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1st AONE Conference: Reflections Of A Grateful Team

by Zlata A. Dikaya & Conor Shanahan

On November 6 and 7, 2003 the American Organization of Nurse Executives (AONE) organized and hosted its first conference "Foreign Nurse Recruitment: Getting It Right" in Philadelphia, Pennsylvania. The theme for the conference was obviously dictated by growing concerns in the healthcare industry with regard to the increasing nursing shortage in the U.S. AONE responded with a great idea to gather representatives of hospitals, nursing credentialing and licensing organizations, recruitment companies, staffing agencies, and immigration lawyers to share their practical advice and experience on how to bring foreign registered nurses (foreign RNs) to lessen the growing shortage.

On the eve of the conference Rita Turley, President of AONE, welcomed participants to exhibit information about their respective organizations and therefore, gave everyone a great networking and learning opportunity. We personally enjoyed many exhibitions that generously poured on us useful information about the nurse recruitment and management. We are likely to speak for the majority of participants when we say that one evening was hardly enough to absorb all the information available and form important personal contacts. Therefore, we hope that the next AONE conference coming in the spring of 2004, will allocate more time for exhibitors' presentations.

AONE was also very successful in assembling the outstanding faculty of experts for the conference who, among others, included Barbara Nichols, CEO of Commission on Graduates of Foreign Nursing Schools (CGFNS), Nancy Chornick, Director of Credentialing at National Council of State Boards of Nursing (NCSBN), Debi Gamble, Director at International Quality Healthcare Professional Connection, Carl Shusterman, an immigration attorney from California, and Cathrene Walsh, Vice-President at Mercy Hospital and Medical Center.

Below we summarize several important issues that were highlighted and discussed during the conference.

1. Healthcare Workforce trends and foreign nurses' demographics

Due to the fact that the U.S. has been the most aggressive recruiter of foreign registered nurses, foreign nurses have become a part of the U.S. workforce since the beginning of 1940s. Since then more than 25 million foreign RNs have emigrated to the U.S. from such countries as Canada, India, and the Philippines. Since the middle of last century most foreign RNs have been entering the U.S. as permanent residents or under trade NAFTA ("TN") status. A smaller fraction of nurses have come under a temporary working status. A majority of the foreign RNs have settled in New York, Los Angeles, Chicago, Miami and Houston.

Despite the 25 million assimilated foreign RNs, most states are projected to face a 20 to 45% shortage by 2010, and therefore, the U.S. hospitals have been actively pursuing sources of qualified registered nurses. According to the latest Labor Department estimate, this shortage will likely worsen since the supply of domestic RNs will not be able to keep up with a predicted additional million of nursing jobs to be created by 2010. A majority of new nursing jobs will be generated in the nursing care facilities, fewer in hospital care facilities. Curiously, only a small fraction of foreign RNs who worked in nursing care facilities expressed job satisfaction, comparing to an overwhelmingly high percentage of foreign RNs working in hospitals who reported being highly satisfied.

According to CGFNS statistical data, a typical foreign RN is a female of Asian or Caucasian decent with a Bachelor's of Science in Nursing and an average work experience of 5 or more years. Unlike domestic RNs, foreign RNs have a better formal nursing education and a better experience, primarily in critical care and adult health care. Interestingly, since the incoming foreign RNs come to the U.S. and start their career from the beginning, they earn less than domestic RNs with the comparable experience and training. The main employment pattern for foreign RNs includes a staff position in adult or critical care at a major hospital.

2. Nursing Executives' Dilemma: Foreign Recruitment vs. Staffing Agency

Hospitals already experience negative consequences of the current nursing shortage ranging from reduction of hospital beds, cancellation of necessary medical procedures and increasing risk of patients' health' deterioration. Therefore, it was not surprising that participants at the conference were tremendously interested in information about opportunities to increase and maintain the acquired RNs.

The verdict was quick and inevitable. With the lack of sufficient domestic supply of RNs, hospitals are now faced with two major ways to attract potential RNs: to use temporary RNs from staffing agencies or to recruit foreign RNs. While both approaches aim to reduce a hospital's nursing shortage, each individual approach is different and displays a fair share of both positive and negative consequences.

The staffing agency approach praises the solid and consistent database of qualified domestic RNs who are licensed, experienced and available immediately to take an assignment with the hospital. The major drawbacks of the whole approach are high cost, high cost, high costů and the temporary nature of nurses' assignments, since assigned RNs are not to fill hospitals' permanent vacancies. In the long run, this approach reduces to paying at least twice as much for an extension of the shortage status quo.

The foreign recruitment approach focuses on a wide pool of qualified foreign RNs and their permanent placement in hospitals through foreign nurses' permanent residency in the U.S. While the cost is reasonable and acceptable, the major drawbacks of foreign recruitment include timing due to a complicated immigration process and a foreign RNs' assimilation to new culture and hospitals' environment. Participants at the conference stressed the fact that it is crucial to recruit foreign RNs who are familiar with the U.S. nursing education and proficient in English language. Therefore, foreign RNs from Europe, Canada, and Philippines have a better chance to ultimately succeed in the process. In the long run, the foreign recruitment approach has a great potential if it gradually evolves into a sophisticated strategy that integrates legal advice, licensure guidance, test preparation and cultural assimilation advice.

3. Untangling the Immigration Maze for Foreign RNs

With the H-1C visa program sun setting in 2004 and a bachelor's standard of the H-1B program that makes it virtually impractical for foreign RNs, the only two solid immigration venues for foreign RNs available are a broad permanent residency option for a qualified foreign RN, regardless of his/her nationality, and a TN status option limited to Canadian and Mexican RNs.

Foreign RNs enjoy the luxury of the U.S. permanent residency option due to the Department of Labor determination that a nursing profession belongs to the Schedule A occupations - those officially designated to suffer from nationwide labor shortage. On the contrary, TN nurses from Canada and Mexico enjoy only the luxury to freely come and temporarily work in the U.S. Due to the fact that Canada, except the province of Quebec, and the U.S. share the same language, the Canadian RNs, unlike the Mexican RNs, obtain a U.S. nursing license by endorsement and can work almost immediately in the U.S. The procedure for the Mexican RNs under TN status is more burdensome and, as a result, only up to 20 Mexican nurses come to the U.S. under TN status annually.

However, it would be unreasonable to think that foreign RNs can achieve U.S. permanent residency easily. The U.S. government by allowing health industry employers to sponsor foreign RNs for the permanent residency has established rigorous licensing and certification requirements for foreign RNs to protect American patients and ensure general safety of the American people.

When applying for permanent residency, foreign RNs are required to have their nursing education reviewed for equivalency with U.S. standards, their nursing licenses verified for good standing, and their English language skills examined for competency. In addition, foreign RNs must take a special predictor nursing knowledge test administered by CGFNS (a majority of the states require such testing) and pass the Nursing Council Licensure Examination for RNs (NCLEX-RN). On top of all this, foreign RNs must succumb to the VisaScreen certification and renew it every 5 years.

On July 26, 2003 the last requirement of the VisaScreen certification became applicable to foreign RNs in non-immigrant visa status (H-1B or H-1C) and those under TN status. However, foreign RNs in the above two categories were granted a temporary exemption from the VisaScreen certification requirement for one full year (until July 25, 2004) to allow foreign nurses adequate time to complete the certification.

4. National Council of State Boards of Nursing: Role and Important Statistics

The National Council of State Boards of Nursing (NCSBN) has always been perceived as the regulatory board that influences and advises the State Boards on appropriate educational and credentialing standards applicable to foreign RNs. At the conference Nancy Cornick, the NCSBN Credentialing Director, dismissed this perception asserting that the National Council has been primarily a research institution, not a regulatory entity of state nursing boards. NCSBN aims to reflect nursing education standards and credentialing requirements currently in force in the states and prepare statistical data on the nursing trends.

According to the NCSBN statistics, since 1996 26,000 less domestic RNs have been tested by the Council for the nursing licensure exam (NCLEX-RN). During the same period of time, the number of foreign RNs tested for NCLEX has doubled, from 12,000 to 24,000. This statistics clearly shows that more foreign RNs have sought to be licensed in the U.S., proving that either more U.S. healthcare industry employers are interested in foreign RNs or the foreign nurses themselves believe that they have a better chance being recruited if they pass NCLEX.

Overall, a majority of the states require foreign RNs to take a predictor CGFNS qualifying test before RNs are allowed to sit for NCLEX. Thirty-two state boards require either a CGFNS exam or a CES (credentialing evaluation review) report before they issue permission to take NCLEX. Only a handful of states (for instance, California and Florida) perform their independent review of foreign RNs' credentials, and it is a great burden on the state board. From the available data, the National Council concludes that foreign RNs face a major credentialing barrier, because they lack sufficient training in psychiatry and pediatrics and usually have to take additional courses to remedy such an insufficiency.

At the conference Nancy Cornick revealed a stunning statistics about the CGFNS exam pass/fail rate among all registered nurses. In general, approximately 50 percent of those taking the predictor CGFNS exam will fail it, and therefore the other 50 percent will have a passing score. Out of the 50 percent of successful takers, 80 percent will pass CGFNS exam on their first attempt. If a nurse passes CGFNS, her chances to pass NCLEX increase dramatically and he/she is likely to pass NCLEX on the first try.

The overall NCLEX passing rate for U.S. educated RNs is approximately 80% comparing to the rate of approximately 40% for foreign educated RNs. The major reason for such a difference in passing scores is the poor English skills of foreign RNs. Surprisingly, the more times foreign RNs take either the predictor CGFNS test or NCLEX hoping to pass, the less chances they have to succeed.

The National Council also shared its plans concerning international testing for NCLEX. It is a sensitive issue for many recruiters who have to fly foreign RNs to the U.S. for NCLEX, because at present NCLEX is offered only in the U.S. According to the National Council, international testing will be offered starting in January 2005. At the beginning NCLEX will be offered only in three or fewer locations worldwide. These locations will be chosen according to the particular NCSBN criteria. NCSBN also plans to establish a Foreign Nurse Subcommittee to monitor and study issues related to foreign RNs.

5. New home: Recruitment Ethics and Cultural Assimilation

In many presentations the issue of ethics in foreign recruitment surfaced many times. Hospitals are primarily concerned about unethical recruitment practices, particularly such as collection of money from foreign nurses for an employment opportunity in the U.S., false promises to foreign nurses, and untrue information to hospitals about the hiring and immigration process. Many hospitals now are very cautious about unethical recruiters who charge, but do not deliver.

Several measures have been suggested to avoid practices of unethical recruiters, including verification of recruiters' credentials, definite terms of the contract to avoid hidden costs and charges in the future, and availability of competent legal expertise. The Government of Philippines, for example, has established the Philippines Overseas Employment Agency (POEA) that licenses and supervises activities of recruiters of Filipino registered nurses. At present, one cannot recruit in the Philippines unless the license is obtained from the POEA. Verifying whether the recruiter in the Philippines has such a license can be a very important safeguard on hospitals' behalf.


The effected customer - the entire healthcare industry - is strained by the current nursing shortage and is desperate to figure out the best way to lessen the severe consequences of such a shortage. The healthcare industry will have to make the ultimate decision on how to cope with the long-term deficiency of RNs in the U.S. It appears appropriate and timely for the healthcare industry to stand up as a united front and demand real solutions to the shortage problem by either making the nursing profession an appealing occupation to young Americans, lobbying the Congress for a particular temporary visa category specifically designed for qualified foreign nurses or abolishing the repetitive nature of VisaScreen requirement to help foreign RNs immigrate. One thing is certain: whatever course of action the health industry chooses, it must do so quickly.

This AONE conference has contributed significantly to raising awareness about the current state of the nursing shortage and to promoting foreign recruitment as the feasible means to reduce it. The conference has become an important milestone for the healthcare industry and undoubtedly has a great potential to become the national forum on the issue of foreign RNs' recruitment.

About The Author

Our grateful team included Zlata Dikaya, an attorney with the firm of Johnson, Murphy, Hubner, McKeon, Wubbenhorst & Appelt, P.C. in Riverdale, NJ who practices exclusively in the area of immigration and nationality law, and Conor Shanahan, Managing Director of ENA Europe, the Irish partner of EuroNurseAmerica, LLC a foreign nurse recruitment firm sourcing registered nurses from Ireland, the UK, and Scandinavia. Zlata can be reached at or at 973-835-0100 and Conor can be reached at

The opinions expressed in this article do not necessarily reflect the opinion of ILW.COM.