ANN ARBOR—As manufacturers and technology firms export jobs offshore to China and India, the U.S. has ramped up its importation of foreign nurses.

Recruiting nurses from the Philippines, India and Nigeria, among other places, isn’t new” the U.S. has relied on foreign nurses for at least 50 years” but it is becoming more prevalent as a way to deal with the current nursing shortage, said Barbara Brush, associate professor of nursing at the University of Michigan.

Some recruiters charge as much as $10,000 for each foreign nurse they hire on behalf of American employers, and in response to communication concerns, some Indian educators are offering accent reduction classes to help nurses sound more American. In the past, would-be foreign nurses had to travel to the United States to take the licensing exam, but now they can take it in London and Seoul.

Brush, a nursing historian who has studied this issue for about 20 years, will receive about $150,000 in funding from the National Library of Medicine for a book that documents the history of foreign nurse migration to the United States.

The book will build on research Brush published in a Health Affairs article” Imported care: Recruiting foreign nurses to U.S. health care facilities.” That article was one of the top 25 most-read in the journal in 2005.

In 1995, nearly 10,000 foreign nurses received their U.S. registered nurse licenses, representing nearly 10 percent of all newly licensed RNs that year. Even as the number of U.S.-trained RNs has increased in recent years, the percentage of foreign nurses has increased to 14.

Generally, foreign nurses are women who send money home to family members, as the salaries they earn here are significantly higher than what they could make at home, Brush said. A nurse in the United States makes an average $50,000 a year; a nurse in the Philippines might earn $2,500.

In the past, foreign nurses have predominantly worked in nursing homes and in hospitals in urban settings, out of sight of many white, middle-class patients, Brush said, but” I think they are going to become more visible across a wider array of institutions and areas in the United States, and that might make the public nervous.” Brush surmises some patients could have concerns about nurses’ culture or language barriers, or about the quality of the nursing education they received outside the U.S.

In 1992, California and New York were home to nearly half of all foreign nurses in the U.S., but by 2000, their share of foreign nurses had declined to 38 percent while Florida, Illinois, Michigan, New Jersey and Texas saw the sharpest gains. Still, about 33 percent of the New York nursing work force comes from countries outside the U.S.

Brush said the increasingly aggressive recruitment of foreign nurses raises several questions she hopes to explore in her book:

–Why has the U.S. recruited nurses from foreign countries while maintaining a predominantly white, female pool of American-trained nurses? Has recruiting a predominantly female foreign labor work force undermined efforts to recruit American men and minorities to professional nursing roles?

–What are our ethical responsibilities to the countries from which we take these nurses? For example, the U.S. has a ratio of about 800 nurses for each 100,000 patients, while 16 African countries have an average of 100 nurses for every 100,000 and many have a much lower nurse-patient ratio. The Ghanaian government has called for an end to the recruitment of its nurses.

–What is the effect on the quality of health care provided in the U.S.? While foreign nurses must supply evidence that they completed nursing instruction and pass the U.S. nursing exam, no studies to date have determined whether foreign nurses’ cultural orientation and technical competence lead to different outcomes for patients than those of their domestic peers.

Brush said that while recruiting foreign nurses might appear to address a need to introduce cultural diversity into the nursing work force, one challenge is that the cultural background and language of foreign nurses often do not match those of the patients they serve in the U.S. Filipino nurses may care for African-American or Hispanic patients in New York hospitals, for example, or for other immigrant groups such as Chinese or Vietnamese.

Brush plans to explore the rise of such groups as the Philippines Nurses Association, the Association of Hispanic Nurses, the Indian Nurses Association and other organized groups of nurses as a way to give voice to the unique concerns of these immigrants.

She plans to survey foreign nurses to find out, in part, if they came to the U.S. with plans to stay permanently or just to earn a higher wage for a few years then return home. In the past, foreign nurses have said they planned to stay for three to five years, but because their visas were not well regulated, they often opted to stay longer.

Brush wants to understand the effects on these immigrant nurses, on patients and on society.

“They’ve been a hidden part of our matrix for a long time,” she said.” And unless we have some major immigration policy changes, I think foreign nurses will be part of our system for the long haul.”

NursingFor more on BrushBrush’s article in Health AffairsLatest news on the U.S. Senate’s debate of immigration reform