title: Exploring longitudinal shifts in international nurse migration to the United States between 2003 and 2013 through a random effects panel data analysis.
abstract: No study has examined the longitudinal trends in National Council Licensure Exam for Registered Nurse (NCLEX-RN) applicants and pass rates among internationally-educated nurses (IENs) seeking to work in the United States, nor has any analysis explored the impact of specific events on these trends, including changes to the NCLEX-RN exam, the role of the economic crisis, or the passing of the WHO Code on the International Recruitment of Health Personnel. This study seeks to understand the impact of the three aforementioned factors that may be influencing current and future IEN recruitment patterns in the United States.
  
  
  
  In this random effects panel data analysis, we analyzed 11 years (2003-2013) of annual IEN applicant numbers and pass rates for registered nurse credentialing. Data were obtained from publicly available reports on exam pass rates. With the global economic crisis and NCLEX-RN changes in 2008 coupled with the WHO Code passage in 2010, we sought to compare if (1) the number of applicants changed significantly after those 2 years and (2) if pass rates changed following exam modifications implemented in 2008 and 2011.
  
  
  
  A total of 177 countries were eligible for inclusion in this analysis, representing findings from 200,453 IEN applicants to the United States between 2003 and 2013. The majority of applicants were from the Philippines (58 %) and India (11 %), with these two countries combined representing 69 % of the total. Candidates from Sub-Saharan African countries totalled 7133 (3 % of all applications) over the study period, with half of these coming from Nigeria alone. No significant changes were found in the number of candidates following the 2008 economic crisis or the 2010 WHO Code, although pass rates decreased significantly following the 2008 exam modifications and the WHO Code implementation.
  
  
  
  This study suggests that, while the WHO Code has had an influence on overall IEN migration dynamics to the United States by decreasing candidate numbers, in most cases, the WHO Code was not the single cause of these fluctuations. Indeed, the impact of the NCLEX-RN exam changes appears to exert a larger influence.
authors.affiliation: New York University College of Nursing, 433 First Avenue, New York, NY, 10010, USA.
authors.forename: Allison
authors.initials: A
authors.lastname: Squires
authors.affiliation: New York University College of Nursing, 433 First Avenue, New York, NY, 10010, USA. mtm411@nyu.edu.
authors.forename: Melissa T
authors.initials: MT
authors.lastname: Ojemeni
authors.affiliation: New York University-School of Medicine-Population Health, 227 East 30th Street, New York, 10016, New York, United States.
authors.forename: Simon
authors.initials: S
authors.lastname: Jones
mesh_terms: D000124:Achievement; D017954:Africa South of the Sahara; D057172:Economic Recession; D004521:Educational Measurement; D004641:Emigration and Immigration; D006801:Humans; D007194:India; D007391:International Cooperation; D008004:Licensure; D009549:Nigeria; D009726:Nurses; D064700:Nurses, International / Q000639:trends*; D010560:Personnel Selection; D010679:Philippines; D011365:Professional Practice Location; D014481:United States
keywords: Internationally-educated nurses; Nurse migration; Nursing credentialing and licensure examination for registered nurses; United States; WHO code