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"Obama against foreign nurses"

March 8, 2009 -- Many reports about the White House Forum on Health Care held on March 5 described key elements of the continuing U.S. nursing shortage and some proposals to address it in the early days of Barack Obama's presidency. Today Will Dunham's generally good Reuters piece discussed remarks that President Obama made about the importance of nursing and the need to resolve the critical faculty shortage. "U.S. healthcare system pinched by the nursing shortage" also included comments from U.S. Rep. Lois Capps, who is a nurse, as well as from nursing work force experts. A March 6 report on India's Sify News site had some of the same basic information, with a stronger focus on the effect proposed measures might have on nurses who have been emigrating from Asia to the U.S. to take jobs available during the shortage. The Sify article was shorter, but it did have quite a headline: "Obama against foreign nurses." In fairness, Obama appears to have said only that it makes no sense for the U.S. to "import" foreign nurses. But reports like this do suggest the complex global nature of the nursing shortage.

The Reuters article explained that the nursing shortage had come up during the White House meeting held to promote Obama's health reforms, where the President "expressed alarm over the notion that the United States might have to import trained foreign nurses because so many U.S. nursing jobs are unfilled." Obama reportedly also said nurses are "the front lines of the healthcare system," that they are not very well paid, and that "their working conditions aren't as good as they should be." The piece noted that about $100 million of last month's federal stimulus package "could" be used to address the U.S. nursing shortage, which the article said now includes about 116,000 unfilled nursing jobs at hospitals, and which was likely to worsen as the Baby Boomers age and require more care.

Most of the piece described specifics of the shortage, using quotes from Rep. Capps and other experts, with a focus on the faculty shortage. Capps, who practiced as a school nurse, noted that nurses "deliver healthcare" and that meaningful health reform will require that the nursing shortage be resolved. The report said that nursing colleges have not been able to keep pace with the increasing demand, with almost 50,000 "qualified applicants" turned away in 2008, a situation for which "some U.S. lawmakers blame years of weak federal financial help for the schools." The piece noted that Senator Dick Durbin and Representative Nita Lowey have introduced legislation to increase federal grants to nursing schools, though it did not say how much additional funding was sought.

In discussing the faculty shortage, the piece quoted Robert Rosseter of the American Association of Colleges of Nursing: "The nursing shortage is not driven by a lack of interest in nursing careers. The bottleneck is at the schools of nursing because there's not a large enough pool of faculty." The report noted that one factor is that graduate-prepared nurses can earn significantly more in clinical practice (about $82,000) than in teaching ($68,000). As is common in such reports, this one does not say if that disparity distinguishes nursing from other professions, and if not, why it may be a particular problem for nursing (e.g., is the teaching salary too low in absolute terms for someone with a graduate science degree?). In any case, some may take Rosseter's statement about what is driving the shortage to mean that simply training more nurses will resolve the shortage. However, the clinical working conditions that Obama mentioned--particularly inadequate staffing even at the intended levels--are a basic factor in the shortage, driving hundreds of thousands of nurses from the profession. Simply injecting more new nurses (foreign or local) into the system will not resolve the shortage if the nurses do not stay at the bedside because they do not get enough resources or respect in their work settings.

The Reuters piece included additional context about the shortage, relying on nursing scholar Peter Buerhaus, who reportedly said that nurses are "the glue holding the system together." That does suggest that nurses play a central role in health care, though "glue" might not be the first metaphor we would offer for skilled professional nurses. Buerhaus noted that hospital staffs may be stretched because of unfilled jobs, potentially causing poor care and errors, though the piece included no comment about whether staffing may be inadequate even at the intended levels, or about Obama's reported support during the 2008 campaign for mandatory staffing ratios. The piece did describe the 2006 study by Buerhaus and others showing that increasing the number of nurses could avert 6,700 patient deaths and 4 million days of hospital care each year. Buerhaus also reportedly pointed out to the reporter that nursing shortages could imperil reforms by driving up nursing wages, and that if the reforms increased access to care by U.S. residents, even more nurses would be needed to provide it.

The Sify News report included some of the same information about the White House meeting and the shortage, with an understandable focus on how it would affect nurses coming from Asia. The item's lead said that Obama had "proposed an increase in the nursing education budget in a bid to end America's dependence on foreign nurses, a large majority of whom come from India, China and the Philippines." The piece included more of Obama's remarks than the Reuters piece:

The notion that we would have to import nurses makes absolutely no sense. ... And there are a lot of people who would love to be in that helping profession, and yet we just aren't providing the resources to get them trained, that's something that we've got to fix. ... That should be a bipartisan no-brainer, to make sure that we've got the best possible nursing staffs in the country. ... Nurses provide extraordinary care. ... And they don't get paid very well. Their working conditions aren't as good as they should be. And when it comes to nurse faculty, they get paid even worse than active nurses. So what happens is, is that it is very difficult for a nurse practitioner to go into teaching, because they're losing money.

Obama's remarks reflect a basic understanding of the problems, though we are a little uneasy about his description of nursing as a "helping profession" involving "extraordinary care," since those terms are positive but very general, and in the case of "helping," pretty faint praise for highly skilled professionals. At least some of Obama's remarks appear to have come in response to comments from Capps, who this piece noted is "one of the three nurses in the US Congress." She reportedly drew attention to the magnitude of the shortage and the nursing faculty "bottleneck." Like the Reuters piece, this one did not ask whether the clinical/teaching pay disparity is unique to nursing.

The Sify report noted that a bill called the Nursing Relief Act of 2009 had been introduced in the U.S. Congress the prior week "to provide for [a] new category of visas for registered nurses with an annual limit of 50,000," which "would make it much faster and easier to bring trained nurses from Asian countries." The item did not try to relate this proposal to what was said at the White House meeting. Permitting many additional foreign nurses to enter the nation could reduce unfilled positions and is not necessarily inconsistent with allocating more resources to train nurses in the U.S. However, it would appear to reflect a different strategy to address the shortage. Integrating many more foreign nurses into the U.S. health system could consume resources that might otherwise be devoted to retaining practicing nurses and training new ones here. Drawing thousands of additional nurses from other nations would also have significant negative effects on the health systems of those nations, although it would offer opportunities for those nurses and presumably increase the remittances they send back to their nations of origin, as Mireille Kingma explained in Nurses on the Move (2006).

On the whole, both pieces provide a useful brief look at potential ways to address the U.S. nursing shortage.

See the Reuters article "U.S. healthcare system pinched by nursing shortage" by Will Dunham posted on March 9, 2009 and the Sify news article "Obama against foreign nurses" posted on March 6, 2009.

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