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International Models of Nursing1

Barbara L. Nichols, D.H.L., M.S., R.N., FAAN

Catherine R. Davis, Ph.D., R.N.

Donna R. Richardson, J.D., R.N.

CGFNS International

EXECUTIVE SUMMARY AND RECOMMENDATIONS

The future of nursing in the United States will be shaped by an array of factors and forces—and each of these, in turn, will be shaped by the myriad international factors and forces created by globalization. This paper describes general trends and broad themes in globalization and international nurse migration, profiles nursing education, regulation and utilization in various countries, and relates them to the future of nursing, both in the United States and globally. It describes foreign-educated nurses in the United States workforce within the context of global variances in nursing education programs, credentialing mechanisms, and employment practices. It also provides a global snapshot of education and regulation in historic and emerging countries that have supplied migrant nurses to the U.S. workforce and describes their migration patterns.

The paper envisions a future with international models of nursing education, regulation and practice. Thus, the impact of international and regional trade agreements is described as they serve as catalysts for these international models. The paper asserts that nursing reform in the United States must be understood and envisioned within an international and historical context that integrates global trends and issues. Against this backdrop, the implications of migration and globalization for education, service delivery and health policy in the United States are identified and discussed.

1

The responsibility for the content of this article rests with the authors and does not necessarily represent the views of the Institute of Medicine or its committees and convening bodies.



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J International Models of Nursing1 Barbara L. Nichols, D.H.L., M.S., R.N., FAAN Catherine R. Davis, Ph.D., R.N. Donna R. Richardson, J.D., R.N. CGFNS International EXECUTIVE SUMMARY AND RECOMMENDATIONS The future of nursing in the United States will be shaped by an array of factors and forces—and each of these, in turn, will be shaped by the myriad international factors and forces created by globalization. This paper describes general trends and broad themes in globalization and international nurse migra- tion, profiles nursing education, regulation and utilization in various countries, and relates them to the future of nursing, both in the United States and globally. It describes foreign-educated nurses in the United States workforce within the context of global variances in nursing education programs, credentialing mecha- nisms, and employment practices. It also provides a global snapshot of education and regulation in historic and emerging countries that have supplied migrant nurses to the U.S. workforce and describes their migration patterns. The paper envisions a future with international models of nursing educa- tion, regulation and practice. Thus, the impact of international and regional trade agreements is described as they serve as catalysts for these international models. The paper asserts that nursing reform in the United States must be understood and envisioned within an international and historical context that integrates global trends and issues. Against this backdrop, the implications of migration and glo- balization for education, service delivery and health policy in the United States are identified and discussed. 1 The responsibility for the content of this article rests with the authors and does not necessarily represent the views of the Institute of Medicine or its committees and convening bodies. 

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 THE FUTURE OF NURSING Trends in International Migration Worldwide, demand for nurses exceeds supply and chronic shortages are characteristic of the current global nurse workforce. The 2006 World Health Re- port (WHO, 2006) identified shortages of human resources as a critical obstacle to the achievement of the Millennium Development Goals (MDGs) for improving the health of global populations.2 Moreover, the report identifies the importance of nursing as an integral element of health systems’ infrastructure. Various studies also have documented the important link between nurse staffing levels, service delivery and health outcomes, suggesting that important issues exist with respect to how the nursing health workforce is managed. One important factor that has received considerable attention is the mobility and migration of nurses and their impact on the global delivery of health services (Kingma, 2006). Globalization of the nursing workforce must be viewed within the context of the worldwide development of the knowledge economy. This phenomenon identi- fies intellectual capital as a valuable asset and encourages the export of educa- tion and knowledge workers as significant contributors to a country’s economy. For example, national policies in the Philippines and India support the export of nurses (Healy, 2006; Thomas, 2006) with China and Korea beginning to follow a similar path (Fang, 2007). The importance of the nurse export business is reflected in the exploding growth of nursing schools in the Philippines and India, and in the large sums of money received through remittances.3 Many countries, such as India and China, see the current demand for nurses as a business opportunity. Khadria (2007) describes the process in India as “business process outsourcing” (BPO). It in- cludes comprehensive training, recruitment and placement programs for popular destinations, like the United States and the United Kingdom. It is assumed that these growing markets facilitate care as a global product delivered by migrating nurses. Worldwide, the education and regulation of nurses is highly diverse and varies considerably in scope and complexity. Despite these international differ- ences, a number of factors allow nurses to migrate throughout the world, creat- ing continuous challenges to the maintenance of nursing education, practice and regulatory standards. For example, the United States is unique in having created 2 WHO estimates that the world needs to increase the number of health workers by more than four million. WHO defines health workers to be all people engaged in actions whose primary intent is to enhance health, such as doctors, nurses, midwives, and others. 3 The World Bank defines remittances as the personal earnings international migrants send back to their family and friends. Remittances represent an important source of added income and stability for individuals, families, and communities. Remittances play a significant role in reducing the level and severity of poverty (each social determinants of health) and contribute to the economic development in many low and middle income countries.

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 APPENDIX J CGFNS International to address these issues, thus creating a comprehensive data base on variances in nursing, education, regulation and practice worldwide, mak- ing it a global resource. A major challenge for all countries is to establish workforce planning mecha- nisms that effectively meet nursing resource requirements in terms of supply and demand. In that regard, nursing shortages in the United States mirror the growing interdependency of labor markets throughout the world and the need for national and international nursing workforce policies. The challenge for workforce plan- ning related to the global migration of nurses, however, is to focus not only on the number of nurses entering the country, but also on the number of nurses leaving the country, the number of new nurse graduates and the effect of internal migra- tion, such as the movement of nurses from state to state and from rural to urban areas. Also essential is an understanding of the education and licensure systems of migrating nurses to ensure a proper skill mix for the nursing workforce of a country (Kingma, 2006). Thus, the global nurse workforce must be viewed, not only within the context of the health status of nations, government investment in health budgets, nurse/ health care migration, economic realities, and working conditions but also within the context of the diverse preparation and practice of its practitioners. Recommendations for the Future of the U.S. Nursing Workforce The authors believe that the Committee has an unparalleled opportunity to challenge the status quo in nurse utilization and to significantly contribute not only to a national but also a global health workforce agenda. Such an agenda requires reliable, stable and competent nurses functioning at all levels of health care systems. The authors have provided specific recommendations for your con- sideration, and present them within a contextual framework that acknowledges the historic and current leadership role U.S. nursing plays in the international nursing community. That framework suggests that the Committee’s recommen- dations will have dramatic domestic and global implications. The authors have identified six recommendations for action: 1. Promote targeted educational investment in foreign-educated nurses in the U.S. nursing workforce. 2. Promote baccalaureate education for entry into nursing practice in the United States. 3. Harmonize nursing curricula. 4. Add global health as subject matter to undergraduate and graduate nurs - ing curricula. 5. Establish a national system that monitors and tracks the inflow of foreign-educated nurses, their countries of origin, the settings in which

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 THE FUTURE OF NURSING they work, and their education and licensure to ensure a proper skill mix for the U.S. nursing workforce. 6. Create an international body to coordinate and recommend national and international workforce policies. Recommendation 1: Promote Targeted Educational Invest- ment in Foreign-Educated Nurses in the U.S. Nursing Workforce One response to the global shortage of nurses is to increase the number of nurses produced. Scaling up the health workforce is on the global agenda (Vujicic et al., 2009). Likewise, the growing demand in the United States for nurses and the predicted nursing shortfall require that the United States increase its number of nurses and nurse faculty (Buerhaus et al., 2009). The clear linkage between quality nursing education and health outcomes identifies that nursing education and continuing professional development are es- sential elements when tackling nursing workforce challenges for the future deliv- ery of care. Moreover, there is a clear linkage between quality nursing education and health outcomes. Since substantial numbers of foreign-educated nurses hold baccalaureate degrees, targeted opportunities for education should be directed at encouraging them to complete masters and doctoral nursing programs as prepara- tion for clinical and faculty leadership roles. This approach would increase the applicant pool for graduate study and enlarge faculty numbers. In addition, it would prepare foreign-educated nurses with graduate degrees to serve in faculty and leadership roles in their home countries when they return—an approach used in many professions to upgrade a country’s knowledge and skill base by profes- sion. CGFNS data identify that many foreign-educated nurses have completed master’s degree programs but are hired to only work in staff nurse positions, suggesting underutilization or lack of consideration for other nursing or faculty roles (CGFNS, 2002). Recommendation 2: Promote Baccalaureate Education for Entry into Practice in the United States Baccalaureate programs are on the rise internationally. In most cases, the rise of baccalaureate nursing programs represents a focused, often mandated, policy agenda—without the complex history that has framed baccalaureate edu- cation in the United States. The Philippines moved to the baccalaureate for entry into the profession in the mid-1980s. Canada also requires the baccalaureate for entry for new graduates in most provinces. The United Kingdom has moved to university preparation of first level nurses. Mexico and India are phasing out their non-baccalaureate nursing programs. The Ukraine has scaled up its nursing pro - grams, as well, in order to enhance the profession in the country and to increase

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 APPENDIX J the global marketability of its nurses. This international trend toward mandated baccalaureate education for entry into the profession places the United States in a less progressive and less competitive position in the global nursing community. Although the Bologna Process4 directly concerns Europe and its immedi- ate neighbors, it has generated global attention because harmonization of nurs- ing standards in this large geographical area will have worldwide implications (Zalalequi et al, 2006). It has heightened awareness in many countries of the need for baccalaureate education in nursing, motivating them to move toward the bac- calaureate as the entry into practice credential.5 Because the requirements and competencies of the Bologna Process and the Tuning Project6 identify the need to address educational equivalences and dif- ferences in nursing education and qualifications worldwide, careful comparisons between education systems will be necessary for the foreseeable future. For example, competencies and hours of instruction of clinical practice will need to continue to be assessed when countries import nurses.7 Although baccalaureate education for entry into U.S. nursing has been con- troversial since 1965 (ANA, 1965), the present complexity and high technology used to practice nursing in all settings requires now and in the future that nurses be grounded in science and critical thinking. The rise of baccalaureate education globally, coupled with the Bologna Process, suggests that the United States must upgrade its educational standards for entry into the profession. The profession needs to muster the political will to make this unrealized goal a reality—not only to address quality gaps in educational preparation, but also to be a credible player in the future domestic and global health care labor market. Recommendation 3: Harmonize Nursing Curricula U.S. nurse educators should form strategic partnerships to share nursing knowledge and exchange information and best practices state-to-state and region- ally. The U.S. nursing education community should promote sustainable global knowledge networks and the open exchange of tools that promote curricula in- 4 The Bologna Process creates the European Higher Education Area by making academic degree and quality assurance standards more comparable and compatible throughout Europe. The Bologna Process currently has 46 participating countries committed to “Harmonizing the Architecture of the European Higher Education System.” It is named after the place it was proposed, the University of Bologna, Bologna, Italy. 5 Canada, India, and the United Kingdom are examples of countries implementing baccalaureate education for nursing. 6 The “Tuning Project” is a methodology utilized with the Bologna Process that establishes refer- ence points and builds templates for learning outcomes and competencies for specific academic disciplines. 7 U.S. immigration law requires that foreign-educated nurses seeking U.S. employment must have their credentials evaluated in terms of comparability of education, English language proficiency, and licensure validity.

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0 THE FUTURE OF NURSING novation based on learning outcomes. Sustained investment in nursing education must become a national and world priority. Recommendation 4: Add Global Health as Subject Matter to Undergraduate and Graduate Nursing Curricula To better prepare nurses to work within a globalized health system, U.S. nursing programs should include courses on global health. Such courses would focus on the characteristics of health systems world wide with course content including, for example, high exposure to infectious diseases, underinvestment in health system infrastructure, deteriorating working conditions and acceleration of health professional migration. This would prepare U.S. students to better deal with the migrating nurse workforce and its future demographic characteristics. Recommendation 5: Establish a National System that Moni- tors and Tracks the Inflow of Foreign Nurses, Their Coun- tries of Origin, the Settings in Which They Work, and Their Education and Licensure A comprehensive database that collects, monitors, and tracks information about foreign-educated nurses in the U.S. workforce would play a significant role in formulating health care policy. Such a database would assist governmental and private agencies regarding the education, skill mix, practice, and immigration patterns of immigrant nurses—all necessary data to intelligently inform health planning and policy decisions. Recommendation 6: Create an International Body to Coordi- nate and Recommend National and International Workforce Policies Globalization has created a world market for a globalized nursing workforce. For nurses to take advantage of these opportunities, mechanisms are needed that compare the education and qualifications of applicants against global standards. Such an entity would acknowledge that mobility is a core element of globaliza- tion and recognize the need for international standards of minimal competence. The United States should work closely with the International Council of Nurses (ICN) in pursuing this goal. The 200 World Health Report (WHO, 2006) focused on health and human resources and identified the central role regulators play in the protection of the public. It also acknowledged that factors such as migration are placing existing approaches to regulating professionals under considerable strain. While regula- tors generally have well established standards and processes for initial registra- tion, this is not usually the case for determining continuing competence. Ensuring

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1 APPENDIX J the competence of health professionals remains an important regulatory issue that is now being framed in the broader context of promoting patient safety and advancing the quality of health care services. Ensuring the competency of health professionals entering the United States remains an important priority—as it is for other countries. In short, a newly established standard of continued competence needs to be offered globally. This new standard must, at a minimum, measure the apti- tude, knowledge and skills of nurses around the world and predict their ability to succeed in patient care in global health care environments. The challenge is to incorporate into workforce planning, the development of appropriate quality assurance processes and mechanisms that encompass foreign providers and edu- cational programs in such a way as to ensure predictability and competence in the workforce (Aiken et al., 2004; Kingma, 2006; Little and Buchan, 2007). OVERVIEW OF INTERNATIONAL NURSING EDUCATION AND REGULATION Key Issues and Challenges in Nursing Education Although nurses share a common professional history, internationally their educational preparation, regulation, and practice patterns are highly diverse and vary considerably in complexity and scope. There are differences in credentialing requirements that include professional licensure, use of titles, and accreditation of educational programs (ICN, 2003). Because of these world-wide differences, the skill mix of the nursing workforce also is diverse. Thus, the globalization of the nursing workforce must be viewed not only within the context of the health status of nations, government investment in health budgets, nurse/health care migration, economic realities, and working conditions but also within the context of the diverse preparation and practice of its practitioners. Achieving global standards for the education of nurses is a vision of many nursing professionals, and has been promoted by the ICN for over a century. However, achieving that goal remains unrealized and is complicated by the variations in nursing education throughout the world. Many countries specify university-level education as the minimum entry requirement for nursing—but the idea of university education for nursing remains challenging, with disparities being common in the programs currently offered in different parts of the world. Compounding the issue is the number of countries that still consider initial nurs- ing education at the secondary school level to be adequate. Educational programs also vary in type, number, size, and degrees offered. For example, all nurses from the Philippines complete a baccalaureate degree. Denmark, Ireland, New Zealand, and Spain also have single programs for qualify- ing as a nurse. On the other hand, in the United Kingdom, nurses receive either a nursing diploma or a degree. In the United States there are three educational

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2 THE FUTURE OF NURSING pathways to become a registered nurse: a 2-year associate degree, a 3-year di- ploma program, or a baccalaureate degree. Also in the United States the model of nurse-midwife is common, for other countries midwifery is considered a profes- sion separate from nursing. In short, universal nursing education standards have not been achieved. Entry-level professional nursing programs are designated as diploma, asso- ciate degree or baccalaureate. Diploma programs are the most prevalent, world- wide, with baccalaureate programs on the rise. However, many countries are experiencing faculty shortages, which substantially impacts the number of nurse graduates from all programs. For instance, schools in Vietnam and Eastern Eu- rope still operate under the practice of physicians serving as the majority of nursing faculty. Other countries, such as those in the Middle East, do not have the infrastructure to support higher education and nurses must travel abroad to be educated as faculty. In many countries shortages of nursing faculty relate to cultural, social and economic norms about the education, status and role of women. In many instances most patient care jobs are held by female nurses while administrative and faculty jobs are held by male nurses or doctors. The shortage of experienced nursing faculty, worldwide, adds to the challenge of establishing and maintaining standards (Blythe and Baumann, 2008). Action by the World Health Assembly (WHA) in 2001 included the develop- ment of global standards for the initial education of nurses. This was followed in 2006 by the World Health Organization (WHO) Task Force on Global Standards in Nursing and Midwifery Education and in 2009 by the WHO publication, Hu- man Resource for Health: Global Standards for the Initial Education of Profes- sional Nurses and Midwives. The WHO goal of global standards is to establish educational criteria and ensure outcomes that (1) are based on evidence and competency; (2) promote the progressive nature of education and lifelong learn- ing; and (3) ensure the employment of practitioners who are competent and who, by providing quality care, promote positive health outcomes in the populations they serve (WHO, 2009). Many source and recipient countries have established educational programs to ease the transition of migrant nurses. For example, colleges and universities in Canada have created courses to respond to knowledge deficiencies. Canada also has created prior learning assessment and recognition (PLAR) initiatives that provide practical validation of immigrant nurse competencies in lieu of and/or in conjunction with course work (Hendrickson and Nordstrom, 2007). Because there can be language and cultural adaptation issues, countries like the United Kingdom require foreign nurses to undergo orientation to the local culture of health care upon their arrival in the United Kingdom (Kingma, 2006). Blythe and Baumann (2008) state, “While international and national nurs- ing bodies are focusing on international standards for nurses, more inclusive movements for educational harmonization that involve national governments are underway. One of the most significant is the Bologna Process.” The purpose of

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3 APPENDIX J the Bologna Process is to make academic degree standards and quality assurance standards comparable and compatible throughout Europe. The process extends beyond the EU to include some 46 countries. Global standards continue to be a goal of the future. In the meantime, coun- tries must work to ensure an adequate source of health professionals to provide care for current and future patient needs. Ideally, global standards will be guide- lines that serve as benchmarks for the profession. The commitment of the United States to pursue this goal would have a significant impact on its realization. Key Issues and Challenges in Nursing Regulation Regulatory Structure In addition to differences in education, the nursing profession varies by country in how it is regulated. Many countries have had statutory nursing regula- tion for years, regulation that ensures a safe and competent nursing workforce. However, there are still countries with no nursing regulation, rules, or other regulatory mechanisms that emanate from the government. In still other countries there is provision for nursing regulation, either in statute or in other systems of rules, however, for various reasons no mechanisms exist that establish a legal framework for nursing as an autonomous regulated profession (ICN, 2009a). Some examples of regulatory systems include: • A single regulatory authority, such as the Nursing and Midwifery Coun- cil (NMC) in the United Kingdom. • A national/governmental body that determines basic competencies but has no regulatory authority, such as Denmark, Ireland, and Taiwan (ICN, 2009a). • Regions acting as autonomous units with the government setting standards for only some of the jurisdictions, for example, Spain (ICN, 2009a). Therefore, as nurse migration accelerates, it should be recognized that the standards, competencies and qualifications required to practice as a nurse vary globally. Licensure All countries do not license nurses. Some countries require nurses to pass an examination after completion of their nursing education before they can practice. Nurses in the Philippines, Australia, Thailand, Japan, Singapore, the Cameroons, Korea, and Poland take a licensing exam that provides national licensure and registration as a first level (registered) nurse. Other countries, such as Nepal and Mexico, do not require a post-graduation examination. The nursing schools

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4 THE FUTURE OF NURSING administer an exit or qualifying examination and upon passage, the student is granted a diploma. The diploma allows the graduate to practice as a nurse. While some countries provide national licensure, still others license nurses by province or state. Countries such as India only allow nurses to be licensed in one state at a time. In Canada, nurses are licensed by the individual provinces. Each province has its own educational structure and regulatory authority; how- ever, nurses licensed in one province can achieve licensure by endorsement in another province. In the United States nursing licensure is at the state rather than the national level. The United States does not offer a single nursing license that is recognized and valid in all states and territories within the United States. Instead, each state controls the practice of nursing within its borders. The nurse must be licensed in the state in which he/she is employed. The United States does offer the mutual recognition model of nurse licensure, which allows a nurse to hold a license in his or her state of residency and to practice in other states, subject to each state’s practice law and regulation. Under mutual recognition, a nurse may practice across state lines unless otherwise restricted (NCSBN, 2009a). As part of emerging practices around increased migration, some countries test nurses’ competencies before they leave their country of origin. For example, the National Council of State Boards of Nursing administers the U.S. Nurse Li- censure Examinations (NCLEX-RN® and NCLEX-PN®) in major cities around the world to test the competencies of nurses who desire to migrate to the United States to work. Pass rates of foreign-educated nurses on the NCLEX-RN exami- nation are generally in the 48−52 percent range but vary by country of education and experience with multiple-choice testing. A number of U.S. states require that foreign-educated nurses take the CG- FNS Qualifying Exam® as a prerequisite for licensure. Annual CGFNS Validity Studies over the last 5 years indicate that foreign-educated nurses who pass the CGFNS Qualifying Exam on the first attempt have an 88−92 percent chance of passing the NCLEX-RN examination on the first attempt, which is comparable to, and in some cases higher than, the pass rates of U.S. graduates taking the NCLEX for the first time. Table J-1 depicts the 2007 NCLEX pass rates of U.S. and internationally educated nurses as well as nurses educated in the countries that are historical and emerging suppliers of registered nurses to the U.S. workforce. Statistics for foreign educated nurses who sat for the NCLEX-PN examination also are provided because many registered nurses who are unable to pass the RN examination go on to take the PN licensure examination. Other countries that import nurses, such as Canada, also give their licensing examinations abroad. Saudi Arabia and the United Arab Emirates give licensure examinations in the Philippines and India for potential immigrants to their coun- tries. Still other countries ensure a supply of foreign-educated nurses by estab- lishing agreements with governments, where nurses are comparably educated to supply quotas of nurses for defined periods (Kingma, 2006). Both the United Kingdom and Japan have such arrangements with the Philippines.

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 APPENDIX J TABLE J-1 NCLEX Examination Statistics, 2007 Country NCLEX-RN Pass Rates NCLEX-PN Pass Rates U.S. educated, first-time takers 85.5% 87.3% Foreign educated, first time test takers 52.0% 48.6% Historic Supply Countries • Philippines 49.2% 58.3% • India 66.2% 39.1% • Canada 65.3% 79.7% • United Kingdom 66.7% 66.7% Emerging Supply Countries • China 53.8% 53.8% • Jamaica 50.9% 26.5% • Nigeria 25.5% 69.4% • Mexico 43.8% 00.0% SOURCE: NCSBN, 2009c. Registration Registration of nurses is an administrative process that allows the govern- ment agency responsible for health and safety to track and monitor health care professionals. In some countries, such as the United Kingdom, registration is the recognition by the professional regulation body that the nurse has completed all educational requirements to practice as a nurse. In countries in which licensure by examination is required, registration by the regulatory body documents that the nurse has passed the examination and met all requirements to be listed on the registry. Registration requires an initial fee, and in most countries, periodic payment of fees to maintain that registration. Graduates of nursing programs in such countries as Peru, Columbia, the Dominican Republic, the Ukraine, Armenia, Russia, and other Eastern European countries are not required to hold licenses. The graduate nurse’s diploma serves as the permit to practice the profession of nursing. The nurse’s professional standing is maintained by the school of nursing, the Ministry of Health, or the professional association. With the trend of increasing globalization and mobility of the nursing work- force, regulators are under increasing pressure to deal with the myriad number of nurses who wish to move from their country of origin to work in new juris- dictions. Because regulations vary considerably in complexity and scope, not all countries or jurisdictions are able to absorb these mobile nurses into their work- force. In general, countries that receive significant numbers of foreign-educated nurses employ a variety of regulatory approaches to ensure that migrating nurses are prepared to practice competently and safely in new, and often unfamiliar,

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32 THE FUTURE OF NURSING mechanisms that effectively address the demands for health care and provide workforce stability. In 2004, when examining the policy implications of nurse migration, Aiken and colleagues highlighted that, “The most promising strategy for achieving in- ternational balance and health workforce resources is for each country to have an adequate and sustainable source of health professionals,” which includes the need for developed countries to be more diligent in exploring actions to stabilize and increase the domestic supply of nurses (Aiken et al., 2004, p. 75). They go on to add that, “Developed countries growing independence on foreign-trained nurses is largely a system of failed policies and underinvestment in nursing.” Similar arguments were noted in the conclusions from a research and policy retreat entitled, Human Resources for Health: National Needs and Global Con- cerns, which identified national self-sufficiency as a goal (Penn Consortium for Human Resources in Health, 2006). Attaining self-sufficiency also was noted in two key international policy documents: The Joint Learning Initiative Report and the ICN report: The Global Nursing Shortage: Priority Areas for Intervention. The ICN Report (2006, p. 12) notes that building national self sufficiency to manage domestic issues of supply and demand, in rich and poor countries alike, is critical. Planning efforts should require that the United States establish a national sys- tem that monitors the inflow of foreign nurses, their countries of origin, the states and settings in which they work, and their impact on the nursing shortage. In order to ensure that the nursing care needs of the public are met, a broader workforce policy is needed that balances foreign nurse recruitment and domestic needs. Much of the work done on workforce planning has yet to be fully integrated with emergent technologies, in particular, telehealth and tele-education. While countries work to establish, maintain and improve regulatory practices and poli- cies, upgrade educational programs and improve patient care, health care and health care education are systematically transcending national and international boundaries, creating global communities. These technologies have the potential to create new approaches to harmonizing curricula, coordinating international policy, and tracking migrating nurses throughout the world. Experts in these technologies will be essential resources for the future of nursing in the United States. Ethical and Moral Challenges Perhaps the most daunting aspect of creating a plan for the future of nursing in the United States, shaped by a deep understanding of globalization, involves the ethics of choice. Many issues surrounding the global nursing shortage, the impact of globalization, the goal of international standards, and the establishment of diverse trade and related agreements have ethical and moral dilemmas imbed- ded within them. It requires that the Committee examine human rights issues and issues of equity.

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33 APPENDIX J Because globalization and migration have dramatically increased the multi- cultural characteristics of the health workforce, in general, and the nursing work- force, in particular, this country will, more and more, consist of people from different ethnic backgrounds who need to be fully integrated into the workplace in a way that respects diversity. As has been noted by current studies on immigration, our present patterns of immigration in the United States are different from the past. The United States, built largely on immigrants from European countries, now attracts immigrants from the African, Arab and Asian nations—a much more diverse array of cultures and countries. As the United States increasingly becomes a more multiethnic, pluralistic and linguistically diverse society, the possibilities for misunderstand- ings, mixed messages, and errors in communication are inevitable. To address and/or prevent the disruptiveness of these factors while delivering care, cultural competence and cultural sensitivity must be added to the knowledge and skills needed for nursing practice in the future. Continuing health policy should be developed that proactively manages a well-prepared, multicultural, multilingual, multiethnic, and multireligious workforce and fosters the develop- ment of intercultural workplaces. Such policies will need to address not only the challenges associated with integrating the foreign-educated nurse into the U.S. workforce, but also the challenges faced by co-workers experiencing the introduc- tion of new cultures. As the population ages, a greater demand for nurses with the skills necessary to provide safe, effective care to the elderly, as well as the ability to apply new technologies, also will be needed. In short, changing U.S. demographics will require that nurses have knowledge and skill in cultural competence, care of the elderly, and use of technology. As competition and demand for skilled nurses increase, ethical recruitment practices must balance the rights of individuals to migrate and at the same time prevent adverse effects on source countries’ health systems. The United Nations Declaration of Human Rights (1948) underscores that point. There has been considerable critique of the migration of nurses from less developed to developed countries as irresponsible brain drain. However, numerous factors relate to the migration of health workers from developing countries resulting in insufficient numbers in the source country’s workforce. These include in-country weakness in policies and restrictions related to wages, recruitment, deployment, transfer, and promotion (Vujicic et al., 2009). Kingma (2006) notes that since most nurses work in the public sector, failure of governments to fill vacant positions may cause in-country unemployment and encourage migration. Governmental poli- cies on remittances and return migration also are factors that encourage nurses to seek employment in other countries. As this paper demonstrates, the brain drain assumption can be an oversimplification of a profoundly complex issue. While developed countries continuing to recruit professional workers from developing countries is a serious ethical issue, the rights of professionals to find a better life in another country is equally compelling as an ethical issue.

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34 THE FUTURE OF NURSING Efforts have emerged to address the dilemma of balancing the rights of individuals to migrate with the potential loss of essential health care services in source countries. In 2004 WHO issued a resolution urging member states to develop strategies to mitigate the adverse effects of international migration and develop an international code of practice. The International Council of Nurses, Sigma Theta Tau International, and the Commonwealth Secretariat have issued codes that provide guidelines and methods to improve the ethical recruitment and treatment of health care workers. The United States, in 2009, issued The Ethical Code for Recruitment of Foreign-Educated Nurses, a voluntary code for ethical recruitment practices developed by an Advisory Council of stakeholders that was convened by Acad- emyHealth, a private-sector health policy organization. The stakeholders were composed of representatives of unions, hospitals, nursing organizations, regula- tory bodies, credentials evaluators, recruiters, staffing agencies and immigration attorneys. The goal was to reduce the harm and increase the benefits of interna- tional nurse recruitment for source countries, host countries, U.S. patients, and migrant nurses. The task force has evolved into the Alliance for Ethical International Re- cruitment Practices. Subscribers to the Code will agree to abide by it. Nurses will be able to refer possible violations of the Code to the Alliance, which will then assist in resolution of the infractions or refer to advocacy or government bodies. This work is essential as it focuses on the actual practices of greatest concern—aggressive, predatory recruitment practices that are abusive to nurses seeking a better life for themselves and their families. U.S. nursing leaders will need to proactively implement these guidelines and continue to monitor abuses that may emerge. The WHO Code of Practice on the International Recruitment of Health Per- sonnel was adopted at the 63rd World Health Assembly in Geneva, Switzerland in May, 2010. The Code is voluntary, global in scope, and directed at health workers, recruiters, employers, health professional organizations and relevant regional and/or global entities. The Code provides principles applicable to the international recruitment of health personnel in a manner that promotes an equi- table balance of interests among health workers in source and destination (host) countries (WHO, 2010). In conclusion, it is the hope of the authors that this paper provides helpful information to guide the Committee’s deliberations and decisions. Our effort to synthesize a massive amount of information demonstrates an honest endeavor to place the future of nursing in the United States within an international context, sensitive to the impact of escalating globalization. U.S. nurse leaders will con- tinue to play a central role in the future of nursing internationally. It is our hope that the work of this Committee will encourage their collaborative endeavors with international governments, communities, nursing organizations and nurses to enhance the profession of nursing worldwide.

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40 THE FUTURE OF NURSING ABOUT CGFNS INTERNATIONAL CGFNS International is an immigration neutral, internationally recognized authority on credentials evaluation and verification pertaining to the education, registration and licensure of nurses and health care professionals worldwide. The mission of CGFNS International is to serve the global community through programs and services that verify and promote the knowledge-based practice competency of health care professionals. CGFNS International protects the public by ensuring that nurses and other health care professionals educated in countries other than the United States are eligible and qualified to meet licensure, immigra- tion and other practice requirements in the United States. CGFNS International and its divisions provide products and services that validate international professional credentials and support international regula- tory and educational standards for health care professionals. The organization focuses on four key objectives: 1. To develop and administer a predictive testing and evaluation program for internationally educated nurses 2. To provide a credentials evaluation service for internationally educated and/or internationally born health care professionals 3. To serve as a clearinghouse for information on the international educa - tion and licensure of health care professionals 4. To conduct and publish studies relevant to internationally educated health care professionals The major CGFNS programs used by internationally educated health care professionals are the VisaScreen Program®, which is the leading health care worker certification program for immigration and for obtaining occupational visas in the United States; the Credentials Evaluation Service, which provides a course-by-course comparison of international education to U.S. standards for licensure, education and employment; and the Credentials Verification Service for New York State, which is required of internationally educated registered and practical nurses, occupational therapists and assistants, and physical therapists and assistants seeking licensure in New York State. CGFNS International celebrated its 30th anniversary in 2007. It has reviewed and/or certified the credentials of over 500,000 internationally educated nurses and other health care professionals for U.S. licensure and immigration. ACKNOWLEDGMENTS This paper was commissioned by the Robert Wood Johnson Foundation for the Initiative on the Future of Nursing at the Institute of Medicine. It serves as a background document to inform the committee’s deliberations, and draws upon

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41 APPENDIX J the extensive experience and database available to the authors through CGFNS International files and research studies. The paper is based on published international literature in the field; docu- ments from CGFNS International files; research studies; trends in the nursing labor market, including globalization and demographic changes; increased use of complex technologies; and the authors’ personal observations and participation in relevant national and international conferences and meetings on the subject. The authors are responsible for the content of the paper. ABOUT THE AUTHORS Barbara L. Nichols, D.H.L., M.S., R.N., FAAN, is the Chief Executive Officer of CGFNS International (Commission on Graduates of Foreign Nursing Schools), which is an internationally recognized authority on credentials evalu- ation and verification pertaining to the education, registration, and licensure of nurses and health care professionals worldwide. Ms. Nichols served as profes- sor of nursing at the University of Wisconsin School of Nursing and director of nursing for the Wisconsin Area Health Education Center System. Currently, she serves on the Board of Directors for the American National Standards Institute (ANSI) and is a member of their Conformity Assessment Policy Committee. She held a cabinet position in Wisconsin State Government, is a former International Council of Nurses (ICN) Board Member and a past President of the American Nurses Association. As Secretary of the Department of Regulation and Licensing for the state of Wisconsin, she was responsible for 17 Boards that regulated 59 occupations and professions. Ms. Nichols is the author of over 70 publications on nursing and health care delivery, including her most recent contribution as a Guest Editor, “Policy, Politics and Nursing Practice,” in the August 2006 edi- tion of Building Global Alliances III: The Impact of Global Nurse Migration on Health Service Delivery. She was a Lieutenant in the United Sates Navy Nurse Corps. Among other accolades, Ms. Nichols was a 2006 Inaugural Inductee into the National Black Nurses Association Institute of Excellence; was named the 2007 Distinguished Scholar, Howard University College of Pharmacy, Nursing and Allied Health Sciences, Division of Nursing; in 2009 received Doctor of Humane Letters degree from Drexel University; and is a Fellow in the American Academy of Nursing. Catherine R. Davis, Ph.D., R.N., is the Director of Global Research and Test Administration for CGFNS International. Dr. Davis provides senior leader- ship for CGFNS test development activities, research initiatives, and related publications. Prior to joining CGFNS International, Dr. Davis was Associate Professor of Nursing at Hahnemann University in Philadelphia. She holds a Ph.D. in Nursing from Adelphi University and a Master’s degree in Child and Adoles- cent Psychiatric Nursing from the University of Pennsylvania. She serves on the National Editorial Advisory Board of Advance for Nurses and as a manuscript

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42 THE FUTURE OF NURSING reviewer for Sigma Theta Tau, International’s Journal of Nursing Scholarship. Dr. Davis has authored and edited numerous publications on international nursing issues and has served as a national and international speaker on nurse migration trends and challenges, international testing and test development issues, and conducting certification programs. Donna R. Richardson, J.D., R.N., is the Director of Governmental Affairs and Professional Standards for CGFNS International in Philadelphia. She moni- tors and tracks legislative and regulatory actions at state, federal and international levels affecting foreign-educated health professionals as well as professional standards of education and licensure. In addition, she is the liaison with the Departments of Homeland Security Citizenship and Immigration Service; State, Labor; and Health and Human Services on matters related to the immigration; recruitment and employment of health care professionals educated outside the United States. She served as an attorney at the Department of Labor, Solicitors Office, Occupational Safety and Health Administration as a regulatory attorney. As Director of Governmental Affairs for the American Nurses Association she directed the legislative and regulatory policies that led to the Nursing Immigration Relief Act and occupational health protections for nurses. She chairs the Compli- ance Committee of the Alliance for Ethical International Recruitment Practices. A registered nurse and attorney she is an experienced lecturer and author on health policy, political action, legal issues in nursing and health administration, foreign- educated nurses, clinical trials, and minority and women’s health issues. She is a past President of the Montgomery County Commission for Women. She is a member of several professional associations and is a recipient of various awards in recognition of her nursing, legal, and community work.