Monday, February 11, 2013

Zondag op De Heuvel

Yesterday was gorgeous, and Amsterdam knew it.  Both of us biked cautiously south through the melting ice and slush with cameras in tow; Ed to his gym and me to Amsterdamse Bos in search of De Heuvel (The Hill).  

Hills are important to my psychological well-being.  I grew up in one of the moundiest regions of the U.S. Northwest, so every once in a while, my legs and soul itch for climbing and vantage.  Chicago had One Hill, which I visited at least once a week while living in that city.  Amsterdam also has its Een Heuvel.  It also has the Nesciobrug, referenced in October, which is slightly closer to our house than De Heuvel and whose ramps I can, in a pinch, run up and down until I get bored and wind-beaten (about twice).  De Heuvel, however, is the real deal, and can be summited via five or more approach routes.  Depending on your, or your coach's, or the race organizer's, degree of masochism, the approach may take anywhere from 45 seconds to two minutes, and your shoes may arrive at the top clean and dry, or saturated with mud and ice water.  Since I spent last Saturday choofing up and down and around De Heuvel at a pitiful distance behind my deer-like 19-year-old teammates, I decided to make my peace with De Heuvel on this visit.

After some minor fishtailing and average roostertailing (no fenders yet), I made it to the bike path behind (west) of Olympish Stadion.  There's a tiny, mounded island back there with no apparent name, but if I had to guess, I'd venture "Eilandje."  

I don't know the "deal" with the stumps, but it seems like a fitting memorial to the Hongerwinter.
 My next landmark after the island is the running track and voetball fields/pitches at the ASV Arsenal clubhouse.  It's a pretty nice, four-lane, 400m track, and only about a five minute jog from Olympisch Stadion.  There was a girl practicing goal kicks in the snow and pumping her arms in the air victoriously whenever she made one.  No picture, sorry.  I did finally take a picture of the Peeing Guy statue, though.

Gets me every time.
The Amsterdamse Bosbaan is only another 5-10 minutes from the Olympisch Stadion.  I locked my bike and stuffed my coat and pannier bags into one of the public lockers, put my euro in the slot, tied the key to my shoelace, and transitioned to a slow, ice-dodging jog into the Bos.  There were a lot of people, a lot of kids, a lot of dogs, and a lot of snowmen.

"YES!  A whole field to myself!"
 After about ten minutes of mincing jog and fotos-maken, I arrived.

There's De Heuvel... and it looks almost... friendly?  
When I volunteered for the Boscross on January 6, this field looked much different.
It looked like this. (Photo by Phanos)
There's me in the yellow vest, standing next to a guy I like to call the "Do you know/Have you seen Dave Baars?" guy.  I've met him twice in the Bos in the last month, and each time he asks. (Photo by Phanos)
Back to the present.
After a very light, easy, no-pressure jog to the top of De Heuvel, I was able to enjoy the scenery.

On the other side of De Heuvel, some less social Amsterdammers were romping in the mud and snow.  I was glad to not be running up it.

I took the asphalt trail down, and retraced my steps to my bike, which is much in need of cleaning.

Saturday, February 9, 2013

Friday, February 8, 2013

Immigrant Nurse: Part III

This one's about me.

I am probably not the kind of nurse that you think I am.  That's right.  Surprise!  My area of specialization is none of these things.  Here's what usually happens when I meet people and try to explain "what I do":

"What do you do, Amelie?"

I'm a nurse.

"Like, in the hospital?"

No. I have a masters degree.

"Oh, so you're a nurse practitioner?"

No, not a nurse practitioner.  Nor a nurse anesthetist, nor a nurse midwife.

"Are you a CNS?"

Well, while I'm impressed that you even know what a CNS is, I regret to say that, as my nursing program did not include advanced pharmacology in my curriculum because it's superfluous to our actual work, I am not a CNS.  I took the same board certification test as for a CNS, but I'm not one myself.

"Oh.  Then... what are you?"

FREAKIN' AWESOME, that's what!... No, I don't really say that.
Always the question:  What, then, am I?  20 months into my 26-month graduate program, I realized, with other members of my small cohort, that we didn't really have any clear answer to this question.  In a desperate panic, I meditated and blazed through a couple of tubs of Trader Joe's Cats Cookies (For People), and by the wee hours had created... a Zoolander-themed Power Point. 

Oh, the profundity!  And there were 21 slides after these!
With characteristically questionable judgment, I shared this slideshow with peers in my cohort, our program chair, and the Assistant Dean of Nursing.  From what I hear, it's still making the rounds, now on its third generation of Advanced Community and Public Health Nursing Leadership and Program Development candidates.  Mildly clarifying and mostly fluff, it included a couple of definitions that are still the clearest, if not the shortest, way I've found to shed light on whatever it is that "I do".

Community Health Nursing: A field of nursing that is a blend of primary health care and nursing practice with public health nursing. The community health nurse conducts a continuing and comprehensive practice that is preventive, curative, and rehabilitative. The philosophy of care is based on the belief that care directed to the individual, the family, and the group contributes to the health care of the population as a whole. The community health nurse is not restricted to the care of a particular age or diagnostic group. Participation of all consumers of health care is encouraged in the development of community activities that contribute to the promotion of, education about, and maintenance of good health. These activities require comprehensive health programs that pay special attention to social and ecologic influences and specific populations at risk.

Public Health Nursing: The practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences.
Public health nursing is a systematic process by which:
  • The health and health care needs of a population are assessed in order to identify subpopulations, families and individuals who would benefit from health promotion or who are at risk of illness, injury, disability or premature death.
  • A plan for intervention is developed with the community to meet identified needs that take into account available resources, the range of activities that contribute to health and the prevention of illness injury, disability, and premature death.
  • The plan is implemented effectively, efficiently and equitably.
  • Evaluations are conducted to determine the extent to which the intervention has an impact on the health status of individuals and the population.
  • The results of the process are used to influence and direct the current delivery of care, deployment of health resources, and the development of local, regional, state, and national health policy and research to promote health and prevent disease. 

That's me.  My training and experience blend community and public health nursing skills, and I specialize in program development.  While hospital RNs assess, make nursing diagnoses, plan, intervene, and evaluate outcomes for individual patients, my job is to complete the same process, or pieces of it, for populations, using frameworks that support health promotion and disease prevention.  

What is a population?  Oh, goodness.  It could be anything, which is ill-defined and can confuse people.  Since public health nursing is more about preventing disease, my populations don't have to consist of patients.  It could be... maybe I work as a community health nurse, and want to improve outcomes or prevent undesirable outcome for all patients with diabetes served by my clinic.  However, it doesn't have to be a group of patients to be pertinent to health.  It could be a smoking cessation program for a population of employees working in a hospital, or it could be assessing need for doula support among a community of immigrant mothers living in rural Washington State.  I take the nursing process and apply it to a bigger picture.  I could work for a community health clinic on quality improvement projects, as I did in my most recent job.  I could assist with community-based participatory action research.  I've worked independently on community assessments for nonprofit education initiatives.  I've assisted in grant-writing.  I've written and implemented FIT-testing protocols.  I've drafted organizational emergency preparedness plans and written clinic safety policy and procedures.  Oh, the things I can do.   

Do I sound frantic yet?  Love me!  Love me!

I only had one cup of coffee today, I promise.
I ate several Trader Joe's Cats Cookies (For People), though!

Trader Joe's Cats Cookies (For People)... thanks, Houseguest!

haven't been shamming you.  I really did work as a psychiatric-mental health RN, and scuffed down dim nighttime hospital corridors during my stint as medical-surgical RN-zombie.  I chose to do "typical" RN work for a couple of years in order to solidify my direct patient care skills and learn more about the hospital environment and management structure.  I can transfuse blood, start an IV, give a vaccine, change a catheter, talk to teenagers about STIs, distract a manic, suicidal person long enough for the Haldol to arrive, and teach someone how to monitor their blood sugar and use insulin on a sliding scale... in Spanish, if needed.  Ta-da!

These things, though, although considered "fundamental nursing skills," are not what I'm best at doing, and not the best of what I have to contribute to the healthcare profession... shortages notwithstanding, and in my opinion until convinced otherwise.  Also... I don't like doing them.  Hate me!  Hate me!  I like people... I just don't like full-time bedside nursing.  It's not for me.  

My self-inflicted challenge is that I graduated from an atypical specialty area of nursing with no guidance for how to market my skill set, resulting in a fair amount of frustration derived from not being a nurse practitioner, nurse midwife, or other type of definable-in-thirty-seconds-or-less advanced practice nurse.  My challenge is getting employers past the "RN" that dominates the top of my C.V., and past the last two years of experience wherein my job title was "nurse."  For some of these employers, I'm pretty sure seeing those things is the written equivalent of me walking into a job interview wearing these pants:

I followed this man for a block, in the opposite direction of my destination.  Yes, I did.
For me, the healthcare shortage and nursing immigration mean that countries everywhere will need RNs, but I'm not the kind of RN for whom healthcare really clamors, nor do I want to be that kind of RN.  I and those of my tribe are the hipsters of the nursing profession.  Or the dirty margaritas.  I really should lay off the metaphors.  Maybe I'll keep writing about it until I figure it out.  Taking a breather from what other people want me to do, I've decided, is pretty nice.

In the meantime, this article provided some awesome labor market food for thought from a University of Pennsylvania business school.  Among other things, it talks about software-based hiring systems, the slow fade of HR departments, apprenticeship programs, and parents buying internships for their kids (aghast!).

Lastly, I found some interesting things on my flash drive from grad school.

This is the clinical where I walked out two weeks before the end of the quarter because the supervisor was treating the clients like dirt and I had to abandon my clinical partner and fill out a disciplinary form and do extra clinical hours but it was okay because the clinical hours were with my favorite faculty member and she helped me get my first nursing job.  No regrets.

My thesis/Scholarly Project.  Yet, somehow, they allowed me to graduate. 
Thank goodness that my fiance is an options trader.  Nobody understands what he does, either.

Wednesday, February 6, 2013

Immigrant Nurse: Part II

Zzzzzz... twitch, twitch... Zzzzzzzz...
In our living room, this was the immediate effect of the title and graphical images from "Part I" of this nursing tirade.  I promise to incorporate more invigorating visual aides into subsequent posts.

As promised, I'm dressed in something other than running tights and there's milk in my coffee. The part where I suggested all these things would come to pass "tomorrow" was apparently metaphorical. "After all," as Scarlett O'Hara once said, "tomorrow is another day."  Since today is another day, that means tomorrow is... today!  Logic wins again.

To resume, the United States has been talking about and planning for a massive healthcare shortage for decades, has been momentarily bailed out of its shortage by the economic recession, but can most definitely expect the mother of all nursing shortages in a few short years when the baby-boom generation makes its delayed exit from the profession.  Everyone has different strategies for using internal and external resources to prepare for this “Big Mama” nursing and healthcare shortage. The US and UK both, for example, think that foreign recruitment is going to play a key role in stocking their hospitals with qualified RNs, as it has in the past.  Australia, on the other hand, is focusing on internal resources and does not mention foreign nurse recruitment in its policies for combating the shortage.  For countries like the US and UK, though, it’s a bit like Life of Pi where fish are nurses and the ocean is the world and the tiger is the healthcare system that doesn’t want to get wet but knows it has to eat or it will die. Who is Pi? I don’t know. Pi is probably the immigration policy makers. This analogy has fallen short of my goal. Onward.

The Netherlands, where I live, is a bit of an interesting case.  First, unlike the U.S. and the U.K., the Netherlands employs far more LPN-level nurses than RNs (LPN = Licensed Practical Nurse). Check it out:

These are nurses working in hospitals, clinics, or other direct-care positions (not research or administration)

Second, the Netherlands is one of the few European countries (with France) that did not see a net outflow of older (50-54 years) between 1996 and 2001, a time that corresponds to the thick of the last "real" shortage in the U.S.  Although the Netherlands did report a shortage in 2005, the shortage was much less severe than in other European countries, and numbers were expected to be pretty stable through 2011.  

Here's what nurse immigration (on the left side) looked like for the Netherlands as compared to similarly-sized European countries from 1995-2005: compared to what it looked like for the U.S. and the U.K. during that same period:
Take note, too, that nurses don't always go where the doctors go.

The point is that some countries will soon need vast numbers of nurses, and some will need fewer, and some may need none (a wishful scenario).  Some countries attract nurses from elsewhere, and some don't.  Some countries make the immigration and license transfer process easier to entice skilled migrants... and some don't.  For those countries competing for foreign nurse help, and also looking to retain the nurses that they already have, it comes down to who is better at recruiting and who has more to offer in terms of salary, work conditions, and quality of living.

The U.S. knows recruiting.  In 2007, about 8% of U.S. RNs were educated in another country, increased from a 2004 estimate of about 3.3%.  In terms of actual volume, that's about 15,000 RNs coming to the United States annually during that time.  They moved mainly to urban areas, were most often employed by hospitals, and were somewhat more likely to have a BSN than US-born nurses, although they were likely to be paid less than U.S. RNs (not shocking; since the majority of experienced RNs at the time were over age 40, the average salary of a U.S.-educated RN would logically have been higher than that of an immigrant RN with fewer years in the U.S. workforce).

From whence came these RNs to the U.S.?  In 2007, more than 30% of originated from the Philippines. Other major countries of origin were Canada, India, and England. The diversity of nursing staff is notable in major city hospitals, such as Advocate Illinois Masonic Medical Center in Chicago, where I worked as an RN from 2010-2011.  During that time, its employees spoke a combined 40 languages. On my own tiny 19-bed unit, both nursing managers were trained as RNs in the Philippines, I worked night shift with four veteran RNs trained in the Philippines, and three of our five receptionists were from the Philippines. In addition, there were a half-dozen or more additional RNs who were second-generation Philippino-American, born and educated in the U.S. Our unit could have been the poster child for nursing immigration. 

Our hospital had put considerable effort into recruitment strategies in the late 1990s and early 2000s, filling human resource gaps and plumping up its diversity.  I sifted through a few annual reports from 2001 through 2008 and learned that, despite being a well-ranked and reputable hospital, they saw expenses exceed revenue by more than $400,000 in 2008, whereas in the preceding two years, their revenues exceeded expenses by more than $200,000.  For some reason, the annual reports post-2008 are not listed on the same page as those from pre-2008.  Their present challenge, like all hospitals, like all organizations in general, public or private, is to maintain quality of service using less money and fewer resources.  While simultaneously taking on and recruiting as many new nurses as they can afford to pay and train, and somehow convincing them to stay.

I slid down that slope unabated. Sorry about that. Let me climb back up.

I slid down a literal slippery slope once.

I detect that you are falling asleep.  Nurse immigration!  It's not the panacea to all of our problems, but it's a necessary piece.

The U.S. is already supporting it, sometimes with hospitals pressuring Congress to make additional employment-based visas available for nurses and other skilled professionals (as they did in 2005, cited from page 2 of this artcle).  After dealing with the immigration process itself, RNs face the equally, if not more, painful process of taking an English proficiency exam, followed by the NCLEX.  If they pass the $300 exam from hell, they then get to deal with the often excruciatingly bureaucratic and frustrating process associated with getting their license recognized by the professional regulation departments of whatever state they plan to settle.  I feel for nurses moving to the U.S.

Some European countries, like the U.K., know they have to do more foreign nurse recruitment, especially since U.K. RNs are leaving the U.K. to work in the U.S.  Again, this doesn't come without a bit of finagling.  The U.K. government wants to reduce net migration in the country, but Europe as a whole has also passed new immigration rules that allow RNs from European Union countries to move to the U.K. to work with free mobility:  no established length of stay, automatic recognition of professional certificates, no aptitude tests.  Nurses must speak English and have at least three years of study or 4,600 hours of theoretical and clinical training.

Other European countries, like the one in which I am currently a legal resident with a work permit, have no interest in recruiting foreign nurses.  Although the same leniency toward  nurses from other EU countries exists here, nurses are still subject to a language exam demonstrating proficiency in Dutch.  If you aren't from the EU, you also shell out 650 euro and take the Dutch equivalent of the NCLEX (in Dutch).  Needless to say, this isn't terribly attractive to most non-EU nurses... or EU nurses, given the necessity (and challenge) of learning Dutch.  Lastly, remember, RNs constitute less than a quarter of the nursing workforce.

Ok, I'm done.  For a bit.

This is the best Chai on Earth.

Monday, February 4, 2013

Lost in Translation

Not about nursing.  Unless you count nursing my feelings.  Then it is kind of about nursing.

I was caught completely off-guard last weekend by a bartender at Cafe de Klos.  I walked into the bar to meet with a cultural hodgepodge of friends for spareribs, purportedly delicious at this particular location.  I'm American, my friends were Dutch, British, and Kazakh.  There was a Dutch family seated in the banquette next to ours, with a small boy who was mesmerized by a brown paper shopping bag.  My Dutch friend had asked him Wat heb jij? in fawning "hey little kiddo" tones, so after a couple of minutes of watching him, I took a deep breath and said to him, "Dat is een fantastisch tasje!" in an effort to amuse the adults, since the bag had kept the kid busy for ten minutes straight.  The two men and the woman at the table all looked at me and laughed.  "Wat heb je gezegt?" asked the man.  "Een fantastisch tasje," carefully enunciated the woman, "zegt zij," and they all ho-ho-ho'd,... at which point the bartender, who had been very friendly with them, looked at me and walked away, sneering "Stick to English.  You're raping my language."

I know that Dutch humor tends to be frank.  I spend a couple of hours a week with Dutch humor at my running club.  This was not Dutch humor.  This was somebody being an asshole.  What still rankles, two days after the fact, is that I was completely unprepared.  It's been so long since someone treated me with unwarranted jerkfacedness that I'm losing my once-proud ability to retort at will.  Does he know what "raping" means?  Does he know anyone who has been raped?  I do.  I know nine-year-olds who have been raped.  My job was to give them support and stability (and medication) on weekends from 15:00-23:00, so that perhaps a fraction of the rest of their lives would not have to be spent trudging, heads down, through a hell of distrust and self-hate.  "Raping" is beating something down, stuffing it in the dirt, leaving it emptier than empty and blacker than black.

Did I do that to "his" language?

Did he do it to "my" language?

Of course, there is also the chance that he was referencing the archaic form of the word "raping," in which case he meant only that I was "seizing" his language and "carrying it off by force."

In any case...

"People" say that Dutch is a difficult language.  I've been told this by as many Nederlands natives as English-speakers.  Most English-speaking expats in the Netherlands don't even try learning Dutch.  "Everyone here speaks English," they say.  They are right, for the most part.  English is nearly innate here.  Everybody speaks at least a basic amount of English, and many people, at least young people in Amsterdam, speak fluent, effortless, enviable English.

They know it.  They know it to the degree that they sometimes forget that it took them some effort to learn English. When I discovered that the process for transferring an American nursing license to the Netherlands "BIG" nurse registry starts with paying 650 euro and taking a Dutch language proficiency test, I knew that was highly unlikely to happen in the two years I planned to live here.  Going from zero to second-language proficiency takes a little longer than a couple of months.  I presented this rationale to my Dutch friends, and still heard from some, "Oh, that shouldn't be a problem!  Are you taking a Dutch course?"  While appreciating their optimism, I had to laugh.  Come on. Get real.  I think I might be able to achieve second-language proficiency in a year, at minimum, and that's only if I can find a way to speak Dutch to people all day long, on subjects pertaining to everything under the sun.

I don't think that Dutch is a particularly challenging language to read or write, in terms of grammar rules and syntax.  Even comprehending spoken Dutch isn't too tricky, once you figure out the slight differences between pronunciation of "v" and "w," and between "ch" and "g," and learn to listen to context to figure out whether a word ends with "d" or "t."  There are fewer conjugations than in a Romance (Latin-derived) language like Spanish, and the irregular verbs are much more intuitive for an English speaker.  This makes sense, as Dutch and English are from the same language family; they are both Germanic languages.

Speaking is the beast, chiefly because many Amsterdammers would rather listen to fingernails on a chalkboard for twelve hours than listen to a non-native speaker trying to hawk up the syllables of their mother tongue.  Some are so pained by this that they will deter you from continuing by switching to English.  Some are truly goodhearted folks, switching to English for your comfort.  For others, it's their own comfort that concerns them.

All Nederlanders are proud of their language, as well they should be.  It's rare.  The only European languages spoken by fewer people than Dutch are Serbo-Croatian, Hungarian, Greek, Czech, and Swedish.  Many Netherlanders seem to want to keep Dutch rare, and not all of them are interested in sharing it.  They see no harm in informing you that your Dutch is not, and never will be, as good as theirs, and some of them will see fit to spare you years of language acquisition pain by letting you know that your Dutch will never survive daily oral transactions.  Some Dutch are such language purists that they will belittle their own countrymen if Dutch is not spoken cleanly.  Some Amsterdammers consider Dutch spoken in Limburg, Groningen, or even Rotterdam or Den Haag, roughly an hour away, as "not proper Dutch."  I have a friend who was born near Amsterdam to one Dutch parent and one British parent, and thus grew up speaking both languages.  She speaks Dutch with a faint accent.  At her last job, her coworkers would correct her speech and tell her that she didn't speak Dutch well.  A bartender once apologized to her, saying, "I'm sorry, I didn't realize you were handicapped."  While criticism always hits a perfect "10" in honesty, it could stand improvement in constructiveness.  I want people to correct me when I make mistakes, but I don't want them to leave me feeling hopeless and stupid with nothing to do about it.

For four months, I've doggedly used the little Dutch I know in everyday conversation, and emphasized to my Dutch running teammates and other friends that I'd prefer that they speak Dutch in front of me, so that I learn it faster.  When I write messages or emails to my Dutch friends, I do it in Dutch, without using Google Translate.  This necessitates humility.  I understand that the majority of my written communication appears to be authored by a first grader.  I've gotten used to the confused looks and "Sorry?" that is the inevitable response to much of what I utter in Dutch.  The temptation to switch to English, or just to abandon Dutch altogether, is ever-present.  But I smile and repeat the question one more time in As-Close-To-Dutch-As-I-Can-Muster, because I know if the other person strains their Wernicke's area ever-so-slightly, they will be able to figure out what I'm saying.  Consider it a linguistic intervention for Amsterdammers.  If I can piece together what the 80-year-old toothless Spanish-speaking woman with a bad mobile connection and screaming grandchildren in the background is trying to tell me about the strange rash that appeared last week, then you can probably figure out that I am asking you where the volunteers are meeting, presuming that I have selected the correct vocabulary.

This is why it is difficult to learn Dutch.  The Dutch language is not difficult.  The atmosphere for practicing it is.  It helps to have weekly exposure to the eternal patience of my Dutch teacher, who knows that we bumble, but loves her language fiercely and wants to ensure that if we learn it, we learn it properly.  It helps to be included in inane track club facebook banter.  It helps to go into stores and say that the blender that I bought in October has a crack in it... in Dutch... and revel in glowing satisfaction that the lady at the counter opens the box and locates the crack, even if I only understand half of her response.  It helps to have a teammate stick an Ajax fanzine in my hand and coach me to read aloud from it for the duration of a 30 minute train ride.  Every mistake that I make is a mistake that I'm less likely to repeat in the future.

After all, if I really am "raping" Dutch, then I might as well call it easy.

Friday, February 1, 2013

Vondelparkloop 10k

I was "eerste dame" once again in the Vondelparkloop 10k.  I wanted to erase all memory from my frozen mind after running it, which is why I mentioned nothing about it here for two weeks.  It was very, very cold and very, very windy.  I did not put on a very good show.  I looked like crap for the last 3k, although my coach was kind enough to lie to me and tell me that I looked "strong."  I ran 41:35 (PR, but I was hoping for a low-to-mid 40:xx), Ed broke 40 minutes, securing the third place team trophy for Optiver, and I won another gift certificate to another running store, but don't know how much because I haven't collected my prize from Phanos yet.  I could get used to this running-for-apparel thing.

Immigrant Nurse: Part I

And now, for something a little different.

No, I haven’t been too busy to post.   I am technically employed with a US-based tutoring agency, but my singular, lonely client finished his 16 hours of TOEFL lessons months ago, and I’ve heard nothing about future requests for a tutor.  I must have been that bad.  One of my lesson plans included this creative compare/contrast exercise.  They also haven’t paid me yet.

I have, however, been learning.  Evidence from recent conversations suggest that I now know more about Dutch nursing workforce market forecasts than do my cardiologist neighbor, my dermatology resident friend, and my surgical technician friend combined.  I will assume that means I also know more than the majority of the Dutch population about the state of nursing in this country… and that I definitely know more than you.  If you have patience, soon you, too, will know more about Dutch nursing than the average Dutch person, and I suggest that you give yourself a pat on the back and an extra helping of stamppotje at the end of this post.  Today, from the ranks of the nursing unemployed, I address the big picture of the ubiquitous “nursing shortage” while grimacing my way through a cup of black decaf because we are out of milk and I have yet to make today’s grocery trek.  Tomorrow, I will provide you with a snapshot of what it is to be a non-EU immigrant nurse hopeful in the Netherlands while dressed in real clothes, not the clothes I’ve been intending to run in for the last five hours.

First, when healthcare experts, economics experts, the media, and other “people in the know” talk about “the nurse shortage” or “the nursing shortage,” they refer to nurses in hospital settings.  The economic data on “the shortage” compares inflow and outflow of nurses in hospital workforces.   I am not a hospital nurse, but my specialization necessitates that I am well-acquainted with hospital nursing, and that I treat the entire nursing profession as one that will impact the future of US health practice and policy in big, important ways.   Slowly, but surely.

The drippy and misinformed sentiment in both the United States and here in Europe seems to be overwhelmingly that, if you are a nurse, you are needed, e.g. “They need nurses everywhere,”  “There’s a shortage of nurses,” “Well, you certainly won’t have trouble finding a job as a nurse,” etc.  In the U.S., the current “shortage” was forecast in the 1980’s, with more precise estimates of just when and how bad it would be arriving with research in the late 1990s and 2000s.  As a giant cohort of baby-boomer nurses started getting excited about retirement in the 2000s… economics happened.  Older nurses either opted to stay working for a few more years or opted to head back to work.  When I was gaining experience as a hospital RN, one of my RN coworkers was 70 years old.  She sure wasn’t there because she loved the work.  The current median age of a nurse in the U.S. is 46 years old (there are as many RNs over age 46 as there are younger, as opposed to the mean age, which I don’t know), and the largest cohort of RNs is ages 50-59 (see table).  In other words, there is actually… NO shortage right now, courtesy of the recession.  The real shortage will hit us in a couple of years, and it will hit us like a 6:58 a.m. code blue.

Buerhaus, P. and Auerbach, D. (2000). Implications of an Aging Registered Nurse Workforce Journal of the American Medical Association (JAMA).

Don’t be miffed.  You haven’t been entirely deceived.  There was a nursing shortage, before the recession, and there will be another.  It started in 1998 and reached its apex in 2001, the “highest of the low,” if you will.  A few years later, experts picked up on the fact that the recession was helping the nursing shortage, and articles like this one in 2009 and this one in 2012 made the information public, at least to those who read economic news.  Those of us in nursing school at the time certainly did not hear faculty shouting this information from the rafters.  In preparation for “the big one,” colleges doggedly persisted in recruiting and belching out BSNs, twice as many in 2010 as they did in 2000.  Fast-track MSN programs cropped up in almost every state, offering a sparkly package of an RN certification in one year and a masters degree in two-to-three.  Bright-eyed new nurse grads, my own 2010 cohort included, continue to emerge from the wombs of their colleges and, within a month or two, wonder sadly why nobody wants them, like puppies abandoned once they’ve matured to slobbery adulthood.  I knew several extremely competent, passionate people who applied to hundreds of nursing jobs before getting hired.  Personally, it took me 55 job applications and three months.  These new grads don’t realize that they are The Replacements, to be called in when the veteran troops are at last depleted.  There’s likely not much consolation in that knowledge, since there’s no paycheck or career opportunity in being a Replacement.

So, the shortage was just a prelude, it's taking an intermission, and the main feature is slated for 2015-2020.  Depending on when the research was done, estimates vary on exactly how severe the nurse shortage is going to be, but it will be big.  One forecast is that the RN workforce will be 20% below “projected requirements” by 2020, or somewhere between 700,000 and 800,000 RN jobs.  In 2010, the first of 78 million baby boomers qualified for Medicaid.  Picture the baby-boomer workforce going from bed-side to bed-in… very slowly.  It’s not happening quickly, because those baby boomers are tough and taught my generation about work ethic, but, as one researcher puts it,
 “unlike past shortages, the coming RN shortage will be driven by fundamental, permanent shifts in the labor market that are unlikely to reverse in the next few years.”    
That’s one way of saying that people, eventually, get too old to work really demanding jobs.  I don't blame them.  I couldn't hack night shift longer than ten months.

As fast as colleges are spitting out RNs (more bodily fluid metaphors for you), it won’t be fast enough to meet the anticipated demand.   Nursing may be the fastest-growing healthcare occupation, and there are many of us standing around thumb-twiddling and drinking grainy coffee at the moment, but in another few years, there won’t be enough nurses to go around.  

Is immigration part of the solution?  For the U.S., it is, and will be.  For some European countries, researchers and policy makers say "yes."  For other European countries, the Netherlands included, it's "no" (at least not right now).  And that’s part of why I need to re-market myself.  

More on Europe, immigration, and nursing after I’ve seen daylight and bought some milk.

Marketing myself as a nurse consultant is like trying to find Flevopark in the snow.