Immigration: More Foreign Nurses Needed?

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In 1994, 9% of the total registered nurse workforce was composed of foreign-born RNs; by 2008 that percentage had risen to 16.3%, or about 400,000 RNs, according to Buerhaus' research. Of those 400,000 nurses, about 10% had immigrated to the U.S. within the previous five years. About one-third of the increase in RNs from 2001 to 2008 was composed of foreign-born RNs.

Many U.S. nurses choosing not to work

The trend worries leaders of nurses' unions, who say importing workers can lower incentives to improve working conditions. Understaffing, mandatory overtime, and physically demanding work, such as lifting and bathing patients, take their toll. And while pay has risen in some regions to attract more nurses, in recent years it has flattened at the national level. That's why up to 500,000 registered nurses are choosing not to practice their profession—fully one-fifth of the current RN workforce of 2.5 million. Union leaders say the down economy is a chance to bring these nurses back into the field. "If unemployment is spiking, why do we need to bring in nurses from another country?" asks Ann Converso, president of United American Nurses, which represents 50,000 RNs. "We believe thousands and thousands of RNs would rejoin the profession if conditions improved." Converso says she doesn't oppose all overseas recruitment, but that lawmakers' focus should be on improving staffing ratios in hospitals to improve working conditions. "We have to again allow nurses to do what they do best: care for human beings," she says.

Mick Whitley, managing director of London-based global health-care staffing firm HCL International, says there's no need for alarm about foreign nurses. He points out that since 2006 it has become increasingly difficult for foreign-born nurses to obtain green cards to work in the U.S.; an applicant backlog has built up as annual quotas have been reached. "While patients in U.S. hospitals wait and suffer from a lack of sufficient care, experienced and caring internationally trained nurses who want to come here to help are also waiting [for a green card] for as long as seven years," says Whitley, a former nurse in the U.K. and Australia. "It's great that President Obama has committed more money to expanding health care, but the nurses that will be necessary to staff such expansions are nowhere to be found—at least not here, not yet."

Moore of El Centro Regional Medical Center says his hospital has been waiting for two years for 20 Philippine nurses he recruited to obtain visas. He says in the meantime he's unable to find talent in the area. "We're in the poorest and least literate county in California, right in the middle of the desert," says Moore. "We're not a destination for [American] nurses." Moore has had success hiring Philippine nurses, many of whom choose to stay and settle in El Centro. To them the U.S. "is the land of milk and honey, and the streets are paved in gold," says Moore. "They're not so particular."

Moore denies he wants to hire foreign-born talent to hold down wages. "We pay [a nurse] fresh out of school $28 an hour and $35-$40 with experience," he says.

One point everyone seems to agree on is that the U.S. needs more capacity to train nurses. Since 2002, enrollments at nursing schools have increased so much that up to 50,000 qualified applicants are turned away each year from training programs. The main problem is a lack of teaching staff at these schools. Dan Stultz, president of the Texas Hospital Assn., which represents more than 500 Texas hospitals, helped form the Texas Nursing Workforce Shortage Coalition to push for funding from the state legislature to boost capacity at Texas nursing schools. Stultz says the state has about 22,000 nurse vacancies now, and that the number could rise to 70,000 by 2020. Meanwhile, for the last five years, 8,000 to 12,000 nursing-student applicants have been denied places at training programs for lack of space. "We have qualified people that get accepted and can't attend," says Stultz. "We don't need more immigration; we need to increase capacity and grow our own workforce."

Herbst is a reporter for BusinessWeek in New York.

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