Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

Immigration policy plays a critical role in the economy and workforce issues related to nursing. With the undersupply of nurses in the U.S. and worldwide education of nurses, the flow of nursing professionals has provided a steady stream of professionals in our hospitals and health care communities. We as a country have relied on internationally educated nurses (IENs) and our professional policies have worked hard to keep pace with establishing global standards for education and competencies that – at least – do not interrupt the flow.

With the federal government tackling the issues of immigration in general, nursing as a profession needs to pay attention to the discussion that generally sounds like topics related to undocumented workers when, in fact, a highly educated group of nurses may be part of that discussion. With the intellectual capital at stake, and with the U.S. no longer the country of choice for some immigrating nurses, we need to be vigilant in balancing the flow of IENs and hospital needs with local economic forces.

The January February 2014 issue of NURSING OUTLOOK tackles the multiple aspects of immigration and the internationalization of markets for goods and services, including the nursing workforce. In this interview, the lead author of the article that describes historic and current trends in countries that have often supplied the U.S. health care system, Dr. Leah Masselink adds commentary to the articles published in Nursing Outlook and provides historic backdrop to the international power of nurses and the intersection of IENs and immigration issues.

Leah E. Masselink, Ph.D., is Assistant Professor of Health Services Management and Leadership at the George Washington University School of Public Health and Health Services. Dr. Masselink joined the HSML in July 2012. Before coming to G.W., she earned a PhD in Health Policy and Management from the UNC Gillings School of Global Public Health and completed a postdoctoral fellowship at UNC School of Nursing. Her work focuses on internationally educated nurses and nurse migration in the Philippines. She has served as a consultant and assisted on the Health Workforce Development team for the USAID Health Care Improvement Project.

For links to the recent Senate and House legislation:

See the full article published in NURSING OUTLOOK at:

Masselink, L. & Jones, C.B. (2014). Immigration policy and internationally educated nurses in the United States: A brief history. Nursing Outlook, 62(1), 39-45.

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN

Leah MasselinkLeah E. Masselink, PhD
Assistant Professor
Department of Health Services Management & Leadership
The George Washington University
School of Public Health & Health Services




Question 1. The article briefly mentions that internationally educated nurses (IEN) hiring patterns in the U.S. reverberate in source countries like India and the Philippines. What has been the political and social impact of the reduced demand for IENs in these countries after the Great Recession?

To listen, click here.

In India, nurses historically have earned very low wages and worked under poor conditions not unlike other sending countries. It historically hasn’t been protested or hasn’t been a much of a problem because usually nurses at least had nurse migration as an opportunity to get out of poverty. With the reduced demand for nurses worldwide (India sends nurses to US, but also to the Middle East, and the U.K.), so the reduced demand after the Great Recession led to protests and strikes in India. The Nurses organized themselves to demand better wages, better working conditions. They protested against bonded service at some hospitals meaning that they were obligated for certain periods of time, including some very dramatic scenes where nurses would go up on the roof of a hospital and threaten to jump. The strikes happened in many states in India but much of the activity was centered in the state of Kerala, which has a long history of nurse migration. The nurses in Kerala have actually formed some of the first independent nurse’s unions. And the state is actually doing now some investigation trying to put some provisions in place to limit work hours and abolish the bonded service.

So the Philippines is in somewhat of a similar situation except probably even more focused on the U.S. market. The U.S. market is somewhat of the gold standard where most nurses are aiming to go. There is a huge production aimed at U.S. market. This overproduction led to thousands and thousands of unemployed nurses in the Philippines when the demand went down in the U.S. So, a few things happened: the nurses were working in private institutions as volunteer nurses who some of them actually had to pay fees to work in hospitals for clinical experience hoping that it would pay off later rather than being paid. This has been outlawed but it is a little unclear whether it is still going on. The government also tried to take some action: started a temporary program for unemployed nurses to send them to remote areas where they could both fill some needs and also get real employment experience for the future; and, has also sponsored some specialty certification programs for nurses to improve their employability in the future. And another really fascinating development has been the formation of a nurse’s political party, which included the election of a congresswoman who is a nurse, who is the former president of the Philippines Nurses Association. That party’s platform includes a lot of activity around protecting nurses fighting exploitation, both domestically and international recruitment, raising salaries and so forth. In both of those countries nurses concerns are a political issue in ways that we probably are not aware and that they certainly are not in the U.S.

Question 2. The article suggests that nurse leaders and hiring organizations bear much of the responsibility for ensuring that hiring of IENs is ethical. Are there any more centralized efforts (regulatory bodies, etc.) in the U.S. to protect IENs and source countries?

To listen, click here.

In the U.S, there are several voluntary efforts to protect IENs mostly headed up by either professional associations such as the American Staffing Association and the American Association of International Healthcare Recruitment, which have adopted codes of ethics which are conditions of membership in those associations. A broad variety of other associations have policy statements also on ethical recruitment including the American Organization of Nurse Executives (AONE). There are a few innovative efforts that try to go a little bit farther including the Alliance for Ethical International Recruitment Practices, which is actually run here at G.W. It has a voluntary code of ethics that recruiters can endorse and seek certification as ethical recruiters. Then certified recruiters are monitored for compliance with the code. One additional step that that organization takes is also seeking to promote corporate social responsibilities or efforts to give back to low income source countries.

Other governments and international bodies have also adopted voluntary codes, most all of these are voluntary, including the World Health Organization. The Code of Practice on International Recruitment encourages member states: (1) to avoid recruiting health workers who have obligations in their home countries, (2) to provide opportunities for training and skills transfer, and (3) to treat migrant workers fairly including compensation and legal protections etc. The U.K. also has a broader code of practice for its National Health Service (NHS) recruitment which is based on the WHO Code. NHS employers are “commended” to use only recruiters that comply with that code and internationally educated health professionals must have access to the same legal protections training compensation etc. Another provision that is interesting is that developing countries are specific – there’s a list – and they must not be targeted for recruitment unless they have entered in to an explicit government to government agreement with the U.K. So obviously this type of thing is a little bit more difficult to imagine in the U.S. because our health system is a bit more complex than a national health system. So there are efforts, but most all of them are voluntary.

Question 3. How might current or future immigration policy changes (e.g. comprehensive immigration reform) affect internationally educated nurses?

To listen, click here.

This is obviously still a work in progress, as of today. But the Senate actually did pass a bill back in 2013, so at least we can examine some of the provisions. Two categories were really affected, one was H1B Visas, which are increased quite a bit under that policy. The increase could create more opportunities for nurses but the impact is a bit unclear because H1B has not been used very much by nurses in the past. It’s intended for skilled immigrants who have bachelor’s degrees, and since nursing jobs are not necessarily posted with bachelor’s degree listed as required, those jobs are not always H1B eligible. The other category is the employment based visas, the immigrant visas. That policy proposed a shift to a merit based system rather than a family based system with points being awarded based on skills, education experience and English language proficiency. So nurses would likely compete strongly under this system, especially those with bachelor’s degrees or higher, as many IEMs do have, especially from the Philippines, which actually most all of their programs are run as BSN programs.

Another provision related to EB employment based visas is that is also seeks to clear the backlogs of visas and eliminates country specific caps, which has historically affected nurses from large sending countries such as India and the Philippines. The House had bills that died in Committee, the House Judiciary Committee and Homeland Security Committee, so they didn’t make it beyond that. But actually the provisions for skilled immigrants like nurses were fairly similar, adding H1B visas and employment based visas. No new visa categories were proposed in either of these pieces of legislation and the House bill also paid less attention to the existing employment based visa backlog. The House just now has unveiled a draft framework again, mostly focused again on undocumented immigrants, but it appears as if the idea of expanding H1B and employment based visas would most likely find support in the House as well. It remains to be seen how that will all turn out.

Follow-up Question. Where do you see this going?

It’s starting to turn around now and there has been now more interest again in trying to come to the U.S. So I think that they are beginning to see hope. I think there is a lot of interesting and probably developments that we cannot even imagine with the Affordable Care Act and future economic changes. It is a little uncertain, but nurses in some of these sending countries are beginning to look at the U.S. again as a destination.