"These findings are alarming," said lead author of the study Patricia Pittman, PhD, an associate professor of health policy at SPHHS. "If confirmed by additional research, this survey raises a host of troubling ethical and practical concerns for health care facilities working to retain nursing staff and provide high quality care to patients."

Historically, the United States has relied on recruitment of foreign-educated nurses (FENs) to fill the gaps caused by widespread nursing shortages. Many parts of the country are grappling with such shortages today and markets that are flush with RNs now could experience shortfalls again soon -- especially if the economy continues to improve and there are fewer U.S. educated nurses in the hiring pipeline.

Past studies had raised questions about employment-based discrimination among FENs, including workplace bias, poor pay and discrimination. Pittman and her colleagues wanted to do a baseline survey from which future improvements could be measured. To do that, the team looked at 502 FENs working in the United States at the time of the survey. Nurses were asked about their country of origin, whether they were recruited by a staffing agency and a host of questions about their perception of treatment on the job.

Pittman and her colleagues found that overall many FENs reported inadequate job training or unequal treatment. For example, about one-third of all survey respondents said they did not receive sufficient orientation to life in the United States or to the cultural differences they might be dealing with on the job, problems that can make it hard for such nurses to fully acclimate in a U.S.-based workplace such as a hospital or nursing home, Pittman says.

Even more troubling were widespread findings of perceived discriminatory practices, especially for FENs that had been recruited by staffing agencies. Pittman and her colleagues found that 68 percent of nurses that had been recruited by such agencies reported at least one discriminatory practice. Pittman says that nurses that had been actively recruited to the United States or who had come from developing countries tend to be especially vulnerable to potentially problematic aspects of the hiring process, including low wages and placement in inferior units or on undesirable shifts.

When Pittman and her colleagues zeroed in on discriminatory practices both overall and for nurses recruited by staffing agencies they found that:

• More than 27 percent of all RNs in the survey believed they did not receive pay comparable to that of U.S. peers. But for those hired by a staffing agency, that perceived discriminatory practice jumped to nearly 47 percent.

• About 16 percent of all RNs said they did not think they were getting the same kind of benefits as their American colleagues. That number rose to 44 percent among FENs recruited by staffing agencies.

• About 18 percent of all nurses in the study said they believed they received less desirable shifts or units compared to their peers. Again, the same number was much higher -- nearly 29 percent for nurses recruited by a staffing agency.

Not surprisingly, the survey also found that FENs who perceived unequal treatment in the workplace were more likely to report job dissatisfaction, a problem that can lead to high turn-over rates in hospitals and other health care facilities. High turn-over can represent a significant cost drain for providers who must pay to recruit and train a new nurse to replace a more seasoned employee who leaves because of job dissatisfaction.

This study's findings must be verified by additional research that can solidly link such results to discrimination or other factors that might explain the differences in treatment. For example, FENs might be paid less in some cases because they have less experience compared to American nurses. At the same time, this study's findings add to other scientific evidence suggesting that FENs are, in many cases, discriminated against or treated differently than American RNs.

Whether it is real or not, Pittman says perceived discrimination takes a toll on individual workers and on the health care system. She says that studies show that workers who believe they are targets of unfair practices are more likely to get sick themselves with higher rates of high blood pressure, depression and other signs of a high stress working environment. Furthermore, poor orientation for foreign nurses may lead to a poor ability to work in teams or to communicate effectively -- a problem that can threaten patient safety.

This is a problem that will not go away anytime soon, Pittman warns. She says that tens of thousands of FENs have already signed contracts and are waiting for visas that will allow them to immigrate to the United States and begin working. Hospitals, recruiters, nurse advocates and others must start to learn from the past and pay better attention to the terms of those contracts and the workplace itself -- or FENs will leave soon after training for a healthier workplace.