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Nurses from Other Lands Dr. Richard J. Tarpey Case: Nurses from Other Lands ..................................................................................................... 2

Introduction ............................................................................................................................. 2 The Problem ............................................................................................................................ 2 The Awakening ....................................................................................................................... 3 The Task Force ....................................................................................................................... 4 Assignment ............................................................................ Error! Bookmark not defined.

Name: Richard Tarpey Nurses from Other Lands

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Case: Nurses from Other Lands

Introduction A report released by the Health Resources and Services Administration (HRSA) in April of 2006 indicated that the U.S. nursing shortage will grow to more than one million nurses in the year 2020 (HRSA, 2006). All indicators concerning the nursing profession point to future shortages based on decreasing enrollment in nursing programs, increasing numbers of nurses approaching the retirement age, and increasing need for nurses due to an aging population. Additionally, according to the American Hospital Association survey, 44% of hospital CEO’s report that it was more difficult to recruit and hire nurses in 2006 than in 2005. These trends are concerning for hospital administrators as they attempt to acquire an adequate labor force in order to meet the increasing demand of patients. As just one of the several possible short term solutions to the nursing shortage issue, the recruitment of foreign-trained nurses to work in the United States has received attention recently. In 2004, foreign-trained nurses accounted for approximately 4% of the nursing workforce, with the numbers of these nurses taking the U.S. nurse licensing examination increasing (Shaw, 2004). The recruitment of foreign-trained nurses does not come without controversy, however. There are strong opinions in the industry as well as within individual hospitals concerning the practice ranging from the ethical dilemma concerning the depletion of other countries’ nursing supplies such as the Philippines where more than half of the foreign trained nurses immigrating to the United States have come from (Brush 2004) to individual co-worker and patient opinions concerning interactions with foreign-trained nurses. Culture and language barriers are common causes for conflict between foreign-trained nurses and U.S. trained nurses, physicians, staff, and patients.

The Problem Bill Samuelsson, CEO of Mercy Hospital in St. Louis, Missouri, is faced with a difficult challenge. Mercy Hospital is a 200-bed non-union facility offering multiple specialty services requiring approximately 500 nurses to adequately staff all departments and areas of the hospital. The hospital has a strong reputation within the community for its Labor & Delivery and Heart programs. He has witnessed the facility nurse vacancy rate (percentage of vacant, un-filled positions) rise steadily over the last three years from 15% to over 18% representing over 90 nursing positions waiting to be recruited and hired. In order to provide patient care and coverage, the facility has been forced to work existing nurses on mandatory overtime, use incentive pay (extra pay per hour) to encourage nurses to pick up extra shifts, and use more expensive contract or agency nurses to fill the gaps. This steady rise in labor cost coupled with recent rising trends in uncollected dept has served to put tremendous pressure on the facility’s bottom line. Adding to the hospital’s troubles, nursing union organization activity in the neighboring state of Kansas has increased over the last three months. The union attempted to organize nurses at Mercy last year, but failed in a vote that was a lot closer than the hospital’s leadership expected. The Board of Directors of the facility has formally asked Bill to find a way to cut labor costs to more manageable levels. The challenge is difficult enough without the prospect of nurse dissatisfaction leading to union organization adding additional pressure.

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Bill has spent the last 30 days analyzing various aspects of the facility’s labor cost to identify areas of opportunity. He has considered multiple options, including wage freezes, benefit reductions, and department or program closures. One morning as he was reviewing his straw-list of unattractive options, a colleague (Joe Kamarand) from a sister hospital within the same health system in St. Louis called with a proposition. “Bill,” Joe said, “we are having a terrible time recruiting new nurses to our facility given the nursing supply shortage in St. Louis. Have you ever given any thought to developing a foreign nurse recruitment program?” Bill had to admit that he had not considered this option to find new nurses to reduce the high vacancy rate. Last year he had attempted to partner with a local university’s nursing program, but the annual supply of nurses graduating was too small to fulfill the demand of 18 facilities within the metro St. Louis area. Other nearby markets within the same region were in the same position, so hopes of recruiting nurses from those markets were limited given Mercy’s constraints on labor costs which would preclude offering more favorable compensation packages. Bill has considered reaching out to other areas of the county but has hesitated for the same reasons. As Joe continued with his idea, Bill’s interest continued to grow as this seemed like a viable answer to his problem. Perhaps, the recruitment of foreign nurses would allow him to bring in more nurses at competitive or even lower rates than what would be required to attract nurses from other areas within the United States. Bill thanked Joe for the idea and indicated his interest in pursuing the idea for both facilities. He hung up and busily prepared his proposal for the rest of the hospital’s leadership team.

The Awakening Bill worked for several days researching the details of a foreign nurse recruiting program and crunching the numbers on costs to see if the idea would be feasible. He was excited to see that the program’s costs shared by the two facilities would easily be offset by the labor cost savings through a reduction in the use of overtime, premium incentive pay, and more expensive contract nurses. Additionally, Bill believed staff job satisfaction would rise given a more balanced workload from having an appropriate number of nurses on staff, resulting in less over-worked nurses. Working excessive hours was the most common complaint he heard from the nursing staff and leadership. He could not immediately find a downside to the proposal, so he went to the Monday morning Leadership Meeting with confidence that he had a viable solution to the problem he could present to the Board of Directors the following week. There was no conceivable way the hospital Leadership Team would not go for this idea. “This should be a quick formality,” he thought as he made his way to this place at the table for the Leadership Meeting. Bill sat through the presentations from the Chief Financial Officer (CFO) on monthly financials, the Chief Nursing Officer (CNO) on monthly patient quality metrics, and the Chief Operating Officer (COO) on other various hospital business items. As the meeting continued, Bill became more and more confident about presenting his solution to the problem that everyone was so concerned about. When the initial presentations were completed, Bill stood up and proceeded to outline his new Nurse Staffing & Hiring plan going over the financial aspects and details. As he summarized, he looked around the room with the expectation of acceptance from everyone around the table. He was surprised at the immediate silence in the room.

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After a couple of seconds of no response, Bill asked the group, “What do you think? At first, no one responded. Then the CNO, Sherri Smith, spoke up. “Well Bill, to be honest with you, I am somewhat concerned about the prospect of bringing 20-50 foreign-trained nurses into our facility. How will our current staff react? Will this give the nurses a final incentive to organize with the union? You know how close the last vote was.” “How can we possibly turn nurses loose in our units without extensive training on our processes and procedures?” asked, Jan Mulky, the Critical Care service line director. Bill Morris head of the Human Resources/Payroll group chimed in, “When our IT group outsourced the support of our payroll system last year, we could not get any help for months due to the language barrier between the outsourcing company overseas and us. Won’t our employees and even our patients have the same problem with foreign nurses?” The Chief Medical Officer (CMO), stated his concern as well, “Bill, if our physicians perceive an internal rift with our nurses or experience issues with working with foreign-trained nurses, they will begin referring their patients down the road to Memorial Hospital. You know most of the physicians have admitting rights at Memorial as well as Mercy. This idea could really backfire! Outside of emergency room admissions, our physicians are our only source of patients. We also need to consider the patients’ reaction to a foreign nurse. We can’t afford to let patient satisfaction decline.” The next 30-minute barrage of questions were all along the same line concerning the ability of foreign nurses to work effectively at Mercy Hospital, and the potential effects on the current staff, patients, and even the hospital’s community reputation. Bill was completely taken aback by the response and was unsure how to react. The group discussed the idea for another hour before adjourning with the decision to create a task force to investigate the proposal.

The Task Force The following week, the Nurse Staffing task force was established with key participants from the various areas of the hospital, including: Clinical/Nursing, Human Resources, Financial, and Medical/Physicians. Bill, as leader of the team, had his work cut out for him. Each of the individuals on the team brought to the table a different perspective from which they would perceive and address concerns. The Clinical/Nursing area’s main concerns would be centered on the clinical employee and patient care quality. This area would most likely focus on the potential negative impacts of employee-employee and employee-patient communication issues and conflicts and how they would potentially affect the quality of care given at the unit level. Additionally, they would be concerned with foreign nurse qualifications and ensuring these nurses were certified and licensed accordingly. The Human Resources area would be most concerned with foreign nurse certifications and licensing to ensure they met all federal and state regulatory requirements as well as about maintaining employee satisfaction to ensure existing nurses do not leave the organization contributing to the job vacancy problem or lending support to union organization efforts. The Financial area would be most concerned about the potential foreign nurse impact on existing productivity of staff members to ensure that the facility still provides quality care in a cost-efficient manner. The Medical/Physicians area would be most concerned about the potential impact on existing physician relationships and the facility’s ability to recruit and attract new physicians to the facility.

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To attempt to get everyone’s thoughts on the table, Bill decided that the first task for the team was to create a list of potential areas of concern. The team met for a couple of hours and listed every concern they could think of from an employee, physician, patient, and administrator perspective. Once duplicate concerns were consolidated, and any concerns that the team agreed was unwarranted were eliminated, they were left with a straw list of items to consider. The list of items is included in Table #1 in no particular order:

Area of Concern: Notes Quality Patient Care Will foreign nurses be able to provide quality patient care?

Will any potential conflicts or communication issues affect patient care?

Foreign nurse training and productivity

Will foreign nurses be able to work within Mercy’s systems and processes effectively and efficiently with comparable productivity of our U.S trained-nurses?

Language and cultural barriers (a potential source of employee-employee or employee-patient conflict)

Will there be communication issues among employees, physicians, and patients? How will our existing employees react?

Unionization issues

Lower wage rates are seen by staff as way to eventually lower their wage rates. The possible incentive for unionization on the part of nurses?

Existing hospital nurse productivity

Will our nurses lose productivity assisting the foreign-trained nurses

Employee job satisfaction Will current staff nurses have issues or problems working with the new nurses?

Physician facility satisfaction Will our physicians be able to work with foreign-trained nurses? Is there a possible loss of physicians using facility services if satisfaction declines?

Patient satisfaction Will patients accept a foreign-trained nurse? Will there be the potential for patient-nurse communication issues or conflict?

Table #1 – List of Potential Foreign-Trained Nurse Issues (meeting notes) As the team reviewed the list, it was clear that most of the potential issues identified shared some root causes involving the impact of adding a foreign nurse to a unit group. The resulting impact would be either on the unit group as a whole (how would the unit team act or perform differently) or would be at the individual employee level (how would each individual staff member act or perform differently). Bill from HR observed, “It seems that our main concern is first, how will each employee react to suddenly working with a foreign nurse and then how those reactions will affect the ability of the unit team to accomplish their tasks effectively.” Sherri agreed, “Absolutely, Bill! We need to foresee how the employees and teams could potentially be affected by the additional stress, potential for conflict, and communication issues. Nursing units are close-knit groups with highly skilled interactions. Any potential distraction can be critical” The team decided to adjourn with the task for each member to brainstorm and determine how the addition of a foreign nurse to the unit group might increase stress, cause communication issues,

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and add conflict to the employees and teams. Bill adjourned the meeting with the expectation that at the next meeting, each team member would come prepared with their thoughts about how the team could proactively address the identified potential issues to prevent negative impacts on employee performance and team performance.

References

AHA. (2007, July). The 2007 State of America’s Hospitals – Taking the Pulse Findings from the 2007 AHA Survey of Hospital Leaders. Retrieved March 16, 2010 from http://www.aha.org/aha/research-and-trends/index.html Bush B.L., Sochalski, J., and Berger A.M. (2004). Imported Care: Recruiting Foreign Nurses to U.S. Health Care Facilities. Health Affair, March 2004, 78-87. HRSA. (2006, April). What is behind HRSA’s Projected Supply, Demand, and Shortage of Registered Nurses? Retrieved March 23, 2010, from http://bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/index.htm Leonard, D. and Swap, W. (2004). Deep Smarts, reprinted in The Organizational Behavior Reader from Harvard Business Review, September 2004, 88-97. Obermeyer, M. (2005, September). Are foreign nurses culturally prepared to work in the U.S.? Retrieved February 20, 2010, from http://www.buzzle.com/editorials/9-23-2005-77386.asp Shaw, G. (2004, September). Recruitment of Foreign Nurses Helping Ease Nursing Shortage. The Washington Diplomat. Retrieved February 16, 2010, from http://www.washdiplomat.com/04-09/a7_09_04.html