est of foreign-educated nurses in coming to this country. Quite the contrary—CGFNS, which screens foreign-educated nurses for immigration purposes, saw only a handful of nurses cancel their plans. Indeed, what the nurses shared was that they were not strangers to such instances of violence and upheaval. Although the size and impact of 9/11 was horrific, the nurses saw it as a rarity compared to the more frequent conflicts they were exposed to in their home countries. Nursing in the United States remains attractive to foreign-educated nurses personally, professionally, and economically because of the opportunities and quality of life it provides.

The United States has the largest professional nurse workforce in the world; yet, according to a study by Buerhaus et al. (2009) there will be a projected shortfall of nurses developing around 2018. As a result of these projections, it is likely that the demand for registered nurses educated in other countries will increase. In other words, foreign-educated nurses will be a permanent feature of the U.S. nursing workforce for the foreseeable future.

It should be noted that the downturn in the world economy in 2009 has affected the health care workforce internationally. Hospitals have revised plans to expand their facilities, have closed beds and units that were not producing revenue, and have restructured their workforce. Those that have collective bargaining agreements are seeking to revise salaries and benefits. These changes, for example, meant that in 2009 large urban hospitals in Philadelphia reported having no vacancies for new graduate nurses; however, hospitals in smaller cities in the northeastern part of the state did have vacancies and were actively seeking nurses. The demand for experienced, specialty nurses continues to increase. Critical care, emergency care and the operating room are areas for which hospitals are recruiting.

Despite the downturn in the economy, the migration of nurses across international borders is expected to be ongoing. Therefore, the successful adjustment of foreign-educated nurses to U.S. practice is critical. The 2004 National Sample Survey of Registered Nurses estimated that, in terms of workforce diversity, 82 percent of U.S. nurses are white (non-Hispanic), and African Americans and Hispanics are under-represented in relation to their proportion to the U.S. population. Foreign-educated nurses, however, are more likely to be Asian. Hence, the international migration of nurses to the United States, historically, has not mirrored the under-represented minority populations of black and Hispanic. The cultural lack of fit between patient and provider has been adequately documented and is germane to this issue.

Health Policy Workforce Planning Issues

Good workforce planning should focus on increasing investment in the supply of nurses and other health professionals to meet the demands of all countries. A major challenge for all countries is to establish workforce planning



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