Nursing shortage

Nursing shortage refers to a situation where the demand for nursing professionals, such as Registered Nurses (RNs), exceeds the supply—locally (e.g., within a health care facility), nationally or globally. It can be measured, for instance, when the nurse-to-patient ratio, the nurse-to-population ratio, or the number of job openings necessitates a higher number of nurses than currently available. This situation is observed in developed and developing nations around the world.
Nursing shortage is not necessarily due to a lack of supply of trained nurses. In some cases, perceived shortages occur simultaneously with increased admission rates of students into nursing schools. Potential factors include lack of adequate staffing ratios in hospitals and other health care facilities, lack of placement programs for newly trained nurses, and inadequate worker retention incentives.
Globally, the World Health Organization (WHO) estimates a shortage of almost 4.3 million nurses, physicians and other health human resources worldwide—reported to be the result of decades of underinvestment in health worker education, training, wages, working environment and management.
Causes.
Nursing shortage is an issue in many countries. To remedy the problem, psychological studies have been completed to ascertain how nurses feel about their career in the hope that they can determine what is preventing some nurses from keeping the profession as a long-term career. In a study completed by sociologist Bryan Turner, the study found that the most common nursing complaints were: 
A report from the Commonwealth of Australia identified a few other matters that led to nurse dissatisfaction: 
Another study found that nurse dissatisfaction stemmed from:
In many jurisdictions, administrative/government health policy and practice has changed very little in the last decades. Cost-cutting is the priority, patient loads are uncontrolled, and nurses are rarely consulted when recommending health care reform. The major reason nurses plan to leave the field, as stated by the First Consulting Group, is because of working conditions. With the high turnover rate, the nursing field does not have a chance to build up the already frustrated staff. Aside from the deteriorating working conditions, the real problem is "nursing’s failure to be attractive to the younger generation." There’s a decline in interest among college students to consider nursing as a probable career. More than half of currently working nurses "would not recommend nursing to their own children" and a little less than a quarter would advise others to avoid this as a profession altogether.
Australian nursing researchers John Buchanan and Gillian Considine described hospitals as "being run like a business" with "issues of patient care… of secondary importance." Emotional support, education, encouragement and counseling are integral to the everyday nursing practice. However, these practices are not easily quantified and are considered by managers as unjustified cost for the patients, who are viewed as consumers. Therefore, only clinical responsibilities, such as medication administration, dressing changes, foley catheter insertions, and anything that involves tangible supplies, are quantified and incorporated into the organization budget and plan of care for the consumers.
The nursing shortage affects the developing countries that supply nurses through recruitment to work abroad in wealthier countries. For example, to accommodate perceived nursing shortage in the United States, American hospital recruit nurses from overseas, especially the Philippines and Africa. This, in turn, can lead to greater nursing shortages in their home countries. In response, in 2010 the WHO's World Health Assembly adopted the "Global Code of Practice on the International Recruitment of Health Personnel", a policy framework for all countries for the ethical international recruitment of nurses and other health professionals.
Impacts on healthcare.
Nursing shortages (including low hospital-level nurse-to-patient ratios) have been linked to the following effects:
Global shortage and international recruitment.
The nursing shortage takes place on a global scale. Australia, the UK, and the US receive the largest number of migrant nurses. Australia received 11,757 nurses from other countries between 1995 and 2000. The U.S. Immigration and Naturalization Service (INS) records show that more than 10,000 foreign nurses were given H-1A visas in the same time frame. The U.K. admitted 26,286 foreign nurses from 1998 to 2002.
Saudi Arabia also depends on the international nurse supply with 40 nations represented in its nurse workforce. Netherlands needed to fill 7,000 nursing positions in 2002, England needed to fill 22,000 positions in 2000, and Canada would need about 10,000 nursing graduates by 2011.
Source: Data from the World Health Organization (2006).
In an American Hospital Association study, the cost to replace one nurse in the U.S. was estimated at around $30,000–$64,000. This amount is likely related to the cost of recruiting and training nurses into the organization. Hiring foreign nurses is more financially taxing compared to hiring domestic-graduate nurses; however, facilities save money in the long run because foreign nurses have a contractual obligation to complete their term. The JACHO in the United States wrote in a 2002 research report on the shortage in the US that recruiting foreign trained nurses from abroad (not referring to those who reside in the United States already) does not help the global nursing shortage and, in fact, perpetuates it.
Countries that send their nurses abroad experience a shortage and strain on their health care systems.
In South Africa, accelerated recruitment by developed countries such as United States, United Kingdom and Australia has placed more pressure on the health care system due to prevalence of diseases, such as AIDS, and limited resources. Similar to the U.S., nurses who leave the organization are a financial disadvantage due to the need to fund recruiting and retraining of new nurses into the system. It has been estimated that every nurse who leaves South Africa is an annual loss of $184,000 to the country, related to the financial and economical impact of the nursing shortage.
The following table represents the number of nurses per 100,000-population in southern African countries.
In India international migration has been considered as one of the reasons behind shortages of nursing workforce. Social, economic and professional reasons have been cited behind this shortfall.
Retention of nurses by sending (often developing) countries can be addressed by improving working conditions, minimizing wage differentials, and promoting medical tourism. Retention can also be promoted through educational activities to improve job satisfaction. There can be additional unintended impacts of nurses migration abroad. For example, there is growing evidence that physicians in the Philippines have shifted to the nursing field for better export opportunities. The World Health Organization (WHO) representative in Manila believes the government should invest more into its health sector as it is 3% of the Philippines' GDP. Others have suggested programs which require domestic service or employment upon graduation.
Ethical concerns.
Foreign nurses that migrate from developing countries to fill the nursing shortage of developed nations pursue their own economic, career, and lifestyle interests, but there are risks. The media and scholars have remained relatively silent on the ethical concerns involving the potential exploitation of foreign nurses. On the level of national sovereignty and global equality, there are ethical concerns about the pull of developed nations on developing countries' skilled workers and assets. U.S. incentives such as signing bonuses can be seen as promoting brain drain. Activists have spread a new term for this: "Brain drain in the south, brain waste in the north." The president of the Philippines Nurse Association, George Codero, was quoted in a "New York Times" article as saying "The Filipino people will suffer because the U.S. will get all our trained nurses".
On an individual basis, foreign nurses are subject to exploitation by employers. In 1998 six Americans were charged with falsely obtaining H-1A visas and using them to employ Filipino nurses as nurse aides instead of registered nurses. In a case in 1996, a Catholic archdiocese employed some of these foreign nurses as nurse aides instead of nurses. In 2000, Filipino nurses in Missouri received $2.1 million for failure to receive proper wages that an American in the same position would receive. While these cases were brought to court, many similar situations are left unreported thereby jeopardizing the rights of foreign nurses. Foreign nurses have the tendency to receive less desirable jobs, such as entry-level positions, because of their immigrant status; they are excluded from jobs that would lead to facilities and are often not paid proper salaries.
Some U.S. health care facilities push to "ease restrictions" on the immigration law to increase the number of recruited foreign nurses. On the other hand, this recruitment practice is a temporary solution that does not fully address the nursing shortage as mentioned by American Nursing Association (ANA). Others have taken a stand on ethically recruiting foreign workers. New York University Medical Center was cited in "The Search for Nurses Ends in Manila" as believing that it is a "poaching exercise" to take nurses from countries in need of their citizens. The former health secretary, Dr. Galvez Tan, in reference to the doctors and nurses working for an American green card said, "There has to be give and take, not just take, take, take by the United States."
Shortage by country.
Morocco.
Morocco has far fewer nurses and other paramedical staff per capita than other countries of comparable national income. The number of nurses in Morocco was 29.025 in 2011, two thirds being registered nurses and one third auxiliary nurses, a ratio of 8 nurses per 10,000 population. As a result, Morocco has been classified among 57 countries suffering from a glaring shortage of medically trained human resources.
A recent study by the European Institute of Health Sciences (Institut Européen des Sciences de la Santé) in Casablanca based on scientific modeling of future needs indicates that the situation will worsen and that to bridge the nursing gap, Morocco needs to produce between 40,000 and 80,000 new nurse graduates until the year 2025.
Philippines.
The Philippines is the largest exporter of nurses in the world supplying 25% of all overseas nurses. An Organisation for Economic Co-operation and Development study reported that one of every six foreign-born nurses in the OECD countries is from the Philippines. Of all employed Filipino RNs, roughly 85% are working overseas. This is partially in response to the inability of Filipino nurses to enter their domestic workforce due to a lack of jobs and instead become heavily dependent upon international job markets for nurses. The United States has an especially prominent representation of Filipino nurses. Of the 100,000 foreign nurses working in the U.S. as of 2000, 32.6% were from the Philippines.
Reasons for international migration.
The international migration of Filipino nurses takes place in response to "push and pull" factors. The push factors are rooted in the economic conditions in the Philippines in which there is an overabundance of RNs and a lack of open employment positions. The unemployment rate in the Philippines exceeds 10%. Additionally, health care budgets set up Filipino nurses for low wages and poor benefit packages. There are fewer jobs available, thereby increasing the workload and pressure on RNs. Filipinos often pursue international employment to avoid the economic instability and poor labor conditions in their native country. The government also highly encourages the exportation of RNs internationally. Filipino nurses are pulled to work abroad for the economic benefits of international positions. While a nurse in the Philippines will earn between $180 and $200 U.S. dollars per month, a nurse in the U.S. receives a salary of $4,000 per month. Nurses abroad are greatly respected in the Philippines as they are able to support an entire family at home through remittances. In 1993, Filipinos abroad sent $800 million to their families in the Philippines thereby supporting the economy. Additionally, remittances from Filipinos made up 5.2% of the Filipino GDP (gross national product) between 1990 and 2000. Further pull factors stem from the additional economic benefits of signing bonuses in the U.S. To attract more foreign nurses, U.S. hospitals increased signing bonuses from $1,000 to $7,000. Positions abroad in the health sector are also enticing for their immigration benefits. Throughout the past 50 years of nurse migration, the U.S. has made efforts to ease the visa application process to further encourage international nurses to relieve the nursing shortage. Scholars note that the better living and working conditions, higher income, and opportunities for career advancement draw nurses from the Philippines to work in the U.S.
As the relation between the U.S. and the Philippines stretches back 50 years, Filipino nursing institutions often reflect the same education standards and methods as the U.S. curriculum. Furthermore, a knowledge of English in the Philippines makes it easier for Filipino nurses (rather than nurses from other developing nations) to work in the U.S.
Since 1916, 2,000 nurses have arrived each year in the U.S. In 1999, the U.S. approved 50,000 migrant visas for these nurses. Today, on average, there are about 30,000 Filipino nurses traveling to the U.S. each year.
Effects of migration.
The transnational migration of Filipino RNs has profound effects on the economy and workforce dynamics in both sending and receiving nations. The departure of nurses from the domestic workforce represents a loss of skilled personnel and the economic investment in education. In addition, the "scarce and relatively expensive-to-train resources" invested are lost when a worker chooses to work abroad. When RNs migrate internationally, the country they emigrate from loses a valuable resource and any financial or educational support that was invested in the individual.
According to many Filipinos working in hospitals, the most educated and skilled nurses are the first to go abroad. There is disagreement among scholars on the extent to which the Filipino health sector is burdened by its nursing shortage. While the numerical data are inconsistent about whether the nurse supply is in excess or a shortage, it is clear that there is a short supply of the most skilled nurses who go abroad. As a result, operating rooms are often staffed by novice nurses, and nurses with more experience work extremely long hours. As skilled nurses decline in the urban areas, nurses from rural areas migrate to hospitals in the cities for better pay. As a result, rural communities experience a drain of health resources. Stories and studies alike demonstrate that a treatable emergency in the provinces may be fatal because there are no medical professionals to help treat them. In fact, "the number of Filipinos dying without medical attention has been steadily increasing for the last decade." The lack of attention from medical professionals has increased despite advances in technology and medicine and the increasing number of trained nurses in the Philippines.
Doctors, too, have changed professions and joined the international mobility trend. Filipino doctors have begun leaving their professions to train as nurses under the title MD-RN with the hope of immigrating to the U.S. or other developed nations more easily. Since 2000, 3,500 Filipino doctors have migrated abroad as nurses. The U.S. incentives for nurse migration encourage doctors to train as nurses in the hopes of increasing their economic prospects. As a result, the Philippines have a lower average of doctors and nurses with 0.58 and 1.69 respectively for a population of 1,000. The average statistics globally in contrast are 1.23 and 2.56. Between 2002 and 2007, 1,000 Filipino hospitals closed due to a shortage of health workers. A study conducted by the former Philippine Secretary of Health, Jaime Galvez-Tan, concluded that close to 80% of government doctors have become nurses or are studying nursing. Of the 9,000 doctors-turned-nurses, 5,000 are working overseas. The extraordinary influence of this international migration has had devastating effects on the health of Filipinos. The number of deaths that were not prevented with medical attention have increased as hospitals are shut down and rural areas are deprived of any medical treatment.
Due to the high interest in international mobility, there is little permanency in the nursing positions in the Philippines. Most RNs choose to sign short-term contracts that will allow for more flexibility to work overseas. Filipino nurses feel less committed to the hospitals as they are temporary staff members. This lack of attachment and minimal responsibility worsens the health of Filipino patients.
The education system has also been hurt by the increase of nurses in the Philippines. As Filipinos are attracted to working as nurses, the number of nursing students has steadily increased. As a result, the number of nursing programs has grown quickly in a commercialized manner. In the 1970s, there were only 40 nursing schools in the Philippines; by 2005 the number had grown to 441 nursing colleges. While the education opportunities for nursing students has grown tremendously, the quality of education has declined. This can be seen by the low rate (50%) of students who pass the nursing exam since the 1990s. Furthermore, the Technical Committee on Nursing Education of the Commission on Higher Education (CHED) determined that 23% of Filipino nursing schools failed to meet the requirements set by the government.
In summary, the emigration of Filipino nurses has encouraged doctors to switch to nursing, created a shortage of skilled specialized and experienced nurses, affected the education system, and distorted health care delivery and attention to medical issues in rural areas. While remittances, return migration, and the transfer of knowledge support the Philippines, they fail to fully compensate the loss of health workers, which disrupts the Filipino health and education sectors.
Dr. Jaime-Galvez Tan, the former Philippine Secretary of Health, warns that if the U.S. passes legislation allowing for freer immigration of nurses the health service of the Philippines could collapse.
United Kingdom.
In October 2015 The UK Government announced that Nurses will be added to the government’s shortage occupation list on an interim basis.
In December 2015, 207 out of 232 English hospitals (90%) reported nursing shortages.
In January 2016 the RCN stated that more than 10,000 nursing posts went unfilled in 2015. This represented a 3% increase year on year from 11% in 2013, 14% in 2014 and 17% in 2015 of all London nursing positions and 10% as an average nationwide. According to a BBC article the Department of Health said it did not recognise the figures.
United States.
According to the American National Council of State Boards of Nursing, the number of U.S. trained nurses has been increasing over the past decade: In 2000, 71,475 U.S.-trained nurses became newly licensed. In 2005, 99,187 U.S.-trained nurses became newly licensed. In 2009, 134,708 U.S.-trained nurses became newly licensed. Therefore, a 9.8% annual increase of newly licensed U.S. nurses has been observed each year over nine years. It is clear that, nursing enrollment in the U.S. has significantly increased over the past decade relative to the 1.19% annual U.S. population growth.
While the number of U.S. trained licensed nurses has increased each year, the projected nursing demand growth rate from 2008 to 2018, as reported by the U.S. Bureau of Labor Statistics, is anticipated to be 22%, or 2.12% annually. Therefore, the 9.8% annual growth of new RN's exceeds the current new position growth rate by a net of 7.7% per year with the assumption of consistent growth figures over the next decade.
The United States population is projected to grow at least 18% over two decades in the 21st century, while the population of those 65 and older is expected to increase three times that rate. The increase in the number of elderly is projected to lead to an increase demand for nurses in senior care facilities as well as the need to fill the positions of nurses as they reach retirement age. Projections suggest that by 2020 to 2025 one third of the current RN and LPN workforce will be eligible to retire. The current shortfall of nurses is projected at 800,000 by the year 2020.
Professional health and related occupations were expected to rapidly increase between 2000 and 2012. The demand for health care practitioners and technical occupations will continue to increase. It is projected that there will be 1.7 million job openings between 2000 and 2012. The demand for registered nurses is even higher. Registered nurses are predicted to have 1,101,000 openings due to growth during this 10-year period. In a 2001 American Hospital Association survey, 715 hospitals reported that 126,000 nursing positions were unfilled.
Other research findings report a projection of opposite trend. Although the demand for nurses continues to increase, the rate of employment has slowed down since 1994 because hospitals were incorporating more less-skilled nursing personnel to substitute for nurses. With the decrease in employment, the earnings for nurses decreased. Wage among nurses leveled off in correlation with inflation between 1990 and 1994. The recent economic crisis of 2009 has further decreased the demand for RNs.
Comparing the data released by the Bureau of Health Professions, the projections of shortage within two years have increased.
US: Supply versus Demand Projections for FTE Registered Nurses 
Source: Data from the Bureau of Health Professions (2002)
However, emergency and acute care nurses are in great demand, and this temporary reduction of the shortage is not expected to last as the economy improves. In 2009, it was reported that in places like Des Moines, Iowa newly graduated nurses were having more difficulty finding jobs and older nurses were delaying retirement due to economic conditions. This hiring situation was mostly found in hospitals; nursing homes continued to hire and recruit nurses in strong numbers.
Some states have a surplus of nurses while other states face a shortage. This is due to factors such as the number of new graduates and the total demand for nurses in each area. Some states face a severe shortage (such as the northwestern states, as well as Texas and Oklahoma), while other states have a surplus of registered nurses.
US: Supply versus Demand Projections for FTE Registered Nurses 
Source: Data from the Bureau of Health Professions. (2004).
Patching up the shortage.
Nursing shortages can be consistent or intermittent depending on the number of patients needing medical attention.
Retention and recruitment are important methods to achieve a long-term solution to the nursing shortage. Recruitment is promoted through making nursing attractive as a profession, especially to younger workers, to counteract the high average age of RNs and future waves of retirement. Refining the work environment can improve the overall perception of nursing as an occupation. This can be achieved by ensuring job satisfaction. Writers Lori Candela, Antonio Gutierrez, and Sarah Keating point out in the journal, "Nurse Education Today", ways the academic nursing administrators can make a change. "Individual support to attend workshops or conferences, participation in on-campus teaching/learning faculty sessions, the use of consultants with expertise in particular areas around teaching and evaluation, and mentoring networks that include senior faculty with teaching expertise" can all create a strong relationship between staff members therefore developing a better environment. Additionally, financial opportunities such as signing bonuses can attract nurses.
To assist the health sector, Congress approved the Nurse Reinvestment Act in 2002 to provide funding to advance nursing education, scholarships, grants, diversity programs, loan repayment programs, nursing faculty programs, and comprehensive geriatric education. Currently, mandatory overtime for nurses is prohibited in nine states, hospital accountability to implement valid staffing plans in seven states, and only one state implements the minimum staffing ratio.
Other ways of assisting to fill the shortage in the United States would include giving nurses the opportunity to pick their own overtime and schedules. Also, it would be a great incentive to young nurses to enter a hospital if they knew there were bonuses for continued excellence.
To respond to fluctuating needs in the short term, health care industries have used float pool nurses and agency nurses. Float pool nurses are staff employed by the hospital to work in any unit. Agency nurses are employed by an independent staffing organization and have the opportunity to work in any hospitals on a daily, weekly or contractual basis. Similar to other professionals, both types of nurses can only work within their licensed scope of practice, training, and certification.
Float pool nurses and agency nurses, as mentioned by First Consulting group, are used in response to the current shortage. Use of the said services increases the cost of health care, decreases specialty, and decreases the interest in long-term solutions to the shortage.
International recruitment is often used to fill the nursing gap but gives rise to concern now that the U.S. Homeland Security has stopped the issuance of the H-1C visa, which was deemed specifically for nurses. Because of the Affordable Care Act, which will result in an increased number of insured Americans, it is estimated that there will be an even greater need for nurses in the near future. U.S. trained nurses are concerned, however, that this recruitment initiative impedes on their ability to obtain positions in the field after completing their training. A nursing shortage does not translate to new nursing jobs.
A growing response to the nursing shortage is the advent of travel nursing a specialized sub-set of the staffing agency industry that has evolved to serve the needs of hospitals affected. According to the Professional Association of Nurse Travelers, there are an estimated 25,500 working in the U.S. The number of LVN/LPN nurse travelers is not known.
There is a nursing recruitment initiative and nursing workforce development program for residents of the United States originally from foreign countries, who were professional nurses in their countries but are no longer in that profession in the United States. This initiative helps them get back into the nursing profession, especially getting through credentialing and the nursing board exams. The original model was developed in 2001 at San Francisco State University in cooperation with City College of San Francisco ("The San Francisco Welcome Back Center"). There are centers in many cities, such as Los Angeles, San Diego, and Boston—where it is called a "Boston Welcome Back Center for Internationally Educated Nurses". It is a program meant for residents of the United States only. The Boston Welcome Back Center was opened in October 2005 with a $50,000 seed grant from the Board of Higher Education’s Nursing Initiative.
Legislation.
In 2004, California became the first state to legally mandate minimum nurse-to-patient staffing ratios in acute care hospitals. A subsequent study evaluated the effect on outcomes for nurses and patients by comparing outcomes in California in the subsequent two years with those of New Jersey and Pennsylvania — two similar states without such mandates. There was substantial compliance with the mandate in California, with over 80% compliance rates reported across several different units of surveyed hospitals; equivalent levels of non-mandated compliance in the comparator states were considerably lower, at 19%, 52%, and 63% compliance in medical/surgical, pediatric, and intensive care units (ICUs) in New Jersey and 33%, 66%, and 71% in Pennsylvania. After extensive adjustment for patient and hospital characteristics, the study revealed statistically significant relationships between the nurse-to-patient ratio and 30-day mortality and failure to rescue (FTR — that is, failure to prevent a clinically-important deterioration, such as death or permanent disability, from a complication of an underlying illness or of medical care) in all three states. Across all three states, facilities with nurse-to-patient ratios consistent with those mandated in California were associated with lower rates of nursing burnout, and nurses reported consistently better quality of care.
In September 2007, in the 110th Congress, Senator Richard Durbin of Illinois introduced S.2064: Nurse Training and Retention Act of 2007 on the floor of the Senate. It was a bill to fund comprehensive programs to ensure an adequate supply of nurses. It was referred to committee for study but was never reported on by the committee.
In April 2008, in the 110th Congress, H.R. 5924: Emergency Nursing Supply Relief Act was introduced as a bill to the House of Representatives by Robert Wexler of Florida. If it had passed, it would have amended the American Competitiveness in the Twenty-first Century Act of 2000 and would have given up to 20,000 visas per year to nurses and physical therapists until September 2011. Immediate family members of visa beneficiaries would not be counted against the 20,000 yearly cap. The bill was referred to committees for study in Congress but was never reported on by the committees.
On February 11, 2009, legislation was introduced by Representatives John Shadegg (R-AZ), Jeff Flake (R-AZ), and Ed Pastor (D-AZ) in the 111th Congress to the House of Representatives, HR 1001 ("The Nursing Relief Act of 2009": To create a new non-immigrant visa category for registered nurses, and for other purposes) making a new non-immigrant "W" visa category for nurses to be able to work in the United States. This was to relieve the nursing shortage still considered to be a crisis despite the economic problems in the country. The proposed bill was referred to the Committee on the Judiciary but was never reported on by Committee.
The 2010 Patient Protection and Affordable Care Act includes more strategies for funding and retention. The act provides funding for advanced education nursing grants, diversity grants, and offers a nurse education loan repayment program. The program repays over half of the student loans if the nursing student signs a contract stating that they will work for two years at a medical facility that has a nursing shortage. 
The Nurse Reinvestment Act of 2002 had many strategies. The law authorized and had provisions that included topics such as loan repayment programs and scholarships, providing more grants to the nursing students, making more public service announcements about nursing and educating the public on what a great profession it is and making nursing school more flexible by creating options for the people who already have a degree but would like to go into nursing.
Immigration process to U.S..
Nurses seeking to immigrate to the U.S. can apply as direct hires or through a recruitment agency. For entry to the U.S. a foreign nurse must pass a Visa Screen which includes three parts of the process. First they must pass a creditable review, followed by a test of nursing knowledge called the Commission on Graduates of Foreign Nursing Schools examination (CGFNS), and finally a test of English-language proficiency.
Foreign nurses compete amongst themselves, with professionals, and other skilled workers for 140,000 employment-based (EB) visas every year. Filipino nurses are only allocated 2,800 visas per year, thereby creating a backlog among applicants. For example, in September 2009, 56,896 Filipinos were waiting for EB-3 visa numbers. This number contrasts with the 95,000 nurses licensed in 2009, many of whom want to migrate to the U.S. Once a nurse obtains a visa number and is approved for a visa and authorized to work in the U.S., they must pass the National Council Licensure Examination to qualify for U.S. nursing standards. (See also employment-based visa retrogression.)