The United States (US) historically has been short on international understanding. We are a people of immigrants, but earlier immigrants came here to participate in a dream of freedom and economic security. Those new to this land often lived in ethnic enclaves, but quickly became assimilated into the larger society by necessity and choice. For many, coming to the US represented a complete break with their roots, or the beginning of the effort to reunite with part of their family already in a new country. Air travel and the advances of modern communication have changed that perspective. For today’s immigrants, the bonds of kinship and the memories of their native land persist and co-exist with the qualities of this new country, hopefully bringing out the best of both.
As the world has grown smaller, there has been a shifting of our attention towards nursing in the rest of the world. The development of nursing and nursing education in the US has proceeded, more or less, as directed by the U. S. nursing profession over the past 150 years. Though slow and often arduous, there has been growth and success which far out-paced development in many other lands. In turn, many international leaders were educated here, and took home the U.S. ways. Sometimes these close attachments have left us blind to the uniqueness of nursing from country-to-country. Of necessity, nursing must take-on the qualities that are unique to each culture, including our own, and those qualities are not easily learned through an orientation program. This message comes through in several of the articles in this issue of OJIN. The expediency which foreign-educated nurses have represented to offset the U. S. nursing shortage is an ill-conceived gain, a gain without an appreciation that those who serve in other lands may bring a different philosophy of care. There is much we in the US can learn from them, but we must remain sovereign over our own context of care.
You will find five informative and enlightening articles in this issue of OJIN. Collectively, they portray in a realistic manner the political and cultural landscape of international nursing. You have to read between the lines and listen with that fine-tuned “third ear” so common to nurses, but the obstacles and opportunities to international recruitment, exchange, and partnership are laid out before us.
Let me correct one misconception, not deriving from these articles, but commonly held. The US, until very recently, was out-paced by the United Kingdom in the numbers of internationally educated nurses that it recruited. That situation corrected itself when the United Kingdom’s National Health Service placed a moratorium on hiring as a partial solution to escalating costs. The United Kingdom had been liberal and welcoming to internationally educated nurses, accepting documents at face value and requiring that immigrant nurses participate, by law, in an adaptation program, which is much a counterpart to preceptor programs as we know them.
The accusations of “brain drain” are discussed in the Kingma article, and observations made that migration is becoming more and more of a temporary arrangement with eventual return to the sending country. In that case, the nurse returns more accomplished than when (s)he left, bringing knowledge of new techniques and strategies for care. And conversely, the international nurse adds richness to nursing practice that is noteworthy for patients in our multicultural society. They should be with us to enrich the caring experience, and not to correct shortages resulting from poor working conditions, the major offender in the nursing shortage in the US. Many of our health systems invest wisely in programs to help the international nurse assimilate into the U.S. culture, yet other health systems just assume that being far from home, and eager to make a salary perhaps fifteen times what they could earn in their sending country, they will tolerate sub-standard conditions.
However, as Kingma reminds us, many nurses would still prefer to stay at home despite poor working conditions and low pay. Unfortunately, in many places, wages are so low for nurses as to be denigrating, and there is no chance to put their education to good use. And then in other countries, despite claims of shortage and accusations of brain drain to more developed countries, there are no jobs for nurses. Nurses are willing to work but refused posts by national health systems unable to absorb them, not for lack of need but for lack of funds or for health sector reform which has been ill conceived. Such is the case in many African nations and in some areas of Eastern Europe. The irony is obvious. The local outcry for nurses is met with immigration to far away countries where nurses can secure a living wage and salvage their self-respect. The blame lies squarely on the shoulders of their governments, since most of these healthcare systems are socialized, and function with less than a token presence of professional or technical nursing. Siantz and Malvarez focus our attention on South America, telling us that in Uruguay 87.8% of care is delivered by auxiliary personnel. Nurses want to nurse, and they will go where that is possible.
The international migration of nurses will continue, and professionals have the right to be mobile in the world community. That experience allows them to give of the richness they bring and to take much back with them or to stay, as their preference dictates. This should be especially understandable in the US, a land of immigrants. Adeniran et al. speak of the Hospital of the University of Pennsylvania’s (HUP) acculturation program for internationally educated nurses, and their need for clinical practice and communication skills. The demands in the US are new and different; pain has a different meaning, as do confidentiality and privacy, and the participation of family in the plan of care. U.S. nurses are first and foremost autonomous, an advocate for their patients, speaking on their patients’ behalf and protecting them from injury and intrusion. With a primary commitment to their patients, before any employer or other healthcare professional, nurses are often the conscience of the delivery system wherein they participate. In that independence, nurses find vulnerability. There is no safe haven if you live by an ethical standard. Adeniran et al. remind us that these nurses bring education in excess of many of the U.S. nurses, and years of clinical experience. I say that I cannot personally vouch for the nature of that education, and their experience was of another people and another place. Yet the HUP’s efforts are valiant and purposeful.
Bauman and Blythe also anticipate continued migration and the need for global acceptance of educational credits and credentials. This is understandable, and it has been the aim of the European community through the Bologna Process to secure this transferability. Beyond this, there is the continuing business of education of nurses for export and distance learning to establish a world-wide educational community. The call is for predictability in education and competency in outcomes.
As a final note of hope and a window into times past, we read Mayor’s chronicle of events which shaped her career in nursing and her love for this country. Coming, not from poverty, but with the eagerness of a new graduate from the Philippines, she has climbed the professional ladder of experience and education. She came during a time when professional immigration was less intense, and when special acculturation programs were less frequent, but human caring was robust and meaningful.
The wonderful articles included here will move your thinking to new heights. Globalization and international migration will take on new meanings and force you to see the world differently. Don’t let your ideas be encumbered by pre-existing stereotypes; rather ask ‘why’ and ‘what would make things better?
Lucille A. Joel, EdD, RN, FAAN
Lucille Joel is a Professor at Rutgers - the State University of New Jersey College of Nursing. She has served as President of the American Nurses Association (ANA) and the New Jersey State Nurses Association, and as First Vice-President of the International Council of Nurses (ICN) headquartered in Geneva. She is the immediate Past President of the Commission on Graduates of Foreign Nursing Schools (CGFNS) International, the corporation that evaluates the educational and practice credentials of healthcare workers who wish to migrate to the United States on an occupational visa; and was President of the International Center for Nurse Migration, a joint venture between the International ICN and CGFNS. Dr. Joel holds official status as ICN’s representative to United Nations (UN) and the United Nations International Children’s Emergency Fund (UNICEF).
Dr. Joel is author of Dimensions of Professional Nursing, The Nursing Experience, and Advanced Practice Nursing. She is an international advisor to the American Journal of Nursing.