Franklin Shaffer, CEO of CGFNS International, envisions a world where nurses can be mobile, free of the barriers of educational portability

The career of Dr Franklin Shaffer, CEO of the Commission on Graduates of Foreign Nursing Schools (CGFNS International), has been varied and progressive, including positions as a hospital nurse executive, a researcher, an educator and an association executive.

Dr Shaffer received his basic nursing education in a three-year diploma programme and after graduating, served as a US army nurse during the Vietnam War. After the army, he earned his baccalaureate degree, while working full-time in critical care and emergency nursing. He continued his education, while working and progressing to the position of nurse executive.

Dr Shaffer holds a doctorate of education in nursing administration, and a masters of arts in nursing administration with a clinical major in adult health from Columbia University, New York. He taught in graduate nursing programmes, including Teachers College, Columbia University, Adelphi University and Hunter College in New York.

Following this, Shaffer became deputy director of the National League for Nursing (NLN), the oldest professional nursing organisation in the US. The NLN published the first standard curriculum for schools of nursing in 1917. In 1952, it assumed responsibility for the accreditation of nursing schools throughout the US.

During his tenure at the NLN, Dr Shaffer was in charge of accreditation of schools and colleges of nursing and was involved with CGFNS International in its early years. He was and still is “deeply committed to its mission”.

As a minority (a male nurse), he has a sense of solidarity with the immigrant nurse, and as a former chief nursing officer, he experienced firsthand the work CGFNS International does to help employers recruit competent immigrant nurses.

Some of his work at the NLN still has impact today: it conducted some of the original research on educational outcomes of US schools of nursing. It also launched the curriculum revolution among US nursing schools to stimulate innovation in nursing education.

Dr Sha f fer al so worked on the development of the educational mobili t y programme to support nurses, moving from one programme to another. He suggests that nurse mobility has moved beyond educational programme and has already begun trade agreements. Memoranda of understanding between nations have already included nursing.

After NLN, Dr Shaffer served as vice president on the education division of CrossCountry Healthcare, before becoming president of its education and training division. He successfully spearheaded efforts to involve the joint commission (TJC) in the development of certification for staffing companies, by helping to develop the necessary metrics for evaluating them. Dr Shaffer specifically sought the accreditation of the TJC since it evaluates hospitals. He believed that staffing firms should be measured in the same manner that their customers are evaluated. Dr Shaffer was eventually appointed to serve on the TJC Nursing Advisory Council.

In 2002, he was inducted into the American Academy of Nursing in recognition of his many contributions to the nursing profession. There has been a common thread in his diverse professional appointments: identifying and establishing standards of education and practice.

The search for outcome measures for nursing has a long, distinguished history, which attracted Shaffer from the beginning. Indicators foster the understanding of a system and how it can be improved. They monitor performance against agreed standards or benchmarks. Crucially, indicators provide a mechanism by which nurses can be held accountable. It should be of no surprise that Dr Shaffer’s doctoral dissertation was on diagnostic related groupings (DRGs) as a utilisation review tool.

Developing performance metrics
The DRG system was not useful in identifying or evaluating nursing’s contributions to patient care – one of Dr Shaffer’s lifetime passions. Thus began his pursuit of the metrics that could identify, measure, evaluate, and require accountability for, nursing education and practice. To be useful, indicators must be measurable with available data at reasonable cost. There must be evidence that the quality or quantity of nursing substantially contributes to changes measured by the indicator.

The indicator must be recognised as important by the public, educators, managers and nurses themselves. Among the most widely used indicators today are safety measures such as failure to rescue, falls, healthcare-associated infection, and pressure ulcers. Such metrics can then enable the public to make informed decisions about their care based on criteria, which matter to them as well as to managers and clinicians.

Dr Shaffer knew that developing performance metrics is only the first step in building a robust infrastructure for the implementation and full integration of nursing into the management of the healthcare service delivery at all levels. The next step is to identify, measure and evaluate the skills nurses must master to produce the desired performance. After this, the education/practices nurses must develop the skills.

Dr Shaffer’s career mirrors his thinking: as a staff nurse he experienced firsthand what is needed to practice; as an administrator and educator, he evaluated nurses’ performance; and as head of an educational accreditation team, he assured nurses received the necessary education. With this background, he joined CrossCountry Healthcare and tackled the complex problem of assuring the improvement of nurses’ performance skills in a highly diverse, mobile workforce.

In 2011, Shaffer was selected to be the CEO of CGFNS International. Here, he talks about his position and responsibilities.

Can you give us some background on how CGFNS has evolved over the years?

“My predecessors provided the leadership and vision that made CGFNS International’s success possible. I especially must recognise my immediate predecessor, Barbara Nichols, who positioned CGFNS International globally by building our strong and credible reputation. The Commission on Graduates of Foreign Nursing Schools has evolved considerably over the years. For example, we changed our name to CGFNS International to reflect more accurately the breadth and depth of our work. We are the largest credentials evaluation organisation for nursing in North America, and we are continuing to evolve globally.

“For 35 years, we worked only for the US. Now, we offer our services to countries other than the US. The CGFNS Qualifying Exam was our original reason for existing, and continues to be a major programme – now offered worldwide online. It still remains an excellent predictor of success on the NCLEX-RN examination.

“CGFNS International has built the largest educational database on nursing in the world, encompassing data on 179 countries. We also have developed the most extensive data base on individual foreign educated nurses who have migrated to the US. These two databases are used internally and are in demand by researchers throughout the world.

“In 1996, President Clinton signed the Illegal Immigrant Reform and Immigrant Responsibility Act, and CGFNS International became the only organisation authorised to assess the credentials of all foreign-educated healthcare professionals (except physicians) prior to obtaining an occupational visa to practice in the US. Promulgated in 2003, the Act was re-authorised by the US Department of Homeland Security for an additional five years in 2004 and again in 2009. The internationally educated healthcare professionals that CGFNS serves by law now includes seven other health care professions as well as nursing.

“VisaScreen: Visa Credentials Assessment is administered by the International Commission of Healthcare Professions (ICHP), a division of CGFNS International, and is comprised of an educational analysis of primary source documents, which are authenticated and verified including: licensure validation; English language proficiency assessment; and, for registered nurses only, an examination of nursing knowledge (CGFNS Qualifying Exam or NCLEX-RN). Once applicants successfully complete all elements of the assessment and evaluation, they receive a CGFNS/ ICHP VisaScreen certificate, which can be presented to a consular office or, in the case of adjustment of status, to the attorney general as part of a visa application. The process ensures that internationally educated healthcare professionals practicing in North American are comparable to their domestic counterparts.

“In 2003, the Department of Homeland Security issued a regulation which made the VisaScreen certification a requirement for both immigrant and non-immigrant healthcare workers. CGFNS International is the only organisation permitted to administer VisaScreen to all seven listed professions (physicians are exempt). The certificate must be presented to a US embassy or consulate for visa approval, a border agent to have North American Free Trade Agreement (NAFTA) status granted, or US Citizens Immigration Services (USCIS) to change or adjust immigration status.

“The VisaScreen certificate is valid for five years and must be renewed if the holder has not been awarded permanent status.

“In 2005, CGFNS International partnered with the International Council of Nurses to establish the International Centre on Nurse Migration (ICNM) to serve as a repository and clearing house on research focused on nurse migration. We are fortunate to have a group of global leaders to advise the ICNM on matters that influence nurse migration globally. They represent organisations such as the World Health Organization, the International Labor Organization, and the International Federation of Hospitals, who comprise our Strategic Action Group (SAG).

“Although recruitment has abated, ethical concerns about migration continues to be an issue in many countries. In 2010, the World Health Organization developed a Global Code of Practice on the International Recruitment of Health Personnel. “ Can you tell us a bit about your role as the CEO of CGFNS International?

“Perhaps the most important thing is that I report to a Board of Trustees. I also recommend and participate in the Board’s formulation of CGFNS International’s mission, strategic plan, and related policies. Within that framework, I have the full authority to plan, organise, co-ordinate, control, direct, and evaluate the programmes, activities and staff of CGFNS International.

“I develop and manage resources in alignment with the organisation’s strategic goals and priorities, and assure that all funds, legal records and physical assets are properly instituted and safeguarded... I monitor international affairs and, as appropriate, initiate actions and involvement with federal and state agencies in the US and throughout the world – while providing timely Board communication regarding the implications of international affairs.

“One of the things I do that I enjoy the most is maintaining effective relationships with other organisations, both public and private, and representing CGFNS International on planning bodies, councils and interagency committees... I see CGFNS International moving from process-based credentialing to outcome-based assessment of practice. I see CGFNS International shifting towards outcomes by integrating the practice aspect of competency to assure continued competency across all aspects of an individual’s portfolio.

“I see CGFNS International moving from primarily serving the US to increasingly serving countries around the globe, assuring that education and practice are appropriate to the practice environment, and assuring safety for patients everywhere. I hope that through educational research, we will shift to a world where professionals can be mobile without encountering unnecessary barriers. The biggest barrier is educational portability.

“I can envision a time when CGFNS International will move from being a onetime service to a lifelong resource for migrating professionals. We have initiated a ‘corporate university’ to enable CGFNS International to become a career centre for immigrant nurses, providing upward mobility through online remediation, education, career coaches and mentors.

“This will be done through leveraging the intellectual capital of CGFNS International staff, and through the development of a collaborative network between CGFNS International University and leading colleges and universities in the US. Some of this is already in progress – and there clearly are many more opportunities to come! “

Interview - Breaking borders