Implication of Foreign-Educated Nurses on United States Nursing Collegiality

Submitted by Dr. Judy Williams, Ph.D., RNC

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Implication of Foreign-Educated Nurses on United States Nursing Collegiality

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The United States (U.S.) has repeatedly experienced a shortage of qualified registered nurses, a situation, which is capable of deteriorating further in view of the U.S. aging population (Clark, Stewart, & Clark, 2006).  In 2004, U.S. Department of Health and Human Services (USDHHS) has projected a deficit of over 405,000 full time equivalent (FTE) registered nurses by 2010 and 1,000,000 by 2020.  Based on the survey of 2008 for registered nurses, approximately 291,000 registered nurses have lapsed activity of their license which could indicate the beginning of the anticipated substantial retirement of registered nurses (USDHHS, 2010). If the shortage continues as projected, it will have disastrous effects on the overall health of the U.S. population and may harshly impede the ability of U.S. to take action effectively in the event of a mass casualty incident.

Various factors have contributed to the nursing shortage such as cutbacks in healthcare institutions, indifference to the nursing profession as a career opportunity, and exhaustion in performance as a registered nurse.  Ea (2008) alluded to this grim scenario further provoked by the escalating number of Americans with chronic and acute diseases requiring expert nursing care.  Therefore, a possible solution to curb these shortfalls is to employ foreign-educated registered nurses. Aiken (2007) estimated that 218,000 of the registered nurses currently working in the United States received their education abroad.  Even though the phenomenon of migration has been in existence for decades, it has today, the potential to change the scope and dimension of the professional nursing labor market.

Although a realistic alternative, the implication on the migration of foreign-educated registered nurses might lack acceptance as an option to assuage the nursing shortage.  The moral or ethical consequences of the foreign-educated registered nurses’ migration on both the source and destination countries can be counteracted by John Stuart Mill’s utilitarianism paradigm which upholds that the moral value is affected by the consequence of the action (Sher, 2002).  Therefore, it is necessary to comprehend the issues governing the migration of foreign-educated registered nurses in order to evaluate migration’s effect on the U. S. nursing collegiality.

With the purpose of providing quality patient care, the development and establishment of collegial relationships are an important component of the registered nurses’ practice.  Problems in the nurse-physician relationship and the working environments of nurses are underlying obstacles that affect the successful development of collegiality (Rosenstein, 2002).  From the research reviewed, this paper will support the concept that the immigration of foreign-educated registered nurses today has had no influence in changing the paradigm of U.S. nursing collegiality. 

Nursing Shortage in the United States

A matter of vital concern in the healthcare delivery system in the U.S. is the existing shortage of qualified registered nurses that threatens the well-being of not only the registered nurses involved, but also the patients (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002).  Buerhaus, Auerbach, and Staiger (2007) identified a number of factors contributing to the nursing shortage in the United States, which includes a decrease in the number of younger registered nurses, a wider range of opportunities entering the nursing profession, low wages, and a decrease in social status associated with nursing profession.  Additionally, Weinberg, Gittell, Lusenhop, Kautz, and Wright (2007) state that the U.S. actually reduced nursing positions as a result of the demands of managed care, which had restricted public and private sector insurance reimbursement rates and placed many hospitals and healthcare facilities in difficult financial positions.  They also stated that many hospital administrators did not seem to understand or highly value the nursing profession and implemented restructuring plans that had the effect of dramatically escalating the workloads of individual registered nurses.  Several tasks and responsibilities performed by registered nurses such as critical nursing assessments were now being performed by unlicensed staff or just not performed at all.  The researchers also mentioned that working in environments with short staffing and the restructuring of task and responsibilities caused many registered nurses to leave their positions (Weinberg et al., 2007).  

In 2009, the International Council of Nurses (ICN) and Pfizer Inc. conducted a survey involving registered nurses’ in Brazil, Canada, Colombia, Japan, Kenya, Portugal, South Africa, Taiwan, Uganda, the U.S., and the United Kingdom.  Results revealed that overall, 46 percent of the registered nurses felt their workload was worse now than in the past five years. The findings also revealed that the health care systems for the U.S., Canada, and Columbia are least favorable now than they were five years ago.  Only 30 percent of the U.S. registered nurses surveyed stated having a high satisfaction working as a professional nurse.  The main factors mentioned for the respondents' dissatisfaction included workload, lack of recognition, not enough pay and benefits, and bureaucracy.  Some registered nurses came to the realization that the responsibilities of nursing care conflicted with their moral and ethical values or they developed burnout signs and symptoms that affected their physiological, mental, and emotional well-being.

The hierarchy of needs theory, put forward by Abraham Maslow, suggests that the key sources of motivation are unmet needs of an individual (Miller, 1972).  He suggested that there are five fundamental needs that influence an individual's decision-making, which include physiological, safety, belonging, self-esteem, and self-actualization needs.  This theory when studied in the context of nursing, however, indicates that despite being satisfied with their profession, the registered nurses may still vacate their jobs for personal reasons, which in turn, makes retention of staff much more difficult.  Thus, in order to increase and improve retention rates, thereby satisfying that as the basic physiological and safety needs of the registered nurses, healthcare institutions may decide to move closer towards attainment of registered nurses’ other needs such as belongingness, acquiring self-esteem and self-actualization.

Healthcare institutions are struggling to address these areas of dissatisfaction based on the condition of the U.S. economy and available revenues such as high unemployment rates, lack of healthcare insurance, and curtailed spending.  This unpleasant state of affairs has contributed greatly to the low esteem upheld by the nursing profession with high turnovers of nursing positions and low recruitment to fill the nursing position’s gaps among native-born registered nurses thus creating an environment with deficient collegiality.

Foreign-Educated Nurses’ Emigration

The utilization of foreign-educated registered nurses has augmented shortfalls among many western countries.  The United States has persistently encouraged immigration of foreign-educated registered nurses to offset the nursing deficiencies.  According to Lorenzo, Galvex-Tan, Icamina, and Jaview (2007), economic and policy forces shaped the migration of nurses which devalue not only the profession of nursing but also nurses as well.  The recent trends in registered nurse migration stemmed from the changes that have occurred in the demand for registered nurses and the immigration policies.

Sparacio (2005) reveals that since the post-World War II era, not only the United States, but other countries as well, have been using foreign-educated registered nurses to supplement their domestic nursing labor pool.  Until the early 1990s, the influx of registered nurses trained abroad generally did not exceed 3,000–4,000 a year (Buerhaus, Staiger, & Auerbach, 2004; Sparacio, 2005).  According to Bieski (2007), President George W. Bush signed a bill in 2005, to release 50,000 visas that registered nurses from the Philippines, India and China were able to use.  This was an attempt to re-open the supply of foreign-educated registered nurses to U.S. health care facilities and address the nursing shortage.  Evidence has shown that foreign-educated registered nurses play a vital role in relieving shortages at many U.S. healthcare facilities (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004; Brush, Sochaleski & Berger 2004; Chandra & Willis, 2005).  Between 1994 and 2005, however, the annual number of foreign-educated registered nurses successfully completing the NCLEX-RN exam tripled to almost 15,000 in 2005.  Research on the trends in nursing employment conducted by Buerhaus et al. (2007) revealed that during the past four years the growth of registered nurses’ employment in the U.S. was due to the employment of foreign-educated registered nurses. 

Immigration laws and related regulations are complex, ever changing, and difficult to understand.  Most health care organizations recruiting foreign-educated registered nurses work with individuals or agencies that are experts in the area of immigration law.  The ratification of the Immigration Act of 1965 heralded radical changes in U.S. immigration policies (Daniels, 2007).  This act encouraged the immigration of skilled workers into the United States to augment areas suffering from labor deficiency like nursing.  This has promoted many registered nurses from many developing countries to migrate to the U.S., mainly due to better pay and work conditions.

Many of these registered nurses are economically motivated to emigrate in search of better wages due to the poor nature of the domestic economies.  Maslow’s hierarchy of needs paradigm can explain the moral and economic motivation underlying the registered nurses’ emigration to the more developed countries (Miller, 1972).  The terms, push and pull, describe the unmet needs required and the central and blended motivators that drive migration.  For example, researchers (Lorenzo et al., 2007; Clark et al., 2006) describe that the push factor of lack of professional growth in the country of origin mirrors the pull factor of numerous avenues for professional growth in the receiving country.  Some of these push factors that encourage registered nurses to leave their countries of origin include the undervalued status of women and nurses, political unrest, low employment opportunities, the desire to travel, the need for adventure, and personal safety.  Some pull factors include higher salaries, political and economic stability, safe work and living environments, family support, active recruitment of the U.S. hospitals, and humanitarian factors.  These registered nurses have opted to leave their homes and families in pursuit of a better life, a better tomorrow. 

The ability and strength to undertake this move reflect Kant’s philosophy about being “free, rational human beings who act for moral reasons” (Stevenson & Haberman, 1998, p.119). For the foreign-educated nurses, it is a moral obligation to provide financially for their families, themselves, and their country.  The existence of foreign-educated nurses’ families is highly valued and forms the essential component of their societies.

The recent trends in registered nurse recruitment stem from the changes that have occurred in the demand for registered nurses and the immigration policies.  The practice of importing foreign-educated registered nurses to solve the nursing shortage in the U.S. has the potential to mask other problems in both source and destination countries.

Disadvantages of Migration

Brush et al. (2004) argues that the emigration of nurses however has adverse effects on the domestic countries, which depletes the meager pool of qualified personnel lured by better foreign prospects in the more developed countries.  A Marxist philosophical approach of materialism or the perpetual class struggle among the capitalist society explains the large-scale economic exploitation of one of his tenets, human labor (Stevenson & Haberman, 1998).  The United States continued supremacy over the global economy has forced the less fortunate developing countries to sell their meager trained labor while depleting and continually maintaining their dependency on international aid assistance while enslaving their populace (Aiken, et al., 2004).  Although the deportees provide a needed source of income to their domestic relatives, the resultant drain on their country’s healthcare institutions far outweighs the gains on the economic front.  However, these countries have poorly developed health systems and are unable to assimilate the graduating nurses within the established healthcare institutions.

The issues that deal with brain drain versus brain gain have major impaction in both countries because it deals with the best and brightest of the nursing profession that leaves their native country for developed countries such as the United States (Christmas & Hart, 2007).  As a classic utilitarian, such as John Stuart Mill, one would have much concern on the imbalance of the utility that occurs among the source and destination countries (Sher, 2002).  In this situation, consider the migration of registered nurses into the U.S as creating the “greatest good” for healthcare institutions, healthcare personnel, and patients.  These developed countries now are receiving qualified registered nurses that will create an optimistic effect on alleviating the nursing shortage, which will certainly affect the perception of the nursing profession and patient outcomes.  For the source country, the emigration of qualified registered nurses minimizes the utility for healthcare institutions, healthcare personnel, and patients.  What remain for the source countries are a weakened infrastructure, inferior technology, inadequate funding, scarce research efforts, and lack of resources to train qualified individuals to become registered nurses (Clark et al., 2006). 

The research conducted by McElmurry et al. (2006) recognizes that due to emigration, the insufficient numbers of trained healthcare registered nurses compounded by the higher acuity patients to care for has created a healthcare crisis in most developing countries resulting in inequities in health care and poor health outcomes.  This healthcare crisis, causing significant suffering, will thereby affect the countries’ mortality, morbidity and their quality of life (Brush et al., 2004; Clark et al., 2006; McElmurry et al., 2006).  The destination country flourishes in their wealth from obtaining the “brightest and smartest” individuals that are capable of improving the various components of the healthcare system.  This alludes to the disruptive nature of nurses’ emigration as a concealed barrier to improving the health of the most disadvantaged populations in the world.

U.S. Concerns on Immigration

Within the United States, the level of competence for foreign-educated nurses is a major concern.  This has emanated from the concern of the perception that foreign countries, particularly the developing nations, lack the capacity to train professional nurses effectively within the context of modern nursing techniques and practice.

In 1977, the Commission of Graduates of Foreign Nursing Schools (CGFNS) established guidelines to make certain that foreign nurses’ cultural and technical competency was adequate prior to employment to the United States healthcare institutions (Commission of Graduates of Foreign Nursing Schools International, 2011).  The commission verifies acceptable educational requirements of the potential emigrated nurses when compared to the educational requirements of the United States (Brush et al., 2004).  The U. S. Citizenship and Immigration Services require a VisaScreen before issuing an occupational visa.  A VisaScreen certificate is required of all applicants. In obtaining the certificate, the individual must submit certain criteria.  These criteria include a credentials review of the applicant’s professional education and licensure required to ensure comparability with U.S. requirements (Mexico nurses fall short of this expectation).  The individuals must successfully pass a required English language proficiency examination and successful completion of either the CGFNS qualifying examination or the National Council Licensure Examination – Registered Nurse (NCLEX-RN) test (Aiken et al., 2004).  Throughout the world, the CGFNS nursing knowledge exams provides foreign-educated nurses with interests in migrating to the United States a good indication of their likelihood of passing the required U.S. licensure exam (NCLEX-RN).  The final step in the process is the passing of the National Council of Licensure Examination – RN (NCLEX-RN) that every emigrated professional nurse must take and successfully complete prior to assuming the responsibilities as a registered nurse in any U.S. healthcare facility (Commission of Graduates of Foreign Nursing Schools International, 2011).  Technical skills, utilization of resources and critical thinking skills are essential constituents for foreign-educated nurses’ professional development.

By seeking continuous professional development, the foreign-educated nurses would have an opportunity to expand and develop professional relationships and networks.  Brown, Belfield, and Field (2004) also refers to the fact that professional development is essential in maintaining high standards of care.  Foreign-educated registered nurses with three years of nursing experience are assets for specific healthcare institutions.  It is feasible that losing the knowledge of proficient registered nurses negatively affects the clinical outcomes, healthcare operations, and productivity.

Nursing Collegiality

One of the most important concepts in the profession of nursing is collegiality.  A professional relationship that develops between registered nurses who share a common purpose whereby, upholding mutual respect for one another’s values, beliefs, and morals defines collegiality.  Through this relationship, registered nurses construct an identity that is coherent across different contexts.  This co-constructed sense of self is what Kegan (1982) identified in his theory on constructive-development, Stage 4, Institutional Balance. Kegan identified that individuals have a desiring need to be members of their own culture and community, which stems from their new level of confidence and self-interest.  Experienced registered nurses solidify these characteristic virtues of confidence and self-interest, and express them in their collegiality by sharing with, sustaining, supporting, and counseling other registered nurses.  The visualization of these behaviors occur when registered nurses, for instance, serve as mentors to novice registered nurses, actively participate in professional organizations, publish professional literature, conduct evidence-based research, or enthusiastically serve as role models for other healthcare personnel.  The Kegan’s theory of development or social maturity explains the need to embrace opponents’ views while creating a win-win situation rather than engaging in confrontational stunts that lessen the likelihood of creating a collegiate situation.  Skilled communication, trust, shared responsibility, mutual respect, and optimism are essential to building successful collegiality among professional nurses.

Inherent to the concept of collegiality is realizing the significance of other individuals’ proficiencies or expertise and the responsibilities carried out by them while providing critical healthcare services to their respective patients.  The nursing role extends beyond the scope of several other professional roles, including those related to social work or chaplaincy.  Proficient registered nurses establish the circumstances for the shaping of their assigned roles that may take place and they establish the type of circumstances whereby their responsibilities must be explicitly comprehensible to assist them in offering quality care to their patients.  For instance, in the case of a fatally ill patient who recently became aware of his or her diagnosis and who wishes to share his or her anxieties, apprehensions or concerns, it might be considered appropriate for either a social worker or a registered nurse to assist the patient in sorting out personal issues and listening to concerns.  If however, such a client belongs to an extremely intricate dysfunctional family, the situation demands superior expertise, and the social worker is regarded as relatively more competent to arbitrate.  It is through such analogous circumstances or occurrences that the profession of nursing must be acquainted with, when role-shaping takes place and when it becomes indispensable or obligatory to engage other authorities who possess the requisite expertise and information for superseding with the patient.  After such an acknowledgment is accomplished, the registered nurses can then proceed to value each other for their expertise that each discipline brings to the patient's plan of care.  It is through such a process, that the registered nurses are educated about the significance of working together with other interdisciplinary members and assisting each other in satisfying the needs of their patients, thereby endorsing the permanence of care concept, in the process. 

The International Council of Nurses (2006) and the American Nurses Association (2005) established a Code of Ethics that places collegiality as one of the vital professional characteristics in the profession of nursing.  In these documents, registered nurses are encouraged to provide a moral environment that emphasizes effective communication, trust, joint decision-making, shared responsibility, and mutual respect for one another, other disciplines, patients, family and community.  The principle of respect for colleagues and oneself is paramount.  In the past, the process of peer review was a mechanism to evaluate the quality of care for patients; today it now serves as a vehicle to enhance self-respect and integrity.

 Watson’s theory of caring believes that creating a type of environment filled with core values of support and protection to the mental, physical and spiritual well-being creates a healing milieu for the patients as well as for colleagues (Watson & Foster, 2003).  The potential for this type of environment would not only produce positive outcomes for patients’ health, but also registered nurses would transfer their dedication and loyalty to each other thus fostering future generations of qualified colleagues.  Unfortunately, this is not the reality of the concept of nursing collegiality in the U.S. today.

Presently the characteristics of hostility, disrespect, and unfriendliness seem to be the environment that many registered nurses encounter in the healthcare setting (Martin, Gray, & Adam, 2007).  The lack of nursing collegiality among the staff reveals a distressing trend whereby their colleagues who engage in negative irrelevant power plays alienate many practicing registered nurses (International Council of Nurses et al., 2009).  Thus, healthcare institutions emphasizes to solve the present day nursing shortage, while diluting the vicious infighting among nursing personnel, requiring healthcare institutions to seek foreign-educated registered nurses.

Lack of Collegiality

It is somewhat ironic that whilst nursing is supposed to be a caring profession, some registered nurses persistently treat other healthcare personnel, including foreign-educated registered nurses, as grossly inferior.  Bally (2007) alludes to the infamous incidence of “nurses eating their young” due to horizontal violence practiced by registered nurses, even as many opt out of the nursing profession citing stress factors, unease, tyranny, and disempowerment.  It is a phrase, which demeans, humiliates, and ridicules the nursing profession, especially the concept of nursing collegiality.  Not only do registered nurses eat their “young” or those new to the profession, but also “older,” experienced registered nurses or more tenured registered nurses also exploited those from foreign lands (Bally, 2007).  Magnusdottir (2005) concluded that foreign-educated registered nurses often felt like outsiders.  There were times when members of the foreign-educated nursing staff encountered racism and the detestation of foreigners therefore experiencing the practice of horizontal violence.  The demonstration of nursing’s lack of collegiality stems from a decreased job satisfaction and reduced professional status compared with that of medicine.

The strained relationship between the physician and nursing colleagues underscores the lack of collegiality in the U.S. nursing profession. Research conducted by Pejic (2005), cites that the lack of a significant collegiality among fellow registered nurses and physicians is one of the leading causes of registered nurses’ turnover.  Kant’s moral philosophy or Kantianism advocates the need to understand the limit of human knowledge within reason or from experience (Stevenson & Haberman, 1998).  Collegiality requires the application of a Kantanian rational concept that will encourage the healthcare workers’ alliance to embrace their counterparts in the nursing and medical professions as well as the migrated foreign-educated recruits to further their professions.

A Nurse-Physician Relationship Survey conducted by the VHA West Coast, (a regional division of VHA, Inc., composed of community-owned hospitals and health care systems) revealed that many registered nurses harbor latent resentment towards their fellow physicians and management, which contributes greatly to the high turnover in the profession (Rosenstein, 2002).  This disruptive environment not only affects the medical personnel, but also the patients and services, leading to cancellations of operations or units closed in some facilities.  Rosenstein (2002) believes that the roots of registered nurses’ concerns of stress, burnout, and frustration are male-dominated physician and administrative cultures that deems the profession of nursing as subservient roles and tolerates vertical hostility behaviors.  The research results also suggest that there is an urgent need to improve the nurse-physician relationship to enhance registered nurse retention and employment.  Before registered nurses can function effectively as colleagues with foreign-educated registered nurses, they need to feel secure and empowered in their professional roles and establish a professional climate with all healthcare workers.  

However, one estimates that the ongoing recession is likely to compensate for the growing shortage in the nursing profession.  With layoffs and rising unemployment on the rise, an account of the economic downturn, more individuals and returning registered nurses are likely to enter and reenter the nursing profession.  A deepening of animosity among registered nurses might prevail when the competition for nursing positions occur between the native and foreign-educated nurses.  Such an animosity will further strengthen the lack of collegiality within the nursing profession. 

A Kuhnian paradigm shift is required within the U.S. healthcare institutions to alter the cold war existing between the healthcare workers that would usher in a more collegial harmony hence halting the perpetual animosity.  Kuhn (1962) introduced the concept of “paradigm,” as a set of values, beliefs, or concepts that are mutual by a community to exemplify genuine problems and solutions.  Additionally, Kuhn (1962) reported changes in paradigms occur in discontinuous, innovative opportunities called “paradigm shifts” whereby, new ways of thinking replaced the old ways.  An envisioned paradigm shift is possible for developing an interdisciplinary structure of nursing collegiality with the development of harmonious relationships between nurse-physician and nurse-nurse, therapeutic working environments for the nursing staff, and the assimilation of the less antagonistic foreign-educated nursing emigrants who can diffuse the simmering underlying tensions and discontent among the nursing profession.  The lack of apathy of foreign-educated nurses can discourage feuding professional aggressive behavior of previous contentious issues.

Registered nurses need to be cognizant of the significance of their knowledge and endeavor to pass this knowledge on to new and inexperienced colleagues.  As nursing professionals, we need to take ownership for our behavior and conduct ourselves in a courteous and professional manner by treating others with kindness, dignity, and respect.  With anticipation, the day will come when the traditional cultures and environments will fade and a philosophy of empowerment will emerge.


For today, the emigration of foreign-educated registered nurses lacks the potential to have a major impact on changing the paradigm of U. S. nursing collegiality.  The potential for a new paradigm of nursing collegiality will encompass the redefining and restructuring of the working milieu for nurses, the support for the assimilation of foreign-educated registered nurses, the development of effective and professional nurse-physician and nurse-nurse relationships. 

The administrators that support nursing collegiality must apply Kegan’s constructive-developmental theorem by assisting the nursing staff to develop in order to meet the demands of the institution.  The prevailing state of animosity between the virtually exploited nursing personnel and the tyrannically oriented but equally overworked physician colleagues underrate the good work done by the disharmonious dual and may have detrimental effect on their patients.

The overriding Marxist tendency of recruiting from the poor developing nations however casts an ethical shadow on the U.S. recruitment methods (Stevenson & Haberman, 1998).  The U.S. slow growth of local recruitment especially among the minorities while seeking the easier option of international staffing is not economically viable in the long term as the exporting countries might seek compensation and levy the departing professionals.

As registered nurses across the globe begin to realize the worth of each other's proficiency and they begin to widen their understanding of their roles, it is likely to culminate into a phenomenon called harmonizing role blending.  It is where the registered nurses as professionals, are appreciated of their roles, irrespective of their socio cultural backgrounds. Through this scope of their extended responsibilities, collegiality becomes an indispensable constituent of their professional framework, which facilitates integration and communication, and ensures sustaining overall quality of continuing patient health care.  As society and healthcare continues to expand and grow more and more complex, such a trend is perhaps, indicative of a time where it is not only essential, but also imperative for us to move steadily away from the old and rigid conceptualization of professions and view them in the light of the new phenomenon.  This new phenomenon will take us forward toward a more prosperous and professional field of nursing and health care.  In the future, foreign recruitment of registered nurses may help create stronger cohesiveness and collegiality in the nursing profession.


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