U.S. Nurse Labor Market Dynamics Are Key to Global Nurse Sufficiency

The United States plays a pivotal role in the global migration of nurses. It has the largest professional nurse workforce of any country in the world, numbering almost 3 million in 2004 (USDHHS 2006). The United States has almost one-fifth of the world's stock of professional nurses and about half of English-speaking professional nurses. With a nurse labor force of this size, even modest supply–demand imbalances exert a strong pull on global nurse resources. A looming projected shortage of nurses in the United States that could reach 800,000 by 2020 (USDHHS 2002) is thus cause for concern among other countries also experiencing nurse shortages. The United Kingdom has been more in the spotlight in recent years than the United States regarding its international nurse recruitment policies and practices because, at one point, nurse migrants outnumbered domestically educated nurses among nurses entering the U.K. workforce (Aiken et al. 2004; Ross, Polsky, and Sochalski 2005). However, the United Sates recently became the world's largest importer of nurses, with almost 15,000 foreign-educated nurses passing the licensing exam for registered nurses (RNs) in 2005 (National Council on State Boards of Nursing [NCSBN] 2006), compared with an estimated 13,000 foreign-educated nurses entering the United Kingdom (see Buchan 2007). Moreover, economic constraints in the National Health Service in the United Kingdom have recently limited immigration, while demand for nurses in the United States continues to grow. Altogether in 2000, just over 300,000 U.S. nurses were foreign born. After taking into account foreign-born nurses who immigrated before the age of 22, and thus probably received their nursing education in the United States, close to 219,000 nurses currently residing in the United States are estimated to have received their nursing education abroad, constituting close to 8 percent of the nation's RN stock (Table 1). Table 1 Registered Nurses by Nativity and Citizenship Status, U.S. 2000 The United States is the destination of choice for many migrating nurses from both developed and lower-income countries because of high wages, opportunities to pursue additional education, and a high standard of living (Kingma 2006). Nurses do not emigrate from the United States in substantial numbers or permanently. The prolonged recent nurse shortage and the large shortage projected for the future have motivated more aggressive nurse recruitment abroad by hospital employers and commercial recruiting firms (Brush, Sochalski, and Berger 2004). Almost 34,000 foreign-educated nurses took the NCLEX-RN registered nurse license exam in 2005, with 44 percent passing the exam, suggesting a great deal of interest among foreign-educated nurses in working in the United States (NCSBN 2006). Increasingly, physicians and others in developing countries are retraining as nurses because of the potential opportunities for migration. Since 2000, 3,500 Filipino doctors have retrained as nurses and left for nurse jobs abroad, and 4,000 Filipino doctors are currently in nursing schools. This paper (1) examines trends and projections in the U.S. RN workforce; (2) reviews recent trends in nurse immigration; (3) explores the extent to which nurse immigration contributes to national health care workforce goals, including diversity and care of underserved populations; and (4) considers policy options that could contribute to solving nurse shortages in the United States, while minimizing adverse impact on global human resources for health.