respect and compatible personalities with the common goal of guiding the nurse towards personal and professional growth” (Hale, cited in Block et al., 2005, p. 134). Mentors fulfill both social and instrumental roles by providing their protégés with support, encouragement, guidance, and opportunities for advancing their educational and professional goals. In some settings, novices have more than one mentor, which expands the scope of employees’ opportunities for learning experiences (Gerrish & Griffith, 2003). Although the traditional concept of mentoring refers to a partnership between a novice and expert, peer mentoring can also be used for mutual growth and career development.

Block et al. (2005) noted that while the terms preceptorship and mentorship are often used interchangeably, they are not identical. Whereas mentoring implies a mutual and supportive relationship, which can be either formal or informal, preceptorship is a structured, time-limited orientation technique whereby preceptors are responsible for the transition of new staff nurses assigned to them. Mentoring is a relatively new phenomenon in nursing. However, the existing research shows higher job satisfaction and retention among mentored RNs.

An identified obstacle to successful mentorship is a lack of available, qualified mentors. The MacMillan Mentorship Training Program (MMTP) was developed by the MacMillan National Institute of Education in the U.K. for the purpose of training nursing specialist practitioners in the knowledge and skills required to support and mentor new nurses (Block et al., 2005). Over the course of the one-year program, prospective mentors learn to guide novices through their role transition into specialist practice and promote their continuous professional development. The program is grounded in experiential learning and reflective practice, and both mentors and protégés are expected to attend ongoing learning groups or peers support groups.

To evaluate the MMTP, Block et al. (2005) surveyed mentors, protégés, line managers, and service development managers at the close of the 12-month program. The mentors were highly satisfied with the program and cited a number of positive gains including greater confidence in their knowledge and skills, ability to provide feedback, and awareness of their own learning and development needs. The protégés unanimously expressed the importance of having a mentor’s support during the role transition. The virtually universal endorsement of the program led Block et al. to conclude that professional support programs such as the MMTP are not only extremely effective, but are essential for maximizing the benefits of mentorship for facilitating the successful role transition of new nurses.

While Block et al. (2005) concentrated on the immediate aftermath of the MMTP, the researchers noted that a similar program for training preceptors resulted in a decline in staff nurse turnover. To promote the successful transition of foreign nurses, mentorship and preceptorship training must include educational components on cultural diversity (Gardner, 2003; Gerrish & Griffith, 2003).

The JNPC Subcommittee also suggested the creation of orientation programs by hospitals employing international nurses. The program should be individualized to assess their skills, orient them to the U.S. healthcare system, and introduce regulatory information to them such as the Nursing Practice Act. It could also provide cultural training for international nurses so that differences in culture and behavior can be tackled and cultural misunderstandings can be averted. The program can also assist international nurses with their daily living activities such as obtaining a driver’s license and finding a suitable living quarters. This will help the nurses adapt to their new environment and shorten the transition period with the new culture (Dumpel & JNPC, 2005).

Gerrish and Griffith (2003) reported on the evaluation of an adaptation program to designed for foreign nurses seeking to gain professional registration from the Nursing and Midwifery Council (NMC) in the U.K. The assessment focused on 17 nurses from the Philippines, China, India, and sub-Saharan Africa. Most of the nurses were highly experienced; some had been practicing nursing for more than 10 years before moving to the U.K. The adaptation program consisted of a two-week classroom-based induction period, with subsequent supervised practice in a specific clinical area for at least 10 weeks. Each of the international nurses was assigned to one or more RN mentors, who were also endowed with the responsibility of appraising the nurse’s progress toward attaining the designated competencies. Two clinical nurses who oversaw the program provided additional support. The evaluation data was collected through focus groups and individual interviews with the participating nurses and nurse managers. The effectiveness of the program was assessed according to five key criteria: 1) gaining professional registration, 2) fitness for practice, 3) reducing nurse vacancies, 4) equality of opportunity, and 5) promoting an organizational culture that values diversity.

            Helping the nurses acquire professional registration was deemed the top priority by all stakeholders (Gerrish & Griffith, 2003). The international nurses sought to gain certification as fast as possible. However, the mentors and managers saw significant differences between the nurses’ prior experience and the tasks and responsibilities of nurses in U.K. hospitals. To ensure that the nurses were able to practice safely and proficiently, all the nurses took longer than the NCM minimum to gain registration. Several factors influenced the time needed to acquire certification. These included the fit between the nurses’ prior clinical experience and their current clinical setting, the complexity of the practice environment, and the quality of the relationship between the nurses and their mentors.

Fitness for practice was largely contingent on the nurses’ adaptation to the environment of British hospitals (Gerrish & Griffith, 2003). The nurses had to adapt to both structural and cultural differences. Most had practiced in a task-oriented environment and were not used to the more holistic and team-oriented approach of their clinical practice units. They were also used to a more hierarchical and structured environment with clearly drawn lines of authority. Some of the nurses were uncomfortable with the “over-familiarity” of the British nurses in relating to patients and staff, which they construed as disrespect. Overall, the degree of support and attention the foreign nurses perceived from the senior nurses was key to their successful integration into the unit.

Among the hospital personnel, the senior nurses held the most favorable opinions of recruiting international nurses to fill staff vacancies (Gerrish & Griffith, 2003). The senior nurses felt that by providing foreign nurses with assistance in gaining certification, accompanied by opportunities for continuing professional development, the nurses would be motivated to remain in the U.K. The senior nurses and unit managers also stressed the need for ensuring that the foreign nurses had the same opportunities given to British nurses. They emphasized equity of opportunity for all nurses. Most of the foreign nurses intended to stay and were eager to take advantage of opportunities to further their professional expertise.

The senior nurses and many of the unit managers viewed the recruitment of overseas nurses as a positive step toward greater diversity in the nursing workforce (Gerrish & Griffith, 2003). They recognized the importance of having a nursing force that better reflects the diversity of the local community. In addition, many participants acknowledged the value of a multidirectional exchange of information. They felt that the overseas nurses could contribute their international knowledge to the British health care system, and that the nurses who chose to return to their home countries could use their acquired knowledge to the advantage of their health care systems.

Overall, the evaluation indicated that the adaptation program was useful promoting the professional competence and staff integration of foreign nurses (Gerrish & Griffith, 2003). In general, the nurses had very positive perceptions of their colleagues and reported feeling welcomed and supported by their British coworkers and managers. At the same time, some of the nurses encountered hostility from a small minority of staff members. A few had negative experiences at the onset of the program, which had a deleterious impact on their confidence and self-esteem. Gerrish and Griffith noted that there were no explicit claims of racism. Rather, some nurses seemed unsure of whether the chilly reception from some unit members was due to their ethnicity or their newcomer status in an established unit.

Gerrish and Griffith (2003) concede that it is not uncommon for more experienced staff nurses to be unfriendly to novices. However, they acknowledge that racism and discrimination have been reported by foreign nurses working in Australia and the U.S. as well as the U.K. They emphasize the importance of having anti-discrimination and diversity policies in place. Consistent with Gardner (2003), Gerrish and Griffith (2003) stress the need to create a workplace culture that values diversity. Their findings demonstrate the utility of a specially designed adaptation program as well as the vital role that nursing staff play in the successful integration of foreign nurses.

Retention of International Nurses

Although retention of nurses is just as important as the recruitment of nurses, the worldwide shortage of nurses has accelerated the recruitment of nurses from other countries and has caused serious retention and migration problems world wide (Booth, 2002). According to a Wall Street Journal and London Guardian report cited by Booth (2002), 500 nurses left Ghana to work in other countries, and 71% more overseas-trained nurses applied to United Kingdom, including almost 13,750 from the Philippines, 2,459 from India, and 2,065 from Nigeria, and 2,056 from South Africa. According to Booth (2002), to retain nurses in the same country, many countries, including the British government, has developed the guidelines for inter-country recruitment of nurses. Provision of these guidelines address some of the concerns raised by the multidisciplinary Global Advisory Group (GAG) for Nursing and Midwifery of the World Health Organization, and the International Council of Nurses (ICN), for example, quality of  healthcare services, right of individual nurses to migrate, and human resources planning for recruiting and retaining in the migrating countries.

Recently, US state Department announced the devastating news that no new “employment-based” visas will be issued to recruit foreign nurses and physical therapists while government processes those already in the queue (AHA, 2006). Numerous reports indicates that the demand for nursing services will exceed the supply by nearly 30% in 2020 if the critical issue of shortage of nurses would not be address appropriately (Health Resources and Services Administration (HRSA), 2002). Hospitals had used up the visa quotas cleared in fiscal year of 2005 for the recruitment of RNs from the Philippines, India, and China (AHA, 2006). Without a change in immigration policy there would be difficult to plug the holes as there are not enough domestic nurses at the present time to reduce the shortage of nurses in the healthcare facilities (AHA, 2006). According to Yvette Mooney, a vice president of South Nassau Community Hospital, international nurses are excellent sources of intelligent, well-equipped, and dedicated caregivers (AHA, 2006).

Although the initial financial outlay for recruiting foreign nurses is higher than the cost of hiring domestic nurses (Brush, Sochalski, & Berger, 2004), an underlying assumption is that the strategy will prove cost-effective in the long-run as a result of lower turnover and agency policies assuring full or partial remuneration if the nurses fail to uphold their contractual obligations. Some administrators may also feel that recruiting nurses from overseas is less expensive than increasing salaries and benefits, and offering other financial incentive needed to retain domestic RNs. There is documented evidence that most attempts to cut costs, rather than investing in efforts to retain qualified RNs, have proven counter-productive (Alexander et al., 1994; Atencio, Cohen, & Goldberg, 2003; Atkinson, 2005; Donley, 2005; Murrow & Nowak, 2005).

The overarching implication is that the employment of international nurses must be viewed within the broad context of how the current health care environment affects the retention of nurses. Numerous studies have been conducted on the nursing shortage to help find solutions for the recruitment and retention of nurses and other healthcare personnel. However, there have been few studies directed toward the examination of costs involved in filling the gap with less expensive, and perhaps, less skilled nurses. Few studies have specifically focused on the implications for foreign nurses (Brush, Sochalski, & Berger, 2004), and almost none that specifically address the issues of cost, turnover rate, and retention of nursing personnel recruited from abroad.

In 2003, the rate of turnover among U.S. hospital nurses was 14.6% (Block, Claffey, Korow, & McCaffrey, 2005). Turnover is expensive. The cost of replacing an RN averages $64,000, while replacing a critical care nurse can be more than $80,000 (Murrow & Nowak, 2006). The cumulative cost of turnover includes the impact on patient care and organizational operations (Jones, 1992). Furthermore, turnover can be self-perpetuating, as negative workplace conditions drive more nurses to leave (Alexander, Bloom, & Nuchols, 1994).

Increasing turnover rate is not only a major concern in providing quality of the healthcare services to consumers, and a safe environment for employee and customer satisfaction. but also a financial concern. Turnover rate, including recruitment and training of new hires, may cost $12,000 to 15,000 or more per RN (Jones, 1992; Relf, 1995), and educational development of a competent Operating Room (OR) nurse can cost as much as $25,000 (Hart, 1988; Shinkman, 2002) to $42,000 per nurse ($64,000 for a specialty nurse) (Advisory Board Company, 2000). For example, the study conducted in 1998 by Prescott and Bowden indicated that the turnover rate for RNs to be about 30%, which can affect the overall nursing budget significantly (Kearney, 1995). Baernholdt (2005) had cited the findings of Shinkman’s (2002) calculation using most conservative estimates in the literature which indicated in the US, the current nurse turnover rates cost about $6 billion annually. Alone, California State’s 500 hospitals must pay between $500 million and $1.1 billion annually to implement a ratio of four patients per nurse. According to Calnurse, (2001) research findings after six months from the implementation of minimum nurse staffing ratios in Victoria, Australia in 2000, the active nursing work force increased by 13% and reports of satisfied nurses also increased (DPE, 2003; Baernholdt, 2005).

The rate of turnover in 2000 was 21.3% with turnover costs up to two times a nurse’s salary and the national average salary of a medical-surgical nurse is $46,832 leading to $92,442 replacement costs for that nurse, and $145,000 for specialty nurse (The HSM Group, 2002). Replacement costs include human resources expenses for advertising, interviewing, and increased use of traveling nurses, overtime, temporary replacement costs for per diem nurses, lost productivity, and terminal payouts (Colosie, 2002). Therefore, if a hospital with 100 nurses experienced turnover at the rate of the national average of 21.3%, expenditures could amount to as much as $1,969,015 yearly, for the turnover of medical-surgical nurses alone (The HSM Group, 2002).

Job Satisfaction and Commitment. Lambert, Hogan, and Barton (2001) concluded that positive job satisfaction is twice as predictive of employee turnover as employment tenure and is four times as predictive as the perception of alternative employment opportunities, age, gender, and educational level (Cohen, 2006). However, job satisfaction is not necessarily the most accurate predictor of employee turnover rate since other variable such as organizational commitment, perceived job alternatives, job-search behavior, and job embeddedness play a key role in retention of employees (McNeese-Smith, 2000; Holtom & O’Neill, 2004; and Cohen, 2006). Provision of mentoring relationships, developing managerial leadership skills, and more flexible work arrangements may increase job embeddedness and satisfaction (Holton and O’Neill, 2004; Cohen, 2006).

Murrow and Nowak (2005) tested their consumer approach theory to improving the retention of nurses. The rationale was that “nurses act as consumers in their employment behavior” (p. 26).  In their study of nursing units where morale was low and turnover high, job satisfaction emerged as the most important dimension in the analysis. A second important dimension was construed as the personal relationship cost of changing jobs. The third major dimension was benefit loss. The fourth was interpreted as being empowered in the job although its influence was attenuated in the final analysis. The conclusion was that hospitals can improve retention by addressing the issues that contribute to nurses’ job satisfaction.

Several factors consistently surface as important contributors to the retention of hospital nurses. AONE delineated five features of successful recruitment and retention efforts: 1) sustained leadership commitment to the nursing workforce as a strategic imperative; 2) an employee- and patient-centered culture; 3) collaboration with other organizations to address workforce needs; 4) a systematic and structured approach to four key strategies: promoting meaningful work, improving workplace partnerships, expanding the base to attract a more diverse workforce, and collaborating with other organizations, including other hospitals and schools, to ensure an adequate future workforce; and 5) excellent human resource practice (Runy, 2006).

Related to these five attributes are nine principles for the establishment of a workplace that supports professional nursing practice and thus promotes the retention of nurses (Runy, 2006). The nine principles, which are endorsed by AONE and other organizations, are: 1) respectful and collegial communication and behavior; 2) communication-rich culture; 3) a culture of accountability; 4) a sufficient number of qualified nurses; 5) expert, competent, credible, visible leadership; 6) shared decision-making at all levels of the organization; 7) support and encouragement for professional practice and ongoing growth and development; 8) recognizing the value of nursing through performance-based pay and rewards and opportunities for career mobility and expansion; and 9) recognition of nurses for their significant contribution to the practice.

Magnet hospitals are based on the nine principles (Upenieks, 2006). By creating a positive professional practice environment, magnets surpass most hospitals in attracting and retaining nurses. Compared to other hospitals, magnets have lower rates of turnover and vacancies and higher levels of job satisfaction.

Takase, Maude, and Manias (2005) contend that the emphasis on environmental factors in nurses’ job dissatisfaction and turnover intentions creates the perception that the relationship between nurses and their environment is a unidirectional phenomenon in which nurses passively respond to their environment. Instead, they propose examining job dissatisfaction and turnover from the perspective of person-environment fit. They suggest that this approach allows for a wider lens through which to explore how nurses’ needs to maintain their professional image, values, skills, and personal well-being are reinforced by features of the environment.

Although person-environment fit theories would add additional perspectives to the issues of nurses’ job dissatisfaction and turnover, there is minimal indication that nurses simply respond passively to their surroundings. Fisher, Hinson, and Deets (1994) found that nurses who were willing to take the risk of acting to change conditions that caused discontent were more likely to stay with the organization. The evidence strongly shows that nurses prefer work environments that promote autonomy, empowerment, collegiality, and professional growth and development (Andrews & Dziegielewski, 2005; Atencio et al., 2003; Campbell, Fowles, & Weber, 2004; Hayhurst, Saylor, Stuenke; 2005; Laschinger & Finegan, 2004; Nedd, 2006; Pierce, Hazel, & Mion, 1996; Upenieks, 2005). This is equally true for nurse managers as staff nurses (Wilson, 2005). Older and more experienced nurses particularly desire professional autonomy as well as flexible work options (Campbell et al., 2004; Cohen, 2006).

The Nurseweek/AONE surveys suggest that most nurses are not likely to change professions (Buerhaus et al., 2005a, 2005b). Nogueras (2006) explored the relationship of nurses’ education, experience, and occupational commitment to intentions to leave nursing. Building on the concept of organizational commitment, occupational commitment has three dimensions: affective (attachment to an organization), normative (obligation to remain with an organization), and continuance (perceived costs of leaving an organization). According to Meyer and Allen’s model, affective, and normative commitment both enhance occupational commitment, whereas continuance commitment reflects weaker ties to the occupation. Underlying assumptions are that one’s occupation is the primary focus of one’s life, education enhances occupational commitment, organizational change raises occupational commitment, and occupational commitment results in retention in the profession. The results were derived from a sample of 908 nurses.

The results as a whole showed a relatively neutral overall level of occupational commitment (Nogueras, 2006). However, further analysis revealed strong affective and continuance commitment with neutral normative commitment. The most notable finding was the link between educational level, occupational level, and intentions to leave nursing. Specifically, nurses who were more educated and had stronger occupational commitment were less inclined to leave nursing. Age and experience also influenced occupational commitment, with older age exerting a significant impact on occupational commitment and experience showing a weaker effect. The pattern implies that nurses who feel they have made a stronger investment in nursing are less predisposed to leave the profession. A study of public health nurses reported similar findings (Campbell et al., 2004). The positive association between age and commitment support recommendations for initiatives to retain older nurses (Cohen, 2006; Runy, 2006; Spetz & Adams, 2006).

As a group, nurses are satisfied with their profession (Buerhaus et al., 2005a, 2005b; Donelan et al., 2005). While occupational commitment is indeed positive, occupational commitment and organization commitment are distinct entities. Tallman and Bruning (2005) applied Meyer and Allen’s model to a study of 122 nurses working hospitals in Western Canada. The findings showed a relationship between perceptions of the work environment, job satisfaction, and affective commitment. The most powerful workplace influences were a safe environment, respect for nurses by managers, and fair policies. Continuance commitment was associated with the duration of time the nurses had worked for the hospital and their ties to the local community. Tallman and Bruning’s recommendation that hospitals actively work to cultivate local nursing talent has been used successfully to recruit ethnic minority nursing students (Fletcher et al., 2003). Both affective commitment and continuance commitment were significantly linked with nurses’ intentions to stay at their present place of employment (Tallman & Bruning, 2005).

Hayhurst et al. (2005) found job satisfaction to be a pivotal factor in the retention of acute care nurses. Nurses who reported higher job satisfaction and consequently stayed with the organization experienced lower job stress, more collegial, cohesive coworker relationships, managerial support, and encouragement for autonomy than nurses who left.

Laschinger and Finegan (2004) and Nedd (2006) turned to Kanter’s theory of organizational empowerment as a framework for investigating nurses’ perceptions of the work environment. According to Kanter’s (1993) model, empowerment is related to access to information, support, resources, and opportunities for growth and development Laschinger and Finegan (2004) examined the relationship of empowerment to interactional justice, trust, and respect in a sample of 273 medical-surgical and critical care nurses. Empowerment affected satisfaction and commitment both directly and indirectly. Perceived empowerment was directly linked with job satisfaction and commitment. In addition, empowerment affected satisfaction and commitment via their influence on perceptions of justice, feeling respected, and trust in management. In Tallman and Bruning’s (2005) study, perceptions of fairness and respect translated into higher commitment.

On the whole, the nurses felt moderately empowered at their place of employment (Nedd, 2006). Access to opportunity was seen as the strongest source of empowerment, followed by support, information, and resources. The findings supported Kanter’s (1993) assertion that individuals who perceived a greater sense of empowerment in the workplace would be less inclined to leave. The pattern held regardless of individual characteristics, which is also consistent with Kanter’s (1993) theory.

Educational programs for retaining nurses. While hospitals are successfully drawing trained nurses from other countries, strategies to recruit and retain ethnic minority nursing students are less successful (Fletcher et al., 2003; Gardner, 2005). Fletcher et al. (2003) noted that despite a history of caring for the sick and needy in their communities, African American nurses are seriously underrepresented in the U.S. nursing workforce. According to 2000 U.S. census data, 38% of individuals identified themselves as members or racial or ethnic minorities (Gardner, 2003). In the same year, less than one-third that proportion (12%) of RNs identified themselves as racial or ethnic minorities. Nursing schools report high rates of attrition for both foreign and minority students, in some cases estimated at up to 85%.

Identified barriers to the success of foreign and minority students include English language proficiency, feelings of alienation and isolation, financial issues, academic issues, and discrimination (Gardner, 2003). To address these obstacles to the successful retention of foreign and ethnic minority nursing candidates, the National Advisory Council on Nurse Education and Practice calls on nurse education programs to strive toward better understanding of the underlying issues with the goal of resolving them (Gardner, 2003).

One institution that has developed a highly successful strategy is the University of Mississippi Medical Center (UMMC) School of Nursing (SON). As part of efforts to overcome the racist image attached to the University of Mississippi, and in response to recognition of the need to attract ethnically diverse nursing students and faculty, the university implemented the UMMC SON Minority Recruitment and Retention Initiative (Fletcher et al., 2003). The initiative has two main goals: 1) to promote the recruitment of qualified ethnic minority students and 2) to promote the retention, socialization, and matriculation of ethnic minority students into the UMMC SON programs.

The initiative relied on three key strategies (Fletcher et al., 2003). The first was the creation of an environment characterized by mentoring and socialization of minority students. Three forums were convened throughout the academic year to encourage open dialogue and communication, allow students to express concerns, and solicit feedback from students. The second strategy was the enactment of collaborative partnerships with other health care professional and educational groups to help facilitate the academic success of minority students. The third strategy involved raising the awareness and knowledge of community members about the academic criteria needed for entry into a professional UMMC SON programs.

As a result of the program, UMMC SON gained nine full-time and one-part time ethnic minority faculty members, all either doctoral degree holders or candidates (Fletcher et al., 2003). Minority students constitute 23% of all UMMC SON programs. Fletcher et al. regard both occurrences as impressive gains for a school with a reputation for being “white”. UMMC SON maintains concerted efforts to improve the school’s image with the African American community, including both formal and informal recruiting techniques.

The UMMC SON program embodies the notion of “growing your own” nurses. Fletcher et al. (2003) view the program as a model for other initiatives designed to recruit ethnic minority nurses. From a divergent perspective, a similar program of mentoring and socialization is valuable for facilitating the successful integration of foreign nurses (Gerrish & Griffith, 2004).

Gardner (2005) undertook a case study of three East Indian nursing students enrolled in a California state university school of nursing. The three female students had all been living in the U.S. for five years or more. The investigator conducted three interviews to delve into their attitudes, perceptions, and experiences in nursing school. The study utilized two theoretical frameworks. The first was drawn from Ibarra’s theory of multi-contextuality, which postulates that cultures can be classified as either “low context” or “high context,” based on “how the individuals perceive and communicate with one another or how they learn about the world” (Gardner, 2005). North American and European countries are predominately low context cultures whereas the cultures of many immigrants and ethnic minorities are high context cultures.

The second framework guiding the study was Tinto’s (1993) model of college persistence. According to the model, the intention to persist in higher education is dependent on the extent to which students are integrated into the academic and social dimensions of the institution. Students who feel they are accepted by peers and faculty and take part in campus activities are most likely to graduate.

The experience of one particular student was used to exemplify the social and cultural barriers experienced by the Indian students (Gardner, 2003). The student experienced strong cultural dissonance in the nurse education program. The fast pace of the program, low power, distance between students and faculty, and lack of close relationships with peers contributed to a sense of alienation and loneliness. Although the student felt support from most faculty members and other foreign students, she felt isolated from most of her peers and was not actively involved in campus life. Gardner noted that the attrition rate for ethnic minority students in the nurse education program was twice the rate for Caucasian students.

Leadership factor. The Branham (2001) study of 20,000 employees’ exit interview concluded that poor supervisory behavior is the top reason cited for their leaving. Although effective supervision experience significant improvement in employees’ ability to manage stress associated with moral dilemmas, manage organizational change, and manage integration of theory and practice; many nurse managers unable to provide their nurses with leadership and support that they need (Cohen, 2006). Close monitoring of staff performance in an attempt to detect and correct mistakes contributes to increased emotional exhaustion and job dissatisfaction among nurses compare to managers who encouraged their staff to participate in decision-making and collaboration tended to create a more positive climate among nursing team ( Staten , 2003; Stordeur, D’hoore, and Vandenberghe et. al., 2001). As turnover rates among nurse managers are comparable with experienced staff nurses, one can reasonably conclude that the nurse managers on whom the organization relies to address critical retention issues are at times ill equipped to meet the challenges of retaining qualified nurses and therefore addressing the issues of shortage of nurses (Andrew & Dziegielewski, 2005; Cohen 2005).

According to a study by the National Healthcare Cost and Quality Association involving 100 major hospitals across the United States, 50% of hospitals hold managers accountable for retention and only approximately 25% actually tracked management performance on this issue (Martin, 2001; Cohen, 2005). Within the literature there have been inconsistencies concerning the perceived effects of the reduction of RNs administrating healthcare and impact on overall quality of care, length of stay of the patient, and level of job satisfaction experienced by the RNs (Barter et. al., 1997). Nurses confront ethical issues in clinical practices that have been difficult to resolve partially because of the complex nature of health and safety issues related with patients, families, physicians, administrators, other nurses, and working conditions. For example, Nurse Practitioners (NPs), as independent providers of health care, face ethical issues as the advocate of the patient and the protector of community health. Therefore, healthcare facilities should select employees more carefully upon recruiting and retain the productive experienced employee by enhancing job satisfaction. Setting nurse recruitment and retention goals, pegging quality performance standard bonuses to achievement of those goals, and providing flexible schedule, ergonomic technologies, and adoption information to value cultural diversity would reinforce the importance of employee retention to nurse managers (Cohen, 2005). Kleinman (2004) study of the relationship between managerial leadership behavior and staff nurse retention concluded that effective leadership skills have been shown to enhance job satisfaction and promote staff nurse retention, however, there is limited evidence present to suggest specific managerial leadership behaviors that contribute most to staff nurse retention and actually stimulate higher levels of turnover. Nurses confront ethical issues in clinical practices that have been difficult to resolve partially because of the complex nature of relationships with patients, families, physicians, administrators, and other nurses. Nurse practitioners (NPs), as independent providers of health care, face ethical issues as the advocate of the patient and the protector of community health.

Ribelin (2003) declares that, “Nurses don’t leave hospitals, they leave managers” (p. 18). Nurses leave institutions when they feel that they are being prevented from accomplishing personal missions (Ribelein, 2003). According to the author, “Nurses’ level of satisfaction with their manager’s leadership style is critical to their work environment” and prediction of level of productivity, quality of performance, and length of stay (p. 18). Other authors support the notion of assertion that the opinions of the employees’ immediate supervisor carried more impact on the employees than overall company policies or procedures (Cline et al., 2003; Hayhurst et al., 2005; Pierce et al., 1996). Ribelin (2003) explored two aspects of management style: thrust and aloofness. Thrust denotes behavior “characterized by an evident effort to ‘move the organization’” (p. 19). Aloofness refers to a manager’s “impersonal and formal behavior” (p. 19). Aloof managers tend to rely on a structured, “by the book” approach. The sample consisted of 1,496 RNs providing direct care in a large Midwestern health care system.

Leadership style had a significant influence on the nurses’ intentions to remain with the organization (Ribelin, 2003). Consistent with expectations, the more favorable the nurses’ perceptions of their manager’s leadership style, the stronger the intention to stay. The nurses preferred managers who engaged in direct communication, provided performance feedback, gave recognition, and made definite efforts to meet their personal needs.

Kleinman (2004) used transformational and transactional leadership as a framework for assessing the impact of leadership on the retention of nurses. Broadly, transformational leaders inspire trust in others, support the intellectual growth of their followers, encourage innovation and new ideas, and work with their followers to fulfill a collective vision (Bass & Avolio, 2000). Transactional leadership is based on an exchange between leader and follower and is more focused on the managerial aspects of leadership. A sizable body of research documents that transformational leadership has a positive influence on job satisfaction and commitment. Nevertheless, good leaders exhibit elements of both transformational and transactional leadership behaviors. Kleinman (2004) conducted her leadership study on a sample of 79 staff RNs and 10 nurse managers.

The findings reflected a common discrepancy in the perceptions of managers and subordinates. That is, the nurse managers saw themselves as engaging in transformational leadership behaviors to a much greater extent than perceived by the staff nurses (Kleinman, 2004). This disparity suggests that nurse managers need to be more aware of and reflect upon their leadership styles. A more positive finding was the low incidence of leadership by exception, in which managers monitor subordinates but take no action until they detect a potential problem or until a problem actually occurs. Management by exception was the only leadership behavior significantly related to turnover. Kleinman surmised that a larger sample would yield an even stronger association between leadership by exception and turnover. Interestingly, there was no discrepancy between staff RNs and managers regarding the frequency of leadership by exception behaviors. However, the managers appear to be unaware of the adverse effect it has on their staff.

Manion (2004) interviewed 26 nurse managers from a variety of health care settings to gain their perspectives on how to create a culture of retention. The overarching viewpoint was that the way to establish a culture of retention was to “create a culture of engagement and contribution” (p. 30). Several themes emerged in response to the question of how to accomplish this. The first theme was to put the staff first. The underlying belief was that if managers put the staff first, the nurses would put the patient first. Behaviors related to this theme included caring for staff members as individuals, meeting their needs, treating them with respect and high regard, showing appreciation and recognition, actively listening, and offering support.

The second theme was to forge authentic connections (Manion, 2004). This included taking time to get to know staff members, fostering a sense of community, diligently hiring people with characteristics that fit the department, and engaging the staff in enjoyable recreational activities. The third theme was to coach for, and expect results by conveying high standards and expectations, supporting nurses’ development, and modeling behavior. Fourth was to focus on results by working with staff to solve problems, empowering and involving staff, and providing adequate resources and a pleasant workplace environment. The final theme was to partner with staff. This included being visible, accessible, establishing clear boundaries, and engaging in honest and open communication.

On the whole, the strategies recommended by the nurse managers for creating a culture of retention reflect the principles of transformational leadership (Bass & Avolio, 2000). Manion (2004) emphasizes that positive work cultures do not require elaborate or expensive measures. Several other sources make the same point. Alexander et al. (1994) concluded that the financial costs of investing in retention efforts are outweighed by the returns.

Implications of recruiting and retaining international nurses

            The recruitment of international nurses has contributed a significant part in resolving the current nursing shortage. The shortage, however, may be far from being resolved which raises the need to look into the implications of the strategy of recruiting and retaining international nurses as a long-term solution to the problem. These include the impact of international nurses to the quality of patient care, the cost-effectiveness of the strategy compared to increasing the domestic supply of nurses, and ethical considerations in relation to the global nursing shortage.

Ethics of recruiting international nurses. There are ethical considerations in the recruitment of international nurses. Nursing shortage is a global issue and some source countries have nursing shortage themselves. The migration of their nurses into the U.S. poses a serious threat to their already dwindling pool of nurses. This introduces an ethical dilemma for the recruiting country. The hardest hit nations are the developing nations, where the populations are willing to migrate to reach a better standard of living, better work pay, and better rewards as promised by the recruiting countries. The lack of proper legislations and regulations of migrating workforce is the main reason why the current departure is leading to chaos in the home countries. The problem of lack of health staff is so acute that it is replacing and over riding the problems related to medical science and technology. (International Mobility of Health Professionals, Part III, 2004)

A good example for this is Africa. This region is among the hardest hit nations in losing its health care workforce to international countries and health care sectors. In 2000 more than 500 nurses left Ghana to work in other countries: that is more than twice the number of nurses who graduated from nursing programs in the country that year (Zachary, 2001). In Malawi, between 1999 and 2001 over 60% of the entire staff of registered nurses in a single tertiary hospital (114 nurses) left for jobs in other countries (Martineau, Decker, & Bundred, 2002). Between 2000 and 2001 alone, 10% of nurses in Barbados left the nursing sector, the majority of whom left the country for employment elsewhere (Buchan & Dovlo, 2004).

The flexibility in the recruitment policies of countries such as the USA and the UK have led to wide migration of health care professionals from these regions of the world. The brain drain effect is already visible and Africa is the most vivid example of what is to follow in other countries as well. The trend of migration and the desire to do so is very high in this region, and more than half of the population of African skilled people will avail the chance to shift to other countries. The USA is among the most desired nations for job permits, followed by other developed countries. This is a very disturbing trend when looking at the current statistics of the African economy and health facts. The life expectancy is low, the aids that are given to these countries is low, there are still high rates of infant mortality, and there is increased incidences of HIV and AIDS among the populations. These statistics have led to much effort from the governments, but are mostly at the primary level, and directed towards the upper and middle classes most of the time. (International Mobility of Health Professionals, Part III, 2004)

     The increased lure of higher pays and more benefits of giving the same service also attract many professionals to go abroad. However, these lures may be temporary and in fact inhibitory as while the pay scales offered to these nurses are higher than those given to them at home countries, the pays are not able to provide them sustenance in the new country as costs are increased (International Mobility of Health Professionals, Part III, 2004). Africa is a common ground for many of the most infectious diseases of the world, which is another reason why a health professional and nurses may opt for emigrations. The loss of the workforce is increasing the workload on the ones who are left behind in their own country, and the ratio of patient to nurses continues to rise.

This is no doubt affecting the quality of care provided by the nurses, for these nurses are forced to work overtime, with low pay, no incentives or bonuses and with no professional advancement in the future. The increase in mortality rates among health workers due to HIV and AIDS is not only reducing the number of workers in the health sector in this region, but is also increasing work demands on the remainder of the nursing staff, regardless of their own condition or health. The high rates of HIV and AIDS in this region demand extensive care from nurses, and these demands continue to rise. AIDS has increased the problems for the African health care sector, and the problems continue to escalate. (Buchan and Calman, 2004). Africa is therefore, one of the hardest affected countries due to international immigration of its health crew. With the already deteriorating and weak health care structure, the country is facing a major crisis and fears a major collapse of its own health care systems. (International Mobility of Health Professionals, Part III, 2004).

According to statistics provided by Booth (2002) to illustrate the reality of the dire need for nurses around the globe, during the previous decade, Zambia had only 500 of the 1,500 nurses needed for one of the hospitals, Chile had only 44.4% of 18,000 required nursing pools, and Poland had a 70% decline in nurses graduating from nursing programs. Furthermore, in six short years between 1995 and 2001, there was a 26% decrease in nursing school graduates taking the licensure examination to become a Registered Nurse (RN) in the United States (Booth, 2002).

In Australia, a government report indicates that the country may confront shortage of 31,000 nurses by 2006 with a prediction that 22,000 currently employed nurses will leave their jobs in the next 4 years (National Review of Nursing Education, 2002; Takase, Maude, & Manias, 2005). Takase, Maude and Manias (2005) introduce the person-environment fit theory as an alternative framework which challenges the assumptions by suggesting that the relationship between person and environment, rather than environmental characteristics and lack of environmental reinforcements alone who affects nurses’ occupational behavior. Nurses, especially female nurses are enticed to migrate from own homeland to another country by promises of better pay, better working conditions, improved learning and practice opportunities, free travel, licensure, and room and board (Brush, 2004). Between 1998 and 2002 the United Kingdom alone recruited 5,259 nurses from South Africa, along with 1,166 from Nigeria, 1,128 from Zimbabwe, and 449 fro Ghana (Buchan, 2004). The Philippines and other countries’ such as sub-Saharan Africa, Southeast Asia, and the Caribbean healthcare system are facing a domestic shortage while recruiting countries are beginning to strain these countries health care system rather than providing economic benefit as they had in previous years (Prystay, 2002).

The upsurge of efforts by developed countries to recruit nurses from developing countries is a global phenomenon. To address the issue, Buchan and Sochalski (2004) examined trends and policies in five countries: Australia, Ireland, Norway, the U.K., and the U.S. The data was drawn from a study sponsored by the World Health Organization (WHO), the International Council of Nurses, and the U.K. Royal College of Nursing. The study used multiple modes of data collection and deliberately focused on countries with increasing recruitment of international nurses.

The most dramatic increases in recruitment of international nurses were observed for Ireland and the U.K. (Buchan & Sochalski, 2004). As in the U.S., Filipino nurses accounted for a substantial proportion of foreign recruits. However, there was also increasing reliance on nurses from South Africa by these two countries. In the U.S., Filipino nurses represented the largest group of new nurses. Nurses from Nigeria, Korea, and India represent a growing constituency of new nurses in the U.S.

There were also consistent patterns of nurse migration from one developed country to another (Buchan & Sochalski, 2004). Australian nurses migrated to both the U.K. and Ireland, and Ireland also reported a growing number of nurses from the U.K. Within the U.K., there are differences in recruiting patterns among countries, although England is the most active recruiter of foreign nurses (Buchan, 2002). Canada remains a major source of foreign nurses in the U.S. (Brush et al., 2004; Buchan & Sochalski, 2004). The recruitment patterns of Australia and Norway differed from the other three countries in that they mainly recruited nurses from other developed countries (Buchan & Sochalski, 2004).

From a global standpoint, the recruiting of international nurses by wealthy countries signifies the failure of these countries to “grow their own” and “keep their own,” with implications of severe nursing shortages in countries with far fewer resources (Buchan & Sochalski, 2004). As a consequence, Buchan and Sochalski (2004) propose that national governments and international agencies enact policies that uphold the rights of individual nurses to move from employees’ home countries within an “ethical” environment that strives for a more equitable flow of trained and qualified nurses. One of the options recommended by Buchan and Sochalski (2004) is encouraging and promoting controlled flows of nurses between countries. Ireland and countries within the U.K. have historically had such arrangements, frequently to advance educational opportunities (Buchan, 2002). At the same time, these counties are experiencing the same problems with retention and job satisfaction that contribute to the nursing shortage in the U.S.

Healthcare quality issues. The predominant focal point in the debate over hiring foreign nurses has been the ethical issue of recruiting nurses from developing countries with urgent needs for qualified health care providers (Brush et al., 2004; Buchan & Sochalski, 2004). Much less attention has been devoted to the implications for the host countries of international nurses. Relevant issues include the integration of foreign nurses into the workforce, patient care quality, and patient outcomes, and present and future workforce planning (Brush et al., 2004).  There is little knowledge regarding any difference in the quality of nursing care between international and U.S.-trained nurses. While studies have shown the negative impact of nursing shortage on patient outcomes, a key concern remains to foreign nurses recruitment is whether they provide high-quality services to US patients or not. Although hiring foreign nurses goes through a stringent certification process to assure the competency in educational training and language, the differences in quality of care remains to be seen. It is understood that quality of care could be affected by, among other things, poor transition and assimilation of new foreign nurses into the U.S. health care system. The Joint Nursing Practice Commission reported that similar factors influencing transition and assimilation factors were observed in other transition groups including new U.S. nurse graduates and U.S. reentry nurses. More comprehensive orientation and training programs are needed. An assessment of the quality of care and patient outcomes are likewise needed and should include an appraisal of the cultural competence foreign nurses bring to patient care.

Foreign nurses are mandated to produce evidence of completing designated levels of didactic and clinical instructions as “first-level nurses as defined by the International Council of Nurses (Brush et al., 2004). They are allowed to practice in the U.S. upon passing the NCLEX-RN. Brush et al. observe that no studies have been conducted examining whether international nurses’ cultural orientation and technical proficiency produce different patient outcomes compared to the U.S. counterparts. The literature reviewed for this project yielded only one study comparing the workplace perceptions and job satisfaction of American RNs and foreign (Filipino and non-Filipino Asian) RNs (Staten, Mangalindan, Saylor, & Stuenkel, 2003). A U.K. study assessed the effectiveness of an adaptation program designed to facilitate the integration of foreign hospital nurses (Gerrish & Griffith, 2004). The most comprehensive information on the adaptation of foreign nurses comes from research sponsored by the National Council of State Boards of Nursing (NCSBN; Dumpel, 2005).

Since the establishment of Commission on Graduates of Foreign Nursing Schools (CGFNS) in 1977, CGFNS verifies foreign nurses’ credentials and educational qualifications and identifies those at risk for failing the US nurse licensure exam (NCLEX-RN) and English Proficiency tests prior to immigration. The Commission on Graduates of Foreign Nursing Schools (CGFNS) is a not-for-profit organization with nearly 30 years of experience in certifying the credentials of over 500,000 internationally educated nurses and other healthcare workers (Dumpel, 2005). CGFNS is an immigration-neutral, internationally-recognized authority on the education, registration, and licensure of nurses’ to ensure that nurses educated in other countries who wish to practice nursing in the United States are eligible and qualified to meet licensure and other practices requirements (Dumpel & JNPC, 2005). Nurses who pass a qualifying examination to evaluate nursing skills and English language proficiency are granted a CGFNS certificate as well as eligibility for non-immigrant occupational preference visas.

Cost and duration of training and orientation of international nurses. Recurring shortages of nurses continue to be a complex healthcare issue of diverse etiology and of widespread concern in 21st century (Hayburst, Saylor, & Stuenkel, 2005). In today’s cost-conscious, changing healthcare environment, health care agencies must identify and implement strategies to promote fiscal responsibility while maintaining employee satisfaction and retention (Kearney, 1995). Because of higher wages for Registered Nurses, labor cost reductions became a major target for in many of the healthcare facilities. A survey conducted in 1992 by Boston and Zimmermann reviewed 102 acute care hospitals in California to ascertain the extent of unlicensed assistive personnel (UAP). This study reported that the majority of the hospitals did not collect data on the cost effectiveness of use of UAP, 23 hospitals monitored salary expenses, and one hospital collected data on cost effectiveness for variables such as length of stay and employment turnover (Boston & Zimmermann, 1993; Barter et. al., 1997). According to Baernholdt’s (2005) study and review of germane literature, only few studies have been conducted to study whether it costs more to have adequate nurse staffing or not. Aiken (2002) conjectured that while hospitals with higher nurse staffing might have higher nurse labor costs, that have a significantly shorter length of stay (LOS) and fewer days spent in an ICU, but had no statistically significant decrease in profit margins.

When determining a wage structure for nurses, hospitals administrators and human resources department managers should consider cost of turnover, recruitment, and training and orienting new employees. If a hospital of with 600 nurses’ experiences 20% turnover rate then that hospital would incur $46,000 per nurse, and will spend $5.5 million per year per nurse in replacement costs (JCAHO, 2002). In 2000, full-time staff RNs who graduated five years earlier had salaries 25% to 17% higher than that received by new nursing graduates with similar degrees; yet earn 1% to 3% less than nurses with 10 to 15 years more experience. Jones (1992) study to measure turnover costs suggested a procedure to calculate turnover cost by incorporating Consumer Price Index (CPI) information as there was a wide variation present in reported nursing turnover costs which ranges from $1,280 to $50,000 per RN. Procedure for calculating nursing turnover costs per RN in the hospital cost category include: Direct costs: advertising/recruiting, unfilled positions (temporary, RNS, overtime, lost, revenues), hiring, and indirect costs: orientation/training, decreased productivity, and termination. Therefore, over 60% of nurses reported reason for job dissatisfaction is that there is a very little difference in pay scale of RNs with more experience and those with less experienced new employees to justify staying in the job and change the position to gain higher salary in other facility or occupation (Reineck and Furino, 2005).

It is unclear whether recruiting and retaining international nurses is a cost-effective approach in resolving the nursing shortage. How much hospitals actually spend for the recruitment and retention of foreign nurses remains to be seen. It is important to determine whether is significant advantages in terms of hospital cost in hiring and training foreign nurses over their domestic nursing graduates. A study investigating these variables will help formulate better policies and sustainable strategies to remedy the nursing shortage.

Conclusion

            Nurses comprise a major percentage of the current health care professionals. This along with the fact that they are the major contributors in the health care system regarding responsibilities makes them quite invaluable for the system. Currently the total numbers of nursing professionals around the globe are hard to calculate as every region and country has a different method of defining a nurse and what and who come under the definition of a nurse. (Calman and Bucham, 2004) Countries may include midwives and auxiliary personnel as nurses, or they may not. Similarly, nurses may be counted on the basis of their numbers, on the basis of their qualification, on the basis of the registered numbers, on the basis of the kind of jobs that they take care of, either separately or taken together. Similarly, different regions may undertake a different definition of a nurse and calculate them according to the set definition or guideline. All in all, there is no way to determining exactly how many personnel are currently constituting the nursing force of the world. With the absence of this information, it is difficult to calculate the shortage of nurses according to area and how many are available to fill the gap. Similarly, it becomes difficult to assess if there is actual surplus or deficit in the number of nurses in a region. (Calman and Bucham, 2004)

            The variations of nursing staff can be different for the same country and region as well, and clearly seen when the urban health care settings contain more nursing staff numbers than the rural areas of the same country. This could be due to improper allocation of the staff and resources, or the absence or lack of health care facilities in the underdeveloped areas within a country. The problem therefore is seen even a grass root levels of the health care systems. (Calman and Bucham, 2004)

            Despite the lack of proper numbers of nurses around the world and in particular areas, there is still some statistical evidence to help calculate the averages of nursing professionals in given regions. It has been calculated that certain areas of the globe have below than average numbers of nurses in a given population, marking these areas as in intense shortage of the nursing force. Among these, Africa and South East Asia suffer the most from the lack of nursing staff. Other areas of the globe include South and Central America, Liberia, Uganda, and Central African Republic to name a few. The compounding factors in these regions is the lack of proper health care delivery systems which could have helped in managing the crisis a little better. Europe and the OECD countries are perhaps the only countries that are enjoying the highest nurse to patient ratios, but even these are below the required numbers for the populations. Hence the numbers of nurses in all areas of the globe are very less, but are felt differently according to the severity of the situation. Even within regions different areas and countries may experience varying severity, for example, American region experiences marked differences in the ratios between the north and south Americas.(Calman and Bucham, 2004)

Significant changes in basic technologies and globalization have been some of the most significant trends in the health care industry. Importing health care professionals and exporting the health care data analysis via information technologies has increased over the past decade. Currently, recruitment and retention are the number one emerging trends in healthcare industry due to shortage of healthcare professionals including registered nurses and laboratory technologists.  In 2000, the national supply of registered nurses was estimated at 1.89 million while the demand was estimated at 2 million, a shortage of six percent; which is estimated to grow to 29% by the year 2020 (Cordeniz, 2002, p.14).

Trends in the shortage in the market for healthcare providers include increasing globalization, technologies that are advancing by leaps and bounds as well as changes in demographics.  Demographic changes affect the patient care along with how many and how specialized the workers are.  Technological change affects the healthcare diagnosis management system and patient care. Globalization influences the ability of abroad personnel to engage in domestic telemedicine, electronically data driven and technological driven healthcare. According to Irwin (2001), nursing and healthcare professional markets reached a surplus in 1990s from shortage in late 1980s, and reverted back to shortage in the current century.

The precise nature of the shortage of healthcare professionals is not clear as the problem may be related to other healthcare issues. Rising healthcare costs, increasing regulatory constraints and requirements, working environments, and limited promotional opportunities inhibit the ability of vacancies in health care staffing to be filled. Healthcare professionals’ migration to more affluent countries creates shortage of staffing in developing countries. Many countries have implemented recruitment strategies to increase their supply of nurses (Irwin, 2001) by advertising campaigns, sign-in bonuses, educational opportunities, and expanding geographic boundaries to other nations. However, importing professionals from abroad only not only delays the implementation of effective measures but raises other issues for healthcare strategic and marketing planning (Buchan, Parkin, & Sochalski, 2003).

Human resource management includes not only consideration for staffing needs but also labor practices, hiring, firing, interviewing, non-discrimination policy, and federal legislations such as The Fair Labor Standards Act, The Equal Employment Opportunity Act of 1972, and The Federal Privacy Act of 1974. Healthcare executives do not want to recruit the wrong employee, experience high turnover, manage difficult people, or engage in risk liabilities. Nursing professionals must perform the eight clinical support services (CSSs) functions, which include: direct care, timeliness, staff and equipment planning, amenities and marketing, scheduling, performance benchmark and process change, budgeting, and human resources management (Griffith & White, 2002, p. 377). Therefore, it is essential that human resource management’s plan for training new employees allows the organization and employees adequate time to respond to changes in the exchange environment with replacement, increases or decreases in the number of members.

According to Fottler (2005) strategic human resources management (SHRM) refers to the comprehensive set of managerial activities and tasks related to developing and maintaining a qualified workforce, which then contributes to organizational effectiveness as defined by the organization’s goals (p. 2). The competitive advantage of the correlation study will promote cost leadership by reducing the cost and product differentiation by increasing the quality of performance standards. The study of HRM practices and productivity levels concluded that those with a high rating for the presence of benefits such as incentive plans, employee grievance systems, formal performance appraisal systems, and employee participation in decision-making, outperform those with low ratings (Huselid, 1994; Huselid, Jackson, & Schuler, 1997). Fottler (2005) cites the 12 HRM practices for healthcare organizations include: employment security, recruiting preferences, high wages, benefits, information sharing, participation and empowerment, self-directed teams, training and skill development, cross-utilization and cross-training, symbolic egalitarianism, wage compensation, and promotion from within (Pfeffer, 1995).

The current SHRM trends affect job analysis and planning, staffing, training and development, performance appraisal, compensation, employee rights and discipline, and employee and labor relations (Fottler, 2005). Compared to old tradition, current trends for training and development require each employee to be responsible for career development and also require creating a skilled employee with training rather than hiring a skilled and experienced employee by the HR department (Fottler, 2005). Ricketts (2005) indicates five basic strategies for planning workforce, which include: population-based estimating, benchmarking, need-based assessment, demand-based assessment, and training-output estimating. These strategies can be used in combination, for example, population-based estimation correlated with training-output estimation may lead to balance investments in training programs for group specific or the overall population of the healthcare organization.

            If the issues of current nursing practice were to be categorized, there are three categories under which accommodate them. The universal problems that are faced by developed and underdeveloped countries alike include shortages of nurses with ineffective planning to reduce the situation. Other factors are the lesser numbers enrolling in nursing education due to lack of incentives, reform and use of skills. The demographical statistics show variance in the patterns leading to nursing shortages. In the developed countries, lack of nursing is due to the increase in the number of the population, while in the underdeveloped countries, this is due to decreasing nurse pool because of both aging nurses as well as the population. The third category is the main influencing factors in the nursing shortage in particular parts of the globe. In African regions for example, the main issue is the increased rates of HIV and AIDS, and low ratios of nurses to populations. In central and south America, the nurses are in low numbers compared to other health care staff. In other areas such as west pacific, Caribbean, some African countries, South East Asia etc., there is increased vulnerability to out migration. (Calman and Buchan, 2004).

In response to current crisis of nursing shortage, Federal and state agencies, legislatures, professional nursing organizations, and private philanthropies have all responded with analysis, recommendations, and in some cases recruit resources from abroad as a temporary remedy (Kimball et al., 2002). Currently foreign-trained nurses account for nearly 15% of the nation’s nursing workforce and the Bureau of Labor Statistics estimates that the nations’ health care system requires more than 1.1 million new nurses through 2012 (AHA, 2006). South Nassau Community Hospital in Oceanside, New York had begun recruiting RNs from the Philippines and India six years ago when hospital’s RN vacancy rate was 13% (AHA, 2006). The Securing Knowledge, Innovation, and Leadership Act (SKIL bill) is supported by many hospital administrators to address the issue of shortage of nurses (AHA, 2006). In support of SKIL bill, on August 31, 2006 Phyllis Norman, a vice president of patient care services of Harris Methodist Fort Worth, Texas, said that without RN shortages can translate into closed hospital beds, over crowded emergency departments, delayed treatment and the elimination or reduction of services (AHA, 2006).

The current literature on outsourcing indicates buoyant global trade in domestic care services, with a massive and increasing demand for migrant domestic workers throughout wealthier countries like the U.S., Belgium, France, Germany, Greece, Italy, Luxembourg, Spain, and Switzerland. It also indicates a supply of domestic workers by a range of less wealthy ones such as Philippines, Dominican Republican, Peru and Morocco to Spain, Sri Lanka to Singapore, Saudi Arabia, Kuwait and Canada, Thailand to Hong Kong, Poland, Albania and Bulgaria to Greece, Mexico, Central America and the Caribbean to the US, (Yeates, 2005, Ehrenreich and Hochschild, 2003, 276-80). Thus a substantial transformational care service economy can be dated back to the nineteenth century when it contributed to the industrialization processes in both care and labor in exporting and importing countries in ways that have been observed in the contemporary industrialization strategies of certain Asian countries (Yeates, 2005, Katzman, 1978, Chin 1998, Haung and Yeaoh, 1996). Historically, the major trend in the 1990s was the increased reliance of the Irish health system on nurses migrating from EU and the traditional direction of care labor migration between Ireland and the UK in particular was reversed (Yeates, 2005).

Furthermore, this inward migration occurred alongside the continued outflow of Irish nurses to other countries, primarily the UK and Australia. In addition, international demand has been for Irish nurses with specialist skills, particularly in fields such as midwifery, intensive care and surgical operation and theatre work, and other peripheral countries’ economies are not supplying the general nursing labor that Ireland formerly supplied (Yeates, 2005). Yeates study (2005) also notes that as demand for nurses increased world wide, the Philippines became target as a major reservoir of nursing labor, and Ireland quickly became a major destination for Filipino nurses in year 2002 (third largest importer of Filipino nurses, after Saudi Arabia, and the UK). The international nurses’ labor recruitment provided earning to Irish, Filipino, and other foreign country nurses in the immediate and longer term by working in the United States and other wealthier countries while their labor sources were enjoying better conditions and career prospects outside of nursing (Yeates, 2005).

However, despite the availability of nurses to migrate, focus groups conducted in eight cities in the US and Canada cited language, culture, and differences in the practice of nursing as major challenges facing nurses who are educated abroad (Loquist, 2002). The suggestions by JNPC Subcommittee may remedy these problems. First, international nurses might be employed in a position related to nursing prior to obtaining U.S. licensure (Dumpel, 2005). Second, many changes have taken place in immigration policies that pose difficulties for international nurses trying to navigate the immigration process. The recent cap on immigration visas for nurses attests to that fact (AHA, 2006). Third, the transition is simpler for foreign nurses whose home language is English. Fourth, having access to a social support group makes the transition much easier. Fifth, employers’ expectations and readiness to provide support affect the ease of assimilation and transition. Finally, the degree of similarity between nursing practices in the nurses’ home country and the U.S. influences the assimilation and transition process.

The Subcommittee also recommended a number of strategies for facilitating the successful assimilation and transition of foreign nurses including language classes, preceptorship and mentorship, support groups, and orientation programs (Dumpel, 2005). The members acknowledged that these strategies basically reflect practices used to promote the integration of the three domestic transition groups. Several sources documented the effectiveness of these techniques for facilitating the integration of ethnic minority nurses (Fletcher et al., 2003), international nurses (Gerrish & Griffith, 2004), and new graduate nurses (Block et al., 2005; Lindsey & Kleiner, 2005). To meet the demands for health care in the U.S., Brush et al. (2004) call for a comprehensive plan that that balances the recruitment of foreign nurses, domestic production, and intensive efforts to retain qualified nurses.

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