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International RN Recruitment Takes Know-how

Monday February 9, 2004
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When Lady Liberty arrived on our shores from France, most of the people who followed her lamp were tired, hungry, and poor. Ship after ship arrived with immigrants who brought little more than the clothes on their backs, the treasures in their steamer trunks, and hope in their hearts. As time has passed, the welcome mat has grown smaller and smaller. Now, more than 100 years later, the climate has changed completely.
Our country still allows entry to those who struggle to get here, but the big welcome is for those who have skills that our country needs. Nurses have such skills, and with the national nursing shortage, it would seem all obstacles would melt away. Not so. Tightened laws since 9/11 have made it more difficult for hospitals to recruit foreign nurses. Despite these hurdles, nurse recruiters arrange for hospitals to successfully sponsor nurses, and the staff reaps the benefits.
A Simpler Time
Andrea "Corky" Holm, RN, BS, manager of Strategic Recruitment for the Atlantic Healthcare System (AHS), has been recruiting foreign nurses since the 1980s. The climate has changed over the years.
"There was a different visa requirement 20 years ago," she says. "The H1B visa was available. Nurses could work in this country, and the hospital could renew their visas annually for six years. Once their visas expired, most of the nurses chose to return home. Many of the nurses came from England, Ireland, Scotland, and the Philippines. The waiting time for the nurses to arrive was relatively short - about six months. We recruited wherever the nursing curriculum was comparable to that taught in the US. That part hasn't changed."
But the availability of foreign nurses has changed a lot. The United Kingdom no longer has a surfeit of nurses, so recruitment there has virtually ended. At the same time, the visa situation has also changed. The H1B visa is still available for nurses with a BSN, but in order for the hospital to use that type of visa, it must hire only nurses with BSN degrees. The alternative is to sponsor foreign nurses as permanent residents, and AHS chose this option. The first group was recruited in early 2001.
Cut the Red Tape
Holm relates that the experience has been positive. AHS uses an agency for the initial screening of candidates. Profiles of the applicants are then forwarded to Holm and her staff for review.
"All the nurses in the Philippines have BSN degrees," she says. "We've been satisfied with the staff we've hired. They bring an excellent knowledge base; they have a great grasp of nursing theory. They need additional training in technology and help with the cultural differences they will encounter here in the US."
In order to become certified to work as a nurse in the US, the Commission on Graduates of Foreign Nursing Schools must be satisfied that the nurse's education is equivalent to that offered in the US. Additionally, it will verify that the individual's work and educational history is authentic, and the license unencumbered.1
"The Philippine nursing curriculum is very similar to that of the US," says Holm. "And that becomes very important as [nurses] move through the process. There are a few more obstacles to overcome now. The waiting time is much longer now than it used to be - anywhere from 18 to 24 months."
However, that time is not wasted. Each nurse must pass an English language proficiency test, the National Council Licensure Examination for Registered Nurses (NCLEX-RN), and be issued the appropriate documents by the US government.
AHS's Workshops Do the Work
The AHS team streamlines the process wherever possible. "We went to the State Board of Nursing to find out where the accredited testing centers outside the US were and found there was one in Saipan," says Holm, referring to an island in the Marianas. "We arranged to have instructors from some colleges go to the Philippines to give an NCLEX review course. We sent representatives from AHS to support the nurses as they took the course, and then we flew the nurses to the testing site to take the test. During the review course, we also held immigration workshops."
The workshops focused on the other bottleneck that the team identified - paperwork problems. When Holm investigated ways to expedite the US Embassy paperwork, she was told that often paperwork simply isn't filled out correctly by the applicant. "Sometimes they don't bring original documents; they bring copies to their interview. When that happens, it postpones the interview for another month. When we conducted the workshop with assistance from our agency, we reviewed the paperwork, showed them the different forms, and explained the different phases of the process."
But the workshop is more than a paper review. Holm and her team use the time to begin the orientation of the nurses to the AHS philosophy and structure. "It's a good time to tell them what we're all about," she says. "We tell them what we have to offer and help them get familiar with what they can expect, including what kinds of clothes they'll need here in the US."
The streamlining process and a focus on preventing problems cut the waiting time for nurses to arrive in the US to between 14 and 16 months. Making it easy pays off in retention. The arrival and retention rate is much higher than the national average, which is about 40%. The retention rate for the AHS group is closer to 60%. When the nurses arrive, they are welcomed with open arms.
Welcome Home
Before they enter the US, the nurses have been introduced to some of the nurse managers at the hospital where they will work. They share e-mail addresses with one another, and relationships and friendships often begin before the plane arrives in the US.
In their new country, the arrivals aren't left to flounder on their own. Furnished apartments are provided during the initial adjustment period. The nurse managers at the hospitals develop a "welcome wagon" for each site. Each apartment is completely equipped with groceries, blankets, sheets, and all the comforts of home. Lunches with Philippine food and visits to the homes of staff add to the feeling of hospitality.
"Two of the nurse managers were recruited in the 1970s," says Holm. "And it was wonderful to have them tell the new nurses about their experiences. It worked out very well for everyone - we have a 100% retention rate so far."
Word of Mouth
AHS uses an agency and overseas visits to recruit. At Palisades Medical Center, North Bergen, NJ, recruitment is usually done by personal referral. Kathleen B. Campbell, RN, MBA, CPAN, nurse recruiter, meets with nurses who are in the country visiting. They apply for positions because friends or relatives suggest they come.
"Everything is more complicated now," she says. "We have one or two staff members who have family and friends in other countries, and they suggest people to us. We work with recruits and then sponsor them for green cards. We've sponsored 24 in the past two years."
Campbell notes that the recruits come from a wide variety of countries, including Tobago, the Philippines, Korea, Nigeria, and Guiana. The hospital uses the services of an immigration lawyer to facilitate the process.
"We're proud of the multicultural range of our staff," says Campbell. "It's worked out very well for our staff and for the new recruits. We make sure they have the courses and additional education they need, like IV certification."
Language is a key part of the entry process, and Campbell notes that the CGFNS English test can be a problem for some of these nurses. Most of the nurses from the Philippines do very well, she notes, because they are usually fluent in English and often speak Spanish. The hospital has a large Spanish-speaking clientele, so multilingual nurses are valuable.
Bloom Where You're Planted
Not every hospital has chosen foreign recruitment. At Stony Brook University Hospital, Stony Brook, NY, Patricia Gilbert, RN, BS, director of Nursing for Personnel Affairs, has steered recruitment efforts in a different direction.
"We feel people should bloom where they're planted," she says. "The most severe shortage is that of the high-tech nurse - ED, OR, critical care, and dialysis nurses are the most difficult to find. We've set up programs to train our nurses to go into these specialty areas. It has given them opportunities to move into new areas."
Gilbert points out that medical/surgical nursing is the cornerstone of nursing, but that many nurses want to move into specialty areas as they grow professionally. These programs allow that, making it easy for staff to stay and grow.
The specialty programs are geared to all levels of practice - there is a one-year residency program for new graduates, an internship program for experienced nurses who want to move into critical care, and a preceptor program for the ED. The three-month refresher program for returning nurses is popular too.
"We've put educators on every unit," says Gilbert, "and that enables these nurses to learn and grow professionally. They do a wonderful job training nurses and helping to retain them - we lose nurses from these areas only when they relocate."
The "Bloom Where You Are Planted" approach has paid off generally in high retention and low vacancy rates. Stony Brook University Hospital is one of the few in which the OR has no need for traveling nurses. The overall vacancy rate is 7%, which is considered quite low.
These efforts notwithstanding, foreign nurses are increasingly becoming an important and valuable part of the nursing profession in the US. As hospitals develop their programs and continue to offer new opportunities, this option becomes more attractive. For immigrant nurses, it is a way to begin a new life in a new place with a whole new world of opportunity.
Marylisa Kinsley, RN, BSN, is a contributing writer for Nursing Spectrum.
1. Bureau of Citizenship and Immigration Services issues final rule on healthcare professionals seeking occupational visas. HealthScope International, Fall 2003; pp 1-3.
EDITOR'S NOTE: More information about the NCLEX exam can be obtained from the Website for the National Council of the State Board of Nursing: http://ncsbn.org.