However, where is the discussion about the hospital in Zambia that requires 1,500 nurses to function effectively, but currently has only 500 nurses on staff? And where is it addressed that while 10 years ago in Poland more than 10,000 new nurses graduated annually, today that number is at 3,000? Even Canada has projected that by 2011 it will need at least 10,000 nursing graduates per year to replace those leaving the workforce, compared with approximately 5,000 now coming out of their nursing programs annually.1 According to the World Health Organization (WHO), each of the six regions it monitors are reporting shortages of nurses and the inability to meet demands for nursing services. With insufficient numbers of nurses so widespread, countries are increasingly recruiting nurses from outside their borders.

Discussion of this practice reflects the impact on health care in the countries losing nurses to recruitment. Fundamentally, the ANA recognizes and strongly upholds the right of individual nurses to migrate, and it recognizes the great value in the sharing of ideas brought about by cultural exchange. However, the ANA has an obligation to its members and to the worldwide nursing community to ensure that the importation of foreign labor is not seen as an alternative to addressing the causal factors of the U.S. staffing crisis. To this end, the ANA continues to advocate against a change in U.S. immigration policy that would open the floodgates to foreign-educated nurses and adheres to the statement from the status report, Nursing Workforce and the Environment of Care, presented at the 2000 ANA House of Delegates meeting (see ANA Targets Proposals to Change Immigration Law, at right).

"It’s clear that nursing workforce planning needs to occur at all levels of government," says ANA President Mary E. Foley, MS, RN. "With our advances in communications technology and the ease of mobility, countries should be actively engaged in human resource planning so that the nursing needs of citizens are met. Planning can help ensure that when migration occurs, it happens without harm to nursing care and services, but instead to the benefit of the nursing profession and all patients."

INTERNATIONAL INITIATIVES: THE ICN AND THE WHO

Human resource planning, the nursing shortage, and migration were hotly debated topics at the recent ICN 22nd Quadrennial Congress held in Denmark. Even representatives from the Philippines Nurses Association, historically a well-developed source of registered nurses, expressed concern about the recruitment, not of their new graduates, but of their experienced registered nurses. Delegates to the ICN’s Council of National Representatives’ meeting held during the Quadrennial Congress called on the ICN to develop guidelines that can be used at a national level concerning the international recruitment of nurses. The ANA intends to work collaboratively with the ICN in the development of these guidelines and will consider possible ways to use the guidelines in the United States.

During the World Health Assembly meeting last May in Geneva, Switzerland, attendees representing the Ministries of Health of WHO member countries debated the report Strengthening Nursing and Midwifery: Progress and Future Directions– 1996-2000 and its recommendations for improving the profession. This report, published by the WHO in 2001, highlighted the fact that workforce shortages are particularly acute in developing countries, and noted that "unstable funding of the health sector, low salaries, and poor working conditions contribute to migration of providers to the private sector or to countries offering better prospects."3 These factors are not unique to developing countries. In fact, except for migration, they are exactly the same factors that are contributing to the current U.S. staffing crisis. Many country representatives addressed the need to educate more nurses and to examine processes that will allow for better utilization of nurses and nursing services.

The report makes several recommendations for consideration by member states and the WHO secretariat, designed to increase use of nurses and midwives for cost-effective health care, especially to vulnerable and marginalized populations. The WHO is called upon to apply its resources-financial, organizational, and human-toward accomplishing the recommendations. The final recommendation calls for the development and use of ”uniform indicators” to measure, monitor, and report progress made, and calls for a progress report on the implementation of these resolutions at the 2003 World Health Assembly. This is a significant recommendation that requires an active and ongoing review on the part of the WHO. The ICN has already begun working toward identifying and developing the uniform indicators that should be used to improve and strengthen nursing and midwifery. Nursing organizations and leadership in every country will also need to work with governments and policy makers to ensure that the report–s recommendations are embraced and that strategies to carry them out will benefit and advance the profession, creating better health outcomes and access to health services. The ANA intends to use this report and its recommendations to work with our federal government and others to address the serious staffing and nurse shortage issues that continue to plague the United States.

ANA Targets Proposals to Change Immigration Law

Position statement condemns certain recruitment practices.

The International Council of Nurses (ICN), in its position statement Nurse Retention, Transfer and Migration, recognizes the right of individual nurses to migrate, while acknowledging the possible adverse effect that international migration may have on health care quality. However, the statement also condemns the practice of recruiting nurses to countries where authorities have failed to address human resource planning and problems that cause nurses to leave the profession and discourage them from returning. The ANA believes that the U.S. health care industry has failed to maintain a work environment conducive to safe, quality nursing practice and one which retains experienced U.S. nurses in patient care. Therefore, the practice of changing immigration law to facilitate the use of foreign-educated nurses is a short-term solution that serves only the interests of the hospital industry, not the interests of patients, domestic nurses, or foreign-educated nurses.

Advice for the Weary

A worldwide survey yields suggestions.

The WHO report, Strengthening Nursing and Midwifery: Progress and Future Directions 1996-2000, included several recommendations for improving circumstances for nurses, midwives, and populations in need of health care.

• Strengthen national health policies, plans, and systems and enhance the contribution of nursing and midwifery services in meeting health needs, particularly those of vulnerable and marginalized populations.
• Establish comprehensive health workforce planning that will ensure that the nursing and midwifery human resources can meet the actual service and health needs of the population.
• Engage in dialogue with internal and external entities to seek solutions to the low levels of remuneration for health workers in developing countries, including nurses and midwives, and strengthen the incentives for effective recruitment, deployment, and retention.
• Identify priority areas in which solid evidence is needed to inform national health policy, particularly on the cost-effectiveness of nursing and midwifery services, and invest in systematic data collection and dissemination systems for best practices.
• Expand the nursing and midwifery service models based on evidence, with special attention to the populations in greatest need.
• Increase the opportunities to build leadership for nurses and midwives and strengthen their involvement in the management of health systems and in health policy development and decision-making processes.

Cheryl A. Peterson is director of the international nursing center at the American Nurses Association.

REFERENCES

1. Kingma M. The emerging global nursing shortage. Geneva: International Council of Nurses; 2001.
2. Congress on Nursing Practice & Economics. Nursing workforce and the environment of care. Paper presented at the House of Delegates, American Nurses Association; 2000, June 23-June 28, Indianapolis (IN).
3. World Health Organization. Strengthening nursing and midwifery: progress and future directions, 1996-2000. Geneva: WHO; 2001.

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