Nurses’ Job Satisfaction: Are There Differences Between Foreign and U.S.-Educated Nurses? Christine M. Pizer, Ann F. Collard, Sherline M. James, Beverly H. Bonaparte

This article reports the results ofa job satisfaction survey administered to foreign-educated and U.S. nurses at six New York City public hospitals. Although a comparison of results for foreign-educated nurses on temporary visas (N=322) and U.S. nurses (N=535) revealed demographic, education and work differences, no differences in level of satisfaction were found between the two groups. Cultural and work status differences that may have affected these results are discussed.

[Keywords: foreign nurses, job/work satisfaction]

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tudies of U.S. nurses suggest that job satisfaction is correlated to both job turnover (Curry, Wakefield, Price, Mueller, & McCloskey, 1985; Weisman, Alexander & Chase, 198l)andjobperfomance(Weisman&Nathanson, S 1985; McCloskey & McCain, 1988). The effect of job

satisfaction on turnover and performance is also likely to apply to foreign-educated nurses recruited to work in U.S. hospitals. Moreover, the positive work environment engendered by satis- fied nursing staff, whether foreign or domestic, is a beneficial outcome in itself.

Recruiting foreign-educated nurses is one way hospitals have responded to a shortage of nurses in the United States. Since World War 11, foreign-educated nurses have filled nurse vacan- cies (U.S. Department of Health, Education and Welfare, 1976), particularly in the nation’s inner city hospitals (Arbeiter, 1988). During the most recent nursing shortage in 1988-89, the federal government estimated that 24,400 foreign-educated nurses were practicing in the United States under temporary, professional H- 1 visas (U.S. General Accounting Office, 1989).

Most H-1 visa nurses are recruited by an overseas agency that serves as a broker for U.S. hospitals seeking foreign nurses. The overseas recruiter may also assist the nurse in preparing docu- mentation and other paperwork required by the Immigration and Naturalization Service (INS), and in preparing for the foreign nurse screening exam. Once in the U.S., nurses must obtain temporary licensure to practice, secure housing and maintain immigration status.

While recruiting foreign-educated nurses has partially allevi-

* *

ated nursing shortages, the efficacy of this strategy has not been comprehensively examined. To examine the strategy more closely, a study was conducted that explored job satisfaction, processes and costs of recruitment, job retention and quality of care (Pizer, Collard, Bishop, James & Bonaparte, 1991). This article reports the results of the job satisfaction survey administered to all nurses at six acute care hospitals in the New York City Health and Hospitals Corporation (HHC). The job satisfaction and demo- graphic characteristics of foreign-educated nurses with H-1 visas were compared to U.S. nurses.

Review of the literature

An exhaustive literature review revealed a paucity of informa- tion about foreign-educated nurses in general and even less

Christine M. Pizer, RN, MS, is Senior Research Associate and Ann F.Collard, RN, PhD, FAAN, Alpha Chi, is Senior Research Associate, both at the Institute for Health Policy, Brandeis University;SherlineM. James, RN,MA, MBA, is Director of Patient Care Service, and Beverly H. Bonaparte, RN, PhD, FAAN, Upsilon, is Chief NursingAdministrator/Consultant, both atthe University of Medicine and Dentistry of New Jersey, Newark. The research reported herewassupported bythelosiah Macy, Jr. Foundation.The authors thank Jacqueline M. Davidson for her editorial assistance and the Nursing Directors and staff of the New York City Health and Hospitals Corporation, whose participation was invaluable to the success of this effort. Correspon- dence to Ms. Pizer, institute for Health Policy, Florence Heller Graduate School for Social Policy, Brandeis University, P.O. Box 91 10, 41 5 South Street, Waltham, MA 02254-91 10.

Accepted for publication July 24,1992.

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Nurses’ Job Satisfaction: Are There Differences Between Foreign and US-Educated Nurses!

information about their job satisfaction. Most job satisfaction information is anecdotal and discusses obstacles for, or concerns of, the nurses.

Foreign-educated nurses with H-1 visas face similar hardships to others arriving in this country, such as language barriers and social isolation (“Wish you were here,” 1975; Momson, 1980). In addition, nurses with temporary work visas may have difficul- ties selecting a reputable recruiter, understanding the details of contracts and commitments and negotiating the bureaucracies of the INS and state licensing agencies (Henning, 1975; McFarlane, 1987; Tichbome, 1980; Tuanquin, 1977; “Wish you were here,”).

Once employed, foreign-educated nurses may face other problems that affect job satisfaction. Several reports (Allan, 1981; Dudas & Dzik, 1971; Tutay, 1975) emphasize the impor- tance of an adequate orientation program to ease the foreign nurse’s adjustment to colloquial speech, medications with unfa- miliar brand names, different equipment, technology, proce- dures and nursing practices unique to the United States.

The satisfaction of foreign-educated nurses may also be affected by unequal treatment in the workplace. Reports of work place discrimination against non-white, foreign-educated nurses (“Struggle of foreign nurses in the U.S.,” 198 1) include the threat of deportation for nurses who are hesitant to work for lower salaries or on extra shifts (Lohr, 1979).

Surveying Filipino nurses employed in four New York City hospitals, Asperilla (1 976) assessed satisfaction with facilities, position and work assignment, salaries and benefits, human relations and relationship with the health team. Overall, 51 percent of the respondents were more satisfied than dissatisfied with their jobs. The areas of greatest dissatisfaction were salaries and fringe benefits. Asperilla (1976) found that salary satisfac- tion and supportive relationships with superiors were important indicators of overall job satisfaction.

Cowart (1983) compared the work situation of Filipino nurses, other foreign nurses and U.S.-educated nurses licensed in Florida. The foci of her study were attitudes, practice patterns and status in the work setting. Results indicated that although foreign- educated nurses were generally older and more experienced, U.S. nurses were more likely to work in specialty areas. Filipino nurses worked longer hours, more evening and night shifts and, as a result, earned higher salaries. Cowart (1983) also found that more foreign-educated nurses expressed a desire for increased work place responsibility, perhaps reflecting their greater expe- rience.

These findings suggest that while some foreign-educated nurses are satisfied with their work situation, others are not. Further, neither of these studies employed both a job satisfaction survey and comparisons between foreign-educated and U.S. nurses.

Methods

Sample The sample for this study (N=857) comprised foreign-edu-

cated nurses with H-1 visas (n=322) and U.S. nurses (n=535) (hereafter called H-1 visa nurses and US. nurses, respectively).

The sample was drawn from a larger sample of all nurses working in direct care positions (N=l,360) at six HHC acute care hospitals.

Direct care nurses were defined as those identifying their current position title as staff nurse, assistant head nurse or head nurse. Nurses at HHC recommended including head nurses and assistant head nurses in this category since, with a severe shortage of nurses, head nurses and assistant head nurses were frequently providing direct care to patients. Nearly all (98 percent) nurses with H-1 visas held direct care positions. The overall response rate for direct care nurses at the six study sites was 51 percent. The response rate for H-1 visa nurses was 55 percent; for non H- 1 visa nurses the response rate was 49 percent.

Survey Development and Distribution A two-part survey was developed by the Institute for Health

Policy research group, and administrators and researchers at HHC’s Corporate Nursing Services Division. Part One of the survey included demographic, education and work characteris- tic questions. Permission was obtained from the American Journal of Nursing to adapt the demographics section of a survey developed for that journal (Wandelt, 1987). Demographic data included age, sex, marital status, parenting status and immigra- tion status. Education questions included the country in which basic nursing education was received, type of basic nursing degree and highest nursing degree attained. Questions about the respondent’s work situation included the number of years as a professional nurse, registered nurse licensure status, length of employment at HHC, unit assignment, job title, shift worked most often, work pattern (full-time versus part-time andor overtime) and approximate gross annual salary.

Part Two of the survey was a twenty-eight item Nurse Job Satisfaction Survey (NJSS) developed by Atwood and Hinshaw (1986) from an instrument originally designed by Brayfield and Rothe (1951). The survey indexes certain professional and occupational aspects of a nurse’s job and has high reliability (alpha coefficient of 0.90). Each of 28 statements relates to one of three satisfaction scales: quality of care (seven items); enjoy- ment of one’s job (12 items); and time to do one’s job (nine items). The respondent rates each of the statements using a five- point Likert scale. Examples of statements on the survey in- clude:

Quality of care: “Most of the time I am satisfied with patient care that I give.” Enjoyment of one’s job: “Most of the time I have to force myself to go to work.” Time to do one’s job: “I could deliver much better care if I had more time with each patient.”

The authors suggest interpreting the three scales separately, rather than calculating a combined score. Each scale can then be used as a management tool to target administrative strategies that address specific problems with job satisfaction.

The survey was pre-tested by a cohort of 58 nurses, including U.S. and foreign-educated nurses, at a non-acute care HHC hospital. Respondents were asked to comment on the format, wording and clarity of the questions. Based on this pre-test,

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Nurses’ Job Satisfaction: Are There Differences Between Foreign and U.S.-Educated Nurses?

appropriate modifications were made to the survey format before it was fielded. The NJSS component of the survey was not modified.

Nurses at six acute care hospitals were surveyed between June and October 1989. Although HHC has eleven acute care hospi- tals, sites for this study were selected only if they employed more than 100 H-1 visa nurses at the time of the survey. Using individual hospital rosters and HHC’s centralized database of H-1 visa nurses, researchers numerically coded each survey to identify the study site, the visa status of the respondent and the respondent. A cover letter to each nurse emphasized that survey responses would remain confidential; surveys would be re- turned in sealed envelopes, and personnel rosters keyed to the survey numeric code would remain at Brandeis University.

Data Analysis Data were analyzed using the Statistical Package for the

Social Sciences. Data for Part One were compared using Chi- square analyses for categorical data and Student’s t-test for continuous variables. In accordance with directions from the survey developers, each response on the NJSS was assigned to one of the three scales (quality of care, enjoyment of one’s job and time to do one’s job) and scored as either positively or negatively related to that scale. For example, strong agreement with the statement: “I find real enjoyment with my work” would indicate a positive response within the enjoyment scale. In contrast, strong agreement with the statement: “Most of the time I have to force myself to go to work would indicate the opposite, a negative response to the enjoyment scale. In calcu- lating respondent scores, negative items were reverse scored. Thus, a response of “strongly agree” on a negative item received a score of 1, while a response of “strongly agree” on a positive item was scored 5.

Individual respondent scores were calculated for each of the three scales. For example, for respondent A, the values for the seven quality of care items were summed, and then divided by the total number of items (in this case, seven). Following scoring guidelines, in cases where a single response was missing within a scale, the denominatoi and possible score on the scale were adjusted accordingly. If more than one response in a scale was missing, the respondent was eliminated from the analysis for that scale.

Next, group mean scores (U.S. and H-1 Visa Nurses) were derived. Low scores reflect relatively low levels of satisfaction while higher scores represent relatively higher satisfaction. Mean scores were compared using Student’s t-test.

The relationship of the dependent variables of interest (qual- ity of care, enjoyment of one’s job, and time to do one’s job) and the demographic, education and work characteristics of the sample were explored using Pearson’s Product Moment Corre- lations. Finally, multivariate regression models were developed to identify key variables related to the three scales of the Nurse Job Satisfaction Survey.

A separate regression model was developed for each depen- dent variable: quality, enjoyment and time. Each model in- cluded those independent variables that were significantly correlated to the dependent variable and had an R2 of at least .30

in the Pearson’s calculation. Although H-1 visa status did not meet this criterion, this variable was also included in the model, as it was the primary characteristic of interest.

Results

Nurses with H-1 visas were younger, less likely to have children and more likely to be male than U.S. nurses (Table 1). As expected, the vast majority (96.6 percent) of nurses with H- 1 visas were educated in the Philippines.

Over 90 percent of nurses with H- 1 visas were baccalaureate educated compared to slightly over a third of U.S. nurses (Table 2). This finding was not surprising since baccalaureate nursing education is the norm in the Philippines.

Compared to U.S. nurses, nurses with H-1 visas worked more evening, night and other shifts. H-1 visa nurses were also employed more frequently in intensive care units, operating or recovery rooms, pediatrics and psychiatric units, and were less often employed in obstetrics and gynecology, and emergency rooms/clinics. Further, H-1 visa nurses worked more overtime, and consequently earned higher salaries than the U.S. nurses.

Compared to H-1 visa nurses, significantly more U.S. nurses

TlMc 1 : t 3 m p a h n of Dcm0gC;rphic Characteristics for NU- wid, Cumnt H-1 Vka SWUS urd NU- Who Arc US. Educated and U.S. Citizens “457)

DEmqy*i ti-1 visa characterktia lyMR

N %

Gender: Mak 28 8.7 Femak 229 - 91.3 T a t 322 100.0

Agc: 20-30ycars 159 49.8 31-35pr~ 139 43.6 36yeanoralderJ! - 6.6

Total 319 Ioo.0

Muitllkahn: Mnied 146 45.6 W m d 174 - 54.4 Total 3m 100.0

ApOiYautypst Child: Nochildren 201 63.2 Under5years 71 22.3 5-loyears 34 10.7 IOyclrsordder a

1-1 318 100.0

where &sic Education Received U.S.A. 0 0.0 Philippim 311 %.6 a h - 11 3.9 Total 322 100.0

us. Chi-square nu- significance

N ’% ... . .

26 4.9 - 95.1

533 1m.o

70 1 1.4 77 14.7

:I .Y - 377 - 524 10.0

225 42.5 I l05 _- 57.5 530 100.0

174 1 3 2 59 1 I ..1 53 111.1 258 95.5 524 100.0

535 1m.n 0 n.n

_o 0.0 535 i0o.n

< 05

< ,001

N .S.

< AM1

< .oOl

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Nurses' Job Satisfaction: Are There Differences Between Foreign and US.-Educated Nurses?

10 years or more (59.7 percent); most H-1 visa nurses (68.3 percent) had been in nursing for five to 10 years. Average job tenure at HHC was 4.7 years for H-1 visa nurses compared to 13.9 years for U.S. nurses. Since an H-1 visa is valid for five, and possibly six years, it is not surprising that H-1 visa nurses had fewer average years of employment at HHC. Further, the mean length of HHC employment for H- 1 visa nurses indicates that the study sample was comprised primarily of nurses who were nearing the end of their H-1 visa allowance.

Table 2:Comparison of Education and Work Characteristics for Nurses with Current H-1 Visa Status and Nurses Who Are U.S. Educated and U.S. Citizens (N=857)

Educatiodwork characteristics

H-1 visa

N YO

WrSeS

us. Chi-square n u m significance

N YO

Highest Degree: Diploma Aswxiate Baccalaureate Other Total

17 5.3 3 0.9

0.0 0 320 100.0

300 93.8 L_ -

a7 16.3 <.Do1 248 46.4 180 33.7

19 I_ 3.6 534 100.0 I_

Job Satisfaction Survey Results Table 3 displays the mean scores for the three scales of the

Nurse Job Satisfaction Survey. Distribution of the scores for all three scales was normal.

Overall, nurses at HHC, both H-1 visa and U.S. nurses, rated their level of job enjoyment and satisfaction with the quality of care they were able to provide higher than they rated satisfaction with the time available to do their jobs. The first two scales were rated, on average, above the midpoint of the five point scale. In contrast, "time to do one's job" was rated below the midpoint by both groups of nurses.

H-1 visa and U.S. nurses did not differ on the quality and time scales. And, although U.S. nurses had statistically higher mean scores on the enjoyment scale (p=<.05), the difference was small.

Because of the difference in job titles among the direct care nurses, all data analyses were run both including and omitting assistant head nurses and head nurses. Demographic characteris- tics and satisfaction levels did not change when assistant head nurses and head nurses were omitted. However, the significant difference found between H-1 visa and US. nurses on the enjoyment scale when all direct care nurses were compared, was not apparent when assistant head nurses and head nurses were omitted.

Since both age and tenure of employment have been correlated with job satisfaction (Blegen & Mueller, 1987; Mottaz, 1988),

Number of Years AsAnRN:

Less than3 yn. 13 4.0 3 . 5 yrs. 37 11.5 5 10 vrs. 220 68.3 10 yn. or more 3 I_ 16.1 Taal 322 100.0

The Shift Worked Most Of the Time: Day 131 40.7 Evening 86 26.7 Night 61 18.9 Other - 44 - 13.7 Total 322 100.0

82 15.4 c.001 49 9.2 a4 15.8 - 318 59.7 533 100.0

353 66.0 .:.Do1 77 14.4 61: 11.4 - 44 8.2 535 I00.0

Current Area of Employment: Medical/Surgical 49 owRecovefy 40 KU 47 Pediatric 62 Off iYN 15

Emergency Rm. /Clinics 26

Administration 2 Othef Areas > Total 322

Psychiatric 65

15.2 12.4 14.6 19.3 4.7

20.2

112 21.1 <.m1 33 6.2 37 7.0 70 14.7 43 8.1 59 11.1

8.1 0.6 - 5.0 100.0

116 21.9 4 0.8 - 48 9.1 530 100.0

Current Work Pattern At HHC: Full-Timeor

Flex-Time 106 33.0 Full-Time & 0-T 208 64.8 P-Tor Other - 7 2.2 Total 321 100.0

Table 3:Comparhn of Mean Satisfaction Scores on the Nurse lob Satisfaction Survey for H-1 Vim and U S . Nurses

334 64.2 <.Gal 147 28.3

7.5 - 39 520 100.0 -

Satisfaction Subscale

H-1 visa U.S. nupses nurses Annual Salav:

Less Than $ t 9,999 5 1.6 $20,OaO - $29,999 79 24.9 $30,000-$39,999 170 53.6 140,000 - $49.999 44 13.9

31 6.0 c.001 143 27.6 323 62.2 19 3.7

Quality Mean Score Standard Error N

3.02 0.M 2 90

3.06 0.04 4 0 0 $SO;MH) or More 19 6.0

Total 31 7 100.0 0.6

519 100.0 - 3 -

Enjoyment Mean Score Standard Error N

3.25' 0.03 31 2

3.23. 0.03 502 Totals may not add to 100 percent due to rounding.

were assistant head nurses or head nurses. Forty-seven percent of U.S. nurses held titles of assistant head nurse or head nurse compared to 20 percent of H-1 visa nurses. This variation may have been due to differences in job tenure and job experience, since job experience and length of time in a hospital increases the likelihood of promotion. Most U.S. nurses had been in nursing

Time Mean Score Standard Error N

2.38 0.04 300

2.30 0.04 426

T-Test probability *PI .05

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Nurses’ Job Satisfaction: Are There Differences Between Foreign and US-Educated Nurses?

and significant differences were found on age and job tenure at HHC between H-1 visa and U.S. nurses, additional analyses were performed to control for these possible confounders. One-way Analysis of Variance was performed with quality, enjoyment and time as the dependent variables and visa status as the covariate. Controlling for age and job tenure, there were no differences between H-1 visa and U.S. nurses on the three scales.

Multivariate Analyses of Satisfaction Results Few variables emerged as explanatory in the multivariate

analyses and the amount of variance explained by these models was low. The adjusted R-squares were .10 (Quality), .04 (Enjoy- ment) and .12 (Time). However, H-1 status was not a significant predictor of satisfaction on any of the three scales.

Hospital and unit assignments were the strongest explanatory variables for the score on quality of care. Working in the operating roodrecovery room (OR/RR) or in pediatrics was also a positive predictor. In contrast, employment at one particular study hospital was negatively related to this construct. Although less strong, having a diploma (as compared to having a baccalau- reate degree) was also a positive predictor of the quality score.

Working in the intensive care unit (ICU) was a significant but negative predictor of job enjoyment, while positive coefficients were found for having a child under five years of age and earning a higher salary.

Hospital and unit assignment as well as having an “other” degree were strong explanatory variables of having time to do one’s job. Positive coefficients were also found for working in the OR/RR, psychiatry, pediatrics and outpatient clinics. How- ever, having an “other” degree (nearly always an associate degree in this study) and a salary below $20,000 were negative predictors of having time to do one’s job.

Discussion

The findings from this study show that H-1 visa nurses did not differ from U.S. nurses in their satisfaction with the quality of patient care they could provide or the time available to do their job. Although, in preliminary analyses, H- 1 visa nurses appeared to enjoy their jobs less than U.S. nurses, the difference disap- peared when age and tenure of employment were controlled in subsequent analyses. Most importantly, H-1 visa status was not a significant correlate to any of the three satisfaction scales in either bivariate or multivariate analyses.

H-1 visa nurses did differ from U.S. nurses on other measures such as age, parenting status, educational preparation, number of years as an R.N., job title and length of employment. Shift assignment also varied between the groups, probably reflecting differing job tenure; that is, the longer-tenured U.S. nurses tended to work the day shift as a function of their seniority. Unit assignment also varied, with H-1 visa nurses predominantly working in specialty units. Work patterns also varied substan- tially: H-1 visa nurses worked more overtime and, as a result, earned higher salaries than their U.S. colleagues.

These comparative characteristics both echo and contradict previous work. Cowart (1983) found that U.S. nurses were more often assigned to specialty areas even though the foreign-

educated nurses were older and more experienced. Although the foreign-educated nurses in this study were younger and less experienced than their U.S. colleagues, they were more likely to be employed in specialty areas such as the intensive care and psychiatric units. These differences in unit assignment remained when assistant head nurses and head nurses were omitted from the sample.

The finding that H-1 visa nurses in this study worked more overtime hours and thus earned higher salaries confirms Cowart’s (1983) results. The apparent willingness of H-1 visa nurses to work overtime also underscores the desirability of these nurses from an administrative viewpoint. In a nursing shortage, a pool of staff nurses who will work overtime reduces the hospital’s reliance on agency nurses who can cost up to double the hourly rate of a staff nurse (Brider, 1991).

In general, few variables emerged as explanatory in the multivariate analyses and the amount of variance explained by these models was low. Hospital and unit assignment explained most of the variance in the quality model, suggesting that nurses in specialty units were more satisfied with the quality of care they could provide than nurses working in the general medical and surgical units (the reference group). The dissatisfaction at one of the hospital sites may be explained by the fact that the hospital was experiencing the worst nursing shortage and high- est turnover rate among the six study sites.

It is difficult to explain the higher level of satisfaction with the quality of care reported by diploma nurses. It is possible that diploma nurses (as compared to the reference group, baccalau- reate nurses) were able to deliver higher quality care and this is reflected in their reported satisfaction. It is also possible that the diploma nurses delivered the same quality care, while feeling more satisfied.

Three variables predicted job enjoyment. Nurses working in the ICU enjoyed their jobs less than nurses working on medical and surgical units, possibly reflecting the stressful and demand- ing nature of acute care units. Although it is not surprising that nurses earning the highest salaries reported higher enjoyment, it was somewhat surprising that nurses with children under five years of age reported higher enjoyment levels. One might expect that the additional requirement of arranging for care of these young children might potentially lower the level of job satisfac- tion for these nurses. However, on the other hand, perhaps the flexible nursing schedules and a stimulating environment pro- vided these mothers with an enjoyable alternative to remaining at home with small children.

As was true in the other two models, unit assignment ex- plained satisfaction with time to do one’s job. Nurses working in specialty units felt they had more time to do their jobs compared to nurses on medical-surgical units. Nurses with “other” degrees, primarily associate degree, felt they had less time to complete their work than their BSN colleagues. With chronic staffing shortages and increasingly ill patients to care for, hospital nurses must provide care to patients in some order of priority. Perhaps the skills of time management and delega- tion, which are emphasized more in baccalaureate preparation, explain why these associate degree nurses felt they had less time to do their job.

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Nurses’ lob Satisfaction: Are There Differences Between Foreign and US-Educated Nurses?

Nurses with salaries less than $20,000, likely representing part-time employees, felt they had less time to complete their work. Working less frequently on a unit may result in greater disorientation and reduced continuity of patient care on a day- to-day basis when compared to full-time employees. The part- time workers may feel there is less time to complete their work.

Although these results suggest that nurses recruited from abroad are not less satisfied with their work than their U.S. counterparts, the findings should be viewed with caution for several reasons. First, as mentioned above, the sample com- prised nearly all Filipino nurses. Thus these data about the characteristics and satisfaction level of H-1 visa nurses may be more reflective of Filipino nurses than foreign-educated nurses in general. However, since nearly three-quarters of all H- 1 visa nurses in the U.S. are from the Philippines, the information is important when examining the recruitment of these nurses.

Second, the NJSS has not been tested for cultural bias. Cultural bias in survey design may result in misunderstanding of language as well as the construct meaning of the survey instrument (Jackson, Tucker & Bowman, 1982). It is possible that a different interpretation of statements could result in an assessed satisfaction for H-1 visa nurses that is different from their true level of job satisfaction.

Third, this study was conducted in a public hospital system. Therefore, it is not clear if these results are generalizable to foreign-educated, H- 1 visa nurses working in either private acute hospitals or in other health care settings.

Finally, the survey instrument did not measure other impor- tant external factors that might affect job satisfaction. For example, Blegen and Mueller (1987) found that job satisfac- tion of hospital-employed nurses is affected by the nurse’s perception about job opportunities elsewhere; a nurse is more satisfied if s h e perceives that there are fewer other opportuni- ties. If this is the case, H-1 visa and U.S. nurses are not operating on a level playing field. By virtue of their temporary immigration status, H-1 visa nurses are not as likely to perceive other job opportunities. Although H-1 visa nurses are pennit- ted to transfer among HHC hospitals or to another New York City hospital, they are clearly less mobile than their U.S. counterparts. Both the paperwork involved in transferring from one sponsoring hospital to another and the reluctance of most H-1 visa nurses to increase their interaction with INS, restrict the free flow of H-1 visa nurses in the job market. The extent to which H-1 visa nurses feel confined may alter their level of satisfaction substantially, creating differences be- tween the groups that were not apparent in this analysis.

Future research should include measures of external factors that might differentiate the job satisfaction of U.S. nurses from those on temporary work visas, as well as survey instruments that have been tested for cultural neutrality. Such information will enhance our understanding of the job satisfaction of this group of nurses, who - though termed temporary and part of a “stop gap” policy - have provided considerable enhancement to the professional nurse work force in the United States for the past 50 years. @!Q

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