AJN/February 1998/vol.98, no.2 |
| Washington Watch | Issues Update | ANA Resources | Vital Signs |
by Michael Stewart
Nurses in the U.S. can expect to feel the impact of global trade in their profession, whether or not they ever intend to work abroad. The North American Free Trade Agreement (NAFTA) "supports a trade in nurses' professional services," says Stephanie Tabone, BSN, RN, director of practice for the Texas Nurses Association. Texas has had an influx of Canadian Trade-NAFTA (TN) visa nurses, mainly due to recruitment efforts by Texas facilities and the lure of a warmer climate.
"It's not futuristic. Your professional value is being traded now," Tabone warns, "whether or not you ever leave the country. You'd better be interested in trade and in leveling the playing field for all RNs." However, in spite of the work ahead to ensure equity for U.S. nurses, "international trade in our services is both inevitable and exciting," she says. "Every U.S. nurse is an international nurse."
The ANA is supportive of the concept of mobility as long as it provides equal opportunities for U.S. nurses. A chief concern is that increased mobility will undoubtedly lead to increased competition for American nurses. "U.S. registered nurses will have to be prepared to be more competitive against an international pool of nurses who are likely to be baccalaureate-prepared and willing to work at a wage below the prevailing U.S. rate," says Cheryl A. Peterson, MSN, RN, senior policy fellow, international affairs, ANA's Department of Health and Economic Policy.
The ANA has been working on many fronts to ensure fair play for U.S. nurses; they successfully advocated for a delay of Congressional "fast-track" trade legislation, in part because the legislation's extension proposals focused on trade in goods, not services. As a result, nursing's concerns were not addressed. The ANA is "committed to international trade agreements that protect and enhance all participating countries' public health systems and promote rising wage standards and working conditions for nurses," says Peterson. "Global trade shouldn't move ahead at the expense of nurses and quality care ."
The ANA also worked closely with Representative Bobby Rush (D-IL) and Senator Richard J. Durbin (D-IL), who introduced legislation (HR 2759) designed to allow for limited, temporary immigration of foreign nurses to work at hospitals that are having difficulty recruiting domestic RNs.
The bill was spurred by nurse staffing needs at two hospitals--one in Chicago and one in Laredo, Texas--and would establish the H1-C visa to allow foreign nurses into a small number of U.S. hospitals that meet carefully defined shortage criteria.
The ANA was successful in including certain protections in HR 2759. Among them was a provision that domestic nurses be notified when a hospital intends to hire H1-C nurses, and that hospitals may not use H1-C nurses if a labor dispute is in progress or if they have laid off RNs in the previous year. Representatives from the Illinois Nurses Association, and the Chicago chapters of the National Black Nurses Association and the Philippine Nurses Association of America, worked with the legislators and the Chicago hospital to help ensure that the hospital's efforts to recruit U.S. nurses are monitored should HR 2759 pass.
Such protections are crucial, according to Nancy McGuckin-Smith, MPH, RN, executive director of the Hawaii Nurses Association. "Trade-in-services agreements tend not to address U.S. labor issues--for instance, the hiring of foreign nurses to replace striking U.S. nurses," she says, adding that nurses need to become much more aware of mobility.
Hawaii has long been a prime destination for both U.S. and international nurses, particularly those from Pacific Rim countries, including the Philippines and Canada. "Get prepared," McGuckin-Smith says. "These are major changes. There may be a significant increase of foreign nurses when we have national licensure."
The contributions of international nurses in the United States are as varied as those of U.S. nurses. However, of special significance are these nurses' contributions to positive patient outcomes in terms of multicultural awareness and bilingual (or multilingual) ability. "In a diverse America, these contributions cannot be minimized," Peterson says. Foreign nurses will prove especially valuable in the next century as the U.S. patient population becomes increasingly diverse. (See the January-February 1998 issue of The American Nurse, which explores cultural diversity among patients and nurses.)
Despite the positive contributions that foreign nurses can make to nursing in this country, they still face challenges entering the U.S. to practice. "Private market forces set one such challenge in that entrepreneurial placement agencies may charge 10 percent of the nurses' salaries as fees," explains Jane Weaver, JD, RN, former director of the ANA International Nursing Center. "Foreign-educated nurses may also have to produce nursing school transcripts and their high school diplomas. They may have to prove that their secondary education is equivalent to a U. S. nurse's high schooling, not always simple when educational systems differ. They must pay to have these documents translated into English. They pay to travel to a location where they can take the Commission on Graduates of Foreign Nursing Schools [CGFNS] tests, and pay lodging costs while there."
CGFNS prescreening includes a predictor examination that indicates potential passage of the National Council Licensure Examination, English proficiency testing, and review of the license in the home country to ensure that it is unencumbered.
"Of course, U.S. nurses may face similar challenges if they wish to work abroad," says Weaver. "However, particularly for nurses in developing countries, the financial and personal costs of preparing to work in the United States are high."
Foreign nurses who already are practicing in this country also face their share of challenges. "There's nothing in place to ensure that foreign nurses understand U.S. and state law. Under NAFTA, a foreign nurse is supposed to be treated like any other RN, but she's not like any RN," says Tabone, because foreign nurses don't know about our wage and hour laws, placing them at a disadvantage. She points out that American nurses who report abuse of wage and hour laws affecting foreign nurses are also at a disadvantage, and that some foreign nurses don't know about the American democratic process and their right to engage in concerted activity in the face of abuse. "One exploited RN," Tabone says, "no matter where, is our nurse. International nursing is something we will all desire in the not-too-distant future. But we want some say in how we get traded."
According to Peterson, there's a tremendous potential in developing countries for U.S. nurses to set up community health centers. Private sector health care is growing, particularly in Latin America. But U.S. nurses wishing to work abroad also face hurdles. Among them is an inequity under current NAFTA treaty provisions toward U.S. nurses who seek to work in Ontario or Quebec. Currently, U.S. nurses wanting a license to practice in these two provinces must be a permanent resident, or obtain Canadian citizenship. This is a direct contradiction to the basic principles upon which NAFTA was negotiated. No similar barrier faces Canadian nurses wishing to work in the U.S. For Canadian nurses, says Peterson, "the process of getting a TN visa is easy. Show you have a job in the country you're going to and that you've met the requirements for licensure."
Mexican nurses must meet the same requirements as Canadian nurses. However, there is a NAFTA limit of 5,500 nurses per year who may enter until 2004. Currently, there are fewer Mexican nurses than Canadian nurses entering the United States to practice. McGuckin-Smith notes that though it's difficult for American nurses to work in England, Australia, and Canada, it is relatively easy for nurses from those countries to work in the U.S. Peterson concurs. "The playing field is far from level for U.S. nurses," she says. "As the U.S. readies to enter into trade agreements with other nations--Chile being the next likely candidate--the ANA is acting now, before current and future inequities are cast in stone and before entering into a free-trade relationship.There has been far too little focus to date on the labor implications of international trade in professional services for both U.S. and foreign nurses."
She adds that international mobility benefits nursing and world health. "But exchange must be on a level playing field, and we must have access to foreign markets. This means that foreign nursing wages be competitive with U.S. wages," says Peterson. And unless wages are competitive, says McGuckin-Smith, "all we have is a trade agreement, not a fair trade agreement."
International mobility of nurses will continue to be a critical issue because global trade in professional services affects the economic value of registered nurses' services, regardless of whether they work in the U.S. or abroad. In the coming year, the ANA will continue to advance the causes of quality nursing and patient care through the protection of all nurses--domestic and foreign. This will be accomplished through close attention to and influence upon the complex patchwork of trade agreements, labor issues, immigration legislation, and private market forces that together comprise the challenge of global nursing.
Michael Stewart is senior public relations specialist in the ANA's Department of Communications.