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The Contributions of Immigrant Nurses in the U.S. During the COVID-19 Pandemic:

A CGFNS International Study
Published:December 01, 2020DOI:https://doi.org/10.1016/j.mnl.2020.11.007
      No other event has put health care—and nursing—at the forefront of local, national, and global discussions in the same way as the COVID-19 pandemic. Studies suggest that immigrant nurses are a critical part of US health care, and we are increasingly reliant on the skills they bring and the care they provide. To quantify and qualify this contribution, CGFNS International designed a data-collection survey and distributed it to nearly 74,000 foreign-educated health care professionals currently practicing in the United States during the early months of the COVID-19 pandemic. Although some challenges were reported, most nurses surveyed reported working with patients diagnosed with COVID-19 and having access to adequate personal protective equipment, and many felt the public perception of nurses has improved since the beginning of the pandemic. Continued research on the experiences of immigrant nurses during the ongoing global pandemic response and beyond could provide more comprehensive information on the immigrant nurses that drive the US health system.
      Key Points
      • The value of foreign-educated health care professionals to destination countries’ health systems and source countries’ economies is becoming increasingly apparent.
      • The COVID-19 pandemic has reaffirmed that foreign-educated nurses, who have always been critical part of US health systems, are more important now than ever.
      • Most nurses surveyed by CGFNS International reported working with patients with COVID-19 and having access to adequate personal protective equipment, and many felt the public perception of nurses has improved since the beginning of the pandemic.
      No other event has put health care—and nursing—at the forefront of local, national, and global discussions in the same way as the COVID-19 pandemic. Since the World Health Organization (WHO) declared it a pandemic in March, the world has struggled to contain and mitigate the virus, pushing many already-stressed health systems to their limit as they struggle to maintain personal protective equipment (PPE) and medical supplies, and address staff shortages. As health care providers are recognized for their essential life-saving work, we must acknowledge the specific contributions of foreign-educated health professionals to the US health systems.
      The State of the World’s Nursing report published in April 2020 found that higher-income nations rely significantly on foreign-trained nurses to supplement their domestically trained workforce.
      World Health Organization (WHO)
      State of the World’s Nursing 2020: Investing in Education, Jobs and Leadership.
      Percentages in the United States vary by state, but according to the Migration Policy Institute, New York and California—2 states hit hard by the pandemic—report over 25% of their nursing workforce to be immigrants.
      • Batalova J.
      Immigrant Health-Care Workers in the United States. Migration Policy Institute (MPI).
      Immigrant nurses are a critical part of US health care and—especially as the US confirmed COVID-19 cases remain in the millions, and more states move closer to hospital capacity—we are reliant on the skills they bring and the care they provide.

      Background

      There is little doubt that 2020 is a momentous year for the global nursing professional. In what would be the 200th birthday of Florence Nightingale, the profession has witnessed many significant milestones. Dr. Tedros, Director General of the WHO, echoed this by appointing the WHO Chief Nursing Officer, Elizabeth Iro, and designating 2020 as the International Year of the Nurse and the Midwife. This significant commitment to nursing by the United Nations (UN) health agency was followed by the culmination of Nursing Now, a 3-year global campaign spearheaded by the WHO and International Council of Nurses (ICN) to elevate the status of nursing worldwide.
      On April 7, 2020, we celebrated the official launch of the momentous “State of the World’s Nursing 2020: Investing in Education, Jobs and Leadership” report by the WHO, ICN, and Nursing Now on World Health Day.
      World Health Organization (WHO)
      State of the World’s Nursing 2020: Investing in Education, Jobs and Leadership.
      The 2020 report, the first of its kind, draws upon data from 191 countries and shows important gaps in nursing workforces while highlighting key priority areas for investing in nursing education, jobs, and leadership. The significance of this publication, and that of the global nursing and midwifery professions, have only been magnified during the ongoing novel coronavirus (COVID-19) pandemic, where nurses around the world are proving yet again to be essential in the war against the virus. When an estimated 1 in 10 U.S. nurses and 1 in 8 nurses of the world are migrants, immigrant nurses need to be recognized for their many contributions to health care delivery and patient care around the world.
      The WHO projects a global shortage of 9 million health care professionals, or, nearly 6 million nurses, with the largest vacancies expected in Africa, Southeast Asia, the WHO Eastern Mediterranean region, and Latin America.
      World Health Organization (WHO)
      State of the World’s Nursing 2020: Investing in Education, Jobs and Leadership.
      Although the wealth of a nation is often measured by its health, throughout history, we have learned that it is the nurses of the world that generate healthy nations.
      As the globe faces the ongoing coronavirus pandemic, the contributions of nurses to the health of populations around the world are even more apparent. The many contributions of nurse migrants in filling workforce shortages and improving nations’ health should be understood, documented, and valued. In this International Year of the Nurse and the Midwife, CGFNS International seeks to highlight the specific and significant contributions of nurse migrants, particularly of foreign-educated nurses (FENs) currently practicing in the United States. These contributions are only further exposed during the unprecedented COVID-19 pandemic.
      The aims of this study were to:
      • Identify the unique impact the pandemic is having on immigrant nurses
      • Capture evidence of the immense contributions made by foreign-educated nurses serving on the frontlines against the COVID-19 pandemic in the United States.

      Methods

      Sample

      CGFNS International designed a data-collection survey and distributed it to all foreign-educated registered nurses (RNs) and licensed practical or vocational nurses (LPN/LVN) who ordered CGFNS Visa Credentials Assessment Service (VisaScreen) and/or Credentials Evaluation Services (CES) evaluations from 2015 through 2020. Hence, the invitation to participate was distributed to about 74,000 CGFNS applicants. The most recent 5-year cohort of CGFNS nurse applicants was invited to participate because it is likely that they are currently practicing nursing in the United States.
      CES reports provide a detailed analysis of the credentials (both professional and academic) earned at multiple levels of nursing education received outside of the United States. CES reports help qualified applicants demonstrate the merits of their education when compared with US standards, facilitating their pursuit of education and/or professional opportunities in the United States. CES reports are ordered primarily to secure licensure and employment in the United States.
      VisaScreen is a comprehensive screening service for health care professionals seeking an occupational visa to work in the United States. Section 343 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA) requires specific health care professionals to complete a screening program before they can receive either a permanent or temporary occupational visa. CGFNS International is approved by the US Department of Homeland Security to validate the credentials of 9 foreign healthcare professions for occupational visas including RN and LPN or LNV.
      The survey was also distributed to several national nursing associations whose memberships encompass a large percentage of the FENs currently practicing in the United States. These organizations included the Philippine Nurses Association of America, the National Association of Indian Nurses of America, the National Association of Nigerian Nurses in North America, and the National Association of Hispanic Nurses.
      Finally, the survey was disseminated via CGFNS International social media channels (i.e., Facebook, Twitter, and LinkedIn).

      Instruments

      The survey questionnaire was administered via a web-based survey platform. It was composed of question collecting information on demographics, education and registration background, migration, work in the United States, COVID-19–specific questions, and open-ended commentary. The survey began with 2 opening questions (“Are you currently a practicing nurse?” and “Did you receive your nursing education outside of the United States?”) to qualify respondents for inclusion in the study. Survey respondents were informed of the study purpose and assured that their responses and personal information would be kept confidential.
      Demographic questions included gender, age, type of nursing license held, and country of birth. Educational and registration background questions included country of initial nursing education, highest level of nursing and non-nursing education, and total number of years practicing nursing. Migration questions asked for country of origin and year of migration to the United States, total number of countries registered to practice nursing, and first US state or territory applied to practice nursing. COVID-19–related survey questions were designed to identify respondents that cared for patients who were diagnosed with COVID-19. Respondents who cared for patients diagnosed with COVID-19 were also asked:
      • How many hours per week were spent treating patients diagnosed with COVID-19
      • Whether they were provisioned with adequate PPE
      • Whether they experienced any significant adjustments to pay, benefits, or schedule due to the COVID-19 pandemic.
      The survey ended with a set of open-ended narrative questions offering respondents the opportunity to provide more details about their perceptions and experiences working as a FEN during the COVID-19 pandemic in the United States. These questions included:
      • 1.
        Please provide comments on your experience working as an immigrant nurse in the United States.
      • 2.
        Please provide comments on your experience working as a nurse during the COVID-19 pandemic.
      • 3.
        How has your perception of the nursing profession changed since the start of the COVID-19 pandemic?
      • 4.
        Please provide any additional comments you may have.
      Survey data collection took place between May 28 and June 11, 2020.

      Results

      Sample demographic

      A total of 1520 responses were submitted by respondents who confirmed they migrated to the United States. Of those, 1374 completed the survey, with slight variations caused by a few respondents not answering each question.∗ Respondents represented more than 100 countries and were overwhelmingly female (84%), RNs (94%), and working full time in the United States (79%). A total of 972 respondents identified with the age range of 25 to 44 years, and of 1343 total responses, 1034 reported that they had been practicing nursing in the United States between 1 and 5 years. Practice settings across the sample are depicted in Table 1, with the hospital setting being most prominent.
      Table 1Respondent Practice Settings
      Practice Settings
      Hospital setting953
      Nursing home, rehabilitation center, or long-term care facility348
      Ambulatory care centers, surgical centers, or outpatient clinics97
      Home health care78
      Educational setting (school and university)30
      Other68
      N = 1574 responses (respondents were able to select multiple settings).
      Several nursing specialties were represented among the respondents with the highest concentrations in critical care nursing (19%), surgical/operating room nursing (13%), and geriatric nursing (12%). Of 1358 responses, 957 (70%) reported working between 31 and 40 hours per week. Of those working as RNs, 79% reported working twelve-hour shifts in hospitals.

      Findings

      Respondents were asked about their working conditions and experiences while practicing nursing during the pandemic.

      Personal Protective Equipment and Safety

      63% of all respondents reported that they were assigned to care for patients diagnosed with COVID-19 during the pandemic, with 63 citing “direct” patient care in the free response. Of those that worked with patients diagnosed with COVID-19, 78% affirmed they had access to adequate personal protective equipment (PPE), with 22% reporting they did not. At least 60% of those reporting inadequate access to PPE worked in a hospital setting, 40% of whom reported being assigned to care for patients diagnosed with COVID-19.
      When given the statement “Since the COVID-19 pandemic, the overall safety for nurses in my given care setting has improved,” 21% of respondents disagreed, with 8% strongly disagreeing (Figure 1). When filtered to include only those assigned to care for patients diagnosed with COVID-19 patients (848 responses), the percentages rose to 24% disagreeing and 10% strongly disagreeing. Those reporting inadequate access to PPE were 6 times more likely to respond with “strongly disagree.”
      Figure thumbnail gr1
      Figure 1Foreign-educated nurse responses to the statement, “Since the COVID-19 pandemic, the overall safety for nurses in my given care setting has improved.” (Location: Findings section, Personal Protective Equipment & Safety).
      These responses provide a glimpse into how nurses view their safety at work. However, additional research into the specific measures of safety and the speed at which additional measures were taken, could provide a more comprehensive understanding of which measures were effective—or perceived to be effective—and how hospitals implement safety measures.

      Employment and Compensation

      Collectively, 1358 respondents reported pre-pandemic weekly work hours estimated at 49,580, with 70% of individual respondents working between 31 and 40 hours a week. Of 859 FEN respondents who reported being assigned to care for patients diagnosed with COVID-19, an estimated 23,945 hours of care per week were administered to patients with this diagnosis since the pandemic began.
      Of 1360 respondents to this survey item, 51% reported their schedule changed due to the pandemic, and 910 of 1362 respondents (67%) reported no pay or benefit changes. When requesting additional information about how their hours, pay, and benefits had been affected, 63 respondents used the keywords “less,” “decreased,” or “reduced,” whereas 110 used keywords “increase,” “extra,” or “bonus.”
      When given the statement “Since the COVID-19 pandemic, I am satisfied with the level of patient care I can provide,” 66% agreed they were satisfied. Of those that disagreed or strongly disagreed, over half reported working in a hospital setting, with 20% of those working in critical care. Respondents who completed their initial nursing education in South Korea were 3.6 times more likely to disagree with the statement.
      To the statement “Since COVID-19, I feel as though my employment is more secure,” 14% strongly agreed, 29% agreed, 33% were neutral, 18% disagreed, and 6% strongly disagreed. Respondents that completed their initial nursing education in Canada and Jamaica had a higher likelihood to report strongly disagreeing. Those that reported having adequate access to PPE were 3.75 times more likely than the average to strongly agree.

      Nursing Perception

      When asked whether they felt the public’s perception of nursing had improved during the pandemic, 79% of respondents agreed or strongly agreed that the overall public perception had improved. However, when asked whether they felt public perception of foreign-educated nurses had improved, only 49% agreed, with 39% remaining neutral and 12% disagreeing (Figure 2). Of those disagreeing, 48% reported delivering nursing care to patients who were diagnosed with COVID-19 in a hospital setting. Of those who strongly agreed, 74% reported working in a hospital, nursing home, or long-term care setting.
      Figure thumbnail gr2
      Figure 2Foreign-educated nurse responses to the statement, “Since the COVID-19 pandemic, the public perceptions of foreign-educated nurses have improved.” (Location: Findings section, Nursing perception).
      Compared with the average, respondents that completed their initial nursing education in Canada were 3 times more likely to strongly disagree with the statement, “Since the COVID-19 pandemic, public perceptions of foreign-educated nurses have improved.” Those that responded they had inadequate access to personal protective equipment were 5.6 times more likely to strongly disagree that public perceptions of nursing overall had improved. Respondents that reported working in a hospital were 2.5 times more likely to disagree, and those that reported working in both a hospital and an education setting were 10 times more likely to answer “strongly disagree.”

      Results analysis

      The survey results reflect a discrepancy between domestic-trained and foreign-trained nurses. In a June 2020 survey conducted by the American Nursing Association, 79% of respondents stated that they were “required or encouraged to reuse single-use PPE” and 59% reported that it made them feel unsafe.
      American Nurses Association (ANA)
      ANA Survey of 14k Nurses Finds Access to PPE Remains a Top Concern.
      The responses from exclusively immigrant nurses collected in the CGFNS study reported far higher access to PPE and higher feelings of safety. Explanations of this may lie in cultural differences and expectations, as well as the how comfortable foreign health professionals feel speaking up about safety concerns.
      Additional research into these differences could yield important information about hospital and health care communication, as well as aid in better understanding the country-specific demographic responses reflected in this report. Although these data provide an opportunity to hypothesize, additional data would be needed to establish causal relationships between COVID-19 concerns and certain foreign-educated nurse responses.

      Discussion

      Although this survey has focused on the experiences of foreign-educated health professionals who were already living and working in the United States, the ongoing pandemic will have continuing ripple effects across a breadth of social issues, including the migration policy landscape.
      Although health professional migration has been a critical component of the health workforce for many wealthy countries, the flow of critical health care workers from poor countries with health workforce shortages to wealthier ones raises ethical concerns about the impact of “poaching” or “brain drain.” Conversely, limiting the ability of health professionals from developing countries to make the best career and personal decisions for the benefit of them and their family has their own concerns. These concerns are addressed by long-standing codes that seek to maximize the benefits and mitigate the harms of international health professional recruitment.
      At the global level, the World Health Organization’s Global Code of Practice on the International Recruitment of Health Personnel established principles in 2010 around health workforce that apply to all stakeholders but are primarily directed at member states. The Alliance for Ethical International Recruitment Practices, a division of CGFNS International, has a Health Care Code for Ethical International Recruitment and Employment Practices that has provided guidelines for recruiters, employers, and professionals since 2008 in the U.S. context.
      Alliance for Ethical International Recruitment Practices
      Health Care Code for Ethical International Recruitment and Employment Practices.
      These concerns are more prominent in the COVID era. Health care needs have spiked, and the stress on health professionals might lead some to retire or change their specialty. The result may be more health worker migration; conversely, the economic shock from the pandemic-induced recession could lead to greater restrictions on immigration.
      This has played out to some extent in the United States; in April, President Trump issued an executive order suspending most permanent (“green card”) immigration for 60 days. In June, President Trump extended that order and expanded it to nonimmigrant worker migration as well (including the H1-B and J visa programs, for example). Although these moves have had dramatic impacts on many sectors, health care workers have some respite; there is a broad exemption for health care professionals in the first order and a narrower one for those who provide COVID patient care in the second one. In Congress, a bipartisan group of 36 senators recognizes more can be done; they have cosponsored the Health Workforce Resilience Act (S.3599) to provide 25,000 additional visas for nurses and 15,000 for physicians during the pandemic.
      There are issues on the emigration side too. Most notably, the Philippines imposed a new ban on emigration of health professionals following an earlier suspension.
      • Valente C.S.
      Palace: Govt Suspends Overseas Deployment of Filipino Health Workers.
      Even without legal restrictions on emigration, there are other issues that act as indirect barriers to emigration. For example, in an effort to combat the spread of COVID-19, the Indian government temporarily banned all domestic and international flights within its borders, effectively preventing all potential Indian emigrants from departing the country.
      Similarly, COVID-induced strains on schools, universities, and postal systems worldwide have had similar impacts on migrants’ ability to migrate, demonstrating the unintended and consequential impacts of the pandemic on the global migration of health workers.
      Yet, even as countries need health care workers, they often need money as well. Remittances are a critical component of many developing nations’ economies and are particularly important because (other than transfer fees) they get right to the pockets of low- and middle-income individuals. While remittances are expected to decline 20% from a record $550 billion in 2019, foreign direct investment is expected to decline by 35%, necessitating developing countries to become increasingly more reliant on the former revenue.

      World Bank Predicts Sharpest Decline of Remittances in Recent History. World Bank; April 22, 2020. Available at: https://www.worldbank.org/en/news/press-release/2020/04/22/world-bank-predicts-sharpest-decline-of-remittances-in-recent-history. Accessed February 19, 2021.

      From this context, a consistent story becomes clear. Foreign-educated health professionals, who have always been a critical part of the health care workforce, are more important now than ever; even if sending and destination countries temporarily re-evaluate their support for migration, the value of foreign-educated professionals to destination countries’ health systems and source countries’ economies is becoming increasingly apparent.

      Conclusion

      The unprecedented nature of the COVID-19 pandemic brings unique challenges. In the time since the deployment of this survey, more information has been found about the virus, nations around the world have faced resurgences, and health systems have new—or continued—PPE shortages. These responses have provided a glimpse into the work of US immigrant nurses several months into the pandemic as they adapted to new work environments.
      Overall, most nurses surveyed reported working with patients diagnosed with COVID-19 and having access to adequate PPE, and many felt the public perception of nurses has improved since the beginning of the pandemic. Periodic research, not only on the experiences of immigrant nurses during the ongoing global pandemic response, but also on the shifting immigration and migration policies, could provide more comprehensive information on the immigrant nurses that drive the US health system.

      References

        • World Health Organization (WHO)
        State of the World’s Nursing 2020: Investing in Education, Jobs and Leadership.
        (Available at:)
        https://www.who.int/publications/i/item/9789240003279
        Date: April 6, 2020
        Date accessed: October 10, 2020
        • Batalova J.
        Immigrant Health-Care Workers in the United States. Migration Policy Institute (MPI).
        (Available at:)
        • American Nurses Association (ANA)
        ANA Survey of 14k Nurses Finds Access to PPE Remains a Top Concern.
        (Available at:)
        • Alliance for Ethical International Recruitment Practices
        Health Care Code for Ethical International Recruitment and Employment Practices.
        (Available at:)
        • Valente C.S.
        Palace: Govt Suspends Overseas Deployment of Filipino Health Workers.
        The Manila Times, August 18, 2020 (Available at:)
      1. Sarkar S. India Extends Ban on International Flights Till August 31. Hindustan Times, July 31, 2020 (Available at:)
      2. World Bank Predicts Sharpest Decline of Remittances in Recent History. World Bank; April 22, 2020. Available at: https://www.worldbank.org/en/news/press-release/2020/04/22/world-bank-predicts-sharpest-decline-of-remittances-in-recent-history. Accessed February 19, 2021.

      Biography

      Franklin A. Shaffer, EdD, RN, FAAN, FFNMRCSI, is president and CEO of CGFNS International, Inc., in Philadelphia, Pennsylvania. He can be reached at [email protected] Mukul A. Bakhshi, JD, is director, Alliance for Ethical International Recruitment Practices, and director of government affairs at CGFNS International, Inc., Kaley N. Cook, MS, is program coordinator, Alliance for Ethical International Recruitment Practices, and Thomas D. Álvarez, MS, is senior research associate to the president and CEO at CGFNS International, Inc.