U.S. Hospitals Are Stepping Up Use of Foreign Nurses

It was an unceremonious arrival, but Robert Mawhinney recalls it fondly. As the car pulled up about midnight at the Doubletree Hotel in Orange, the door opened and a fussy 5-month-old infant was thrust into Mawhinney’s arms.

Mawhinney, who had been waiting at the hotel to welcome the child’s mother to America, immediately assumed responsibility for finding hot water to mix up a batch of baby formula.

It was an unusual assignment for the administrator of Midwood Community Hospital in Stanton, but one he gladly accepted. For it marked the arrival of his first nurse recruit from Ireland, who landed at Los Angeles International Airport with her baby and a toddler in tow.

Today, Mawhinney has three nurses on his staff from Ireland and three more on the way, and he is rolling out the red carpet for each.

Besides giving the nurses a hearty welcome, Mawhinney is paying their plane fares and providing a free month’s rent in comfortable, furnished apartments. The combined recruitment costs average about $6,500 per nurse.

Like Midwood Community, an increasing number of American hospitals are recruiting nurses from foreign countries to alleviate a critical shortage of domestic nurses.

In some cases, hospital administrators and nurse recruiters are going abroad on their own, placing advertisements in foreign publications and interviewing candidates directly.

Others are turning to a new but growing group of independent recruitment agencies that handle screening, visa applications and professional licensing requirements. In return, hospitals generally pay the agencies a fee of 10% to 20% of the nurses’ first-year salaries.

Still others are doing business with a second group of agencies that provide foreign nurses on a contractual basis. The nurses work as employees of the agencies, which pay their salaries and provide them with housing, uniforms and plane tickets to and from their home countries.

The influx of foreign recruits reflects the declining population of U.S. nurses as increasing numbers of women pursue less traditional, and usually more lucrative, career options.

Faced with chronic staff shortages and unable to recruit sufficient numbers of domestic nurses, many hospitals have decided that hiring foreigners is more cost-effective than paying skyrocketing fees for temporaries.

Some hospitals are old hands at overseas recruitment, having given it a whirl during the nursing crunch of 1979-1982, while others are trying it for the first time.

Although reliable national figures are not available, the Hospital Council of Southern California estimates that 4,650 foreign nurses are working on temporary working visas in California.

Arthur Sponseller, the council’s vice president of human resources, estimated that about 30,000 of the 200,000 registered nurses in California are foreign educated. That figure, which includes foreign nurses who have become permanent U.S. residents, has increased significantly since the last wave of foreign nurse recruitments in the late 1970s, he said.

Because of the necessity of hiring nurses with a firm grasp of English, the recruitment tends to be concentrated in the United Kingdom, Ireland and Canada. But it also has reached into Australia, New Zealand, Scandinavia, China, Korea, the Caribbean and English-speaking African nations.

The Philippines, where English is widely learned as a second language, has traditionally produced a surplus of nursing school graduates and has exported more nurses to the United States than any other country. Nearly 3,000 of the foreign nurses working in California on temporary visas are from the Philippines, according to the Southern California Hospital Council.

In the international competition for nurses, the United States has an edge because its salaries for nurses are relatively high. Average annual salaries for registered nurses in the United States in 1987 ranged from $21,000 to $29,000, according to a survey published by the American Journal of Nursing.

A separate Journal survey showed that registered nurses in Southern California received salaries considerably higher than the national average last year, ranging from $21,000 to $41,000. According to the Hospital Council of Southern California, staff nurses with one to three years of experience now earn about $32,000 a year.

Although salaries paid by U.S. hospitals are not high enough to entice sufficient numbers of Americans to enter nursing school or remain in the profession, they typically are two to three times the pay received by nurses in England. The discrepancy is even greater in the case of developing countries like the Philippines, where an average registered nurse earns only $100 a month.

Ann Gardner, a 25-year-old Irish nurse who left a $10,000-a-year job in a British hospital to take a $30,000-a-year position at Midwood Community, said most of her nursing school classmates are no longer practicing in Great Britain because of low salaries and poor working conditions.

But money wasn’t the only reason that Gardner signed a two-year contract with Midwood and came to the United States on a temporary working visa. “I came for the experience and for the sunshine and to see America,” she said.

Gardner said that when she was in London, she found plenty of opportunities to emigrate. During one year, she attended 10 seminars in London and two in Ireland conducted by agencies recruiting nurses for U.S. hospitals, mostly in the Northeast, Texas and California.

Only a year ago, few hospitals were willing to pay a foreign nurse’s way to the United States, said Joseph O’Grady, managing director of O’Grady-Peyton International, a Dublin, Ireland, firm that recruits Irish and English nurses for 25 American hospitals.

But today, O’Grady said, most hospitals will not only pay the air fare, many also are picking up rental expenses for three months or longer.

Lynn Hajek, associate administrator at Doctors Medical Center in Modesto, said her hospital’s employment package for foreign nurses includes a $1,000 bonus if they pass a three-month probationary period. “I tell them it is for a down payment on a car,” she said.

Hajek recently returned to America after interviewing nurses in Australia and New Zealand for 2 1/2 weeks. She said she became keenly aware of the global competition for qualified candidates when she interviewed a British nurse interested in working in the United States. The woman told her that only a year earlier, she and about 500 other British nurses had been recruited to Australia in an effort to reduce that country’s acute nurse shortage.

“There is an incredible amount of recruiting going on right now,” said Virginia Maroun, executive director of the Commission on Graduates of Foreign Nursing Schools in Philadelphia.

CGFNS administers tests that foreign nurses must pass before they can enter the United States on working visas. The exams, given in foreign countries in April and October of each year, are designed to predict whether a foreign nurse has the basic nursing skills and command of English needed to pass state nurse licensing exams.

Based on CGFNS test figures, it appears that the number of foreign nurses entering the United States is accelerating. From 1986 to 1987, the number of tests administered jumped to 18,000 from 14,000. The organization expects to give 20,000 tests in 35 countries this year.

The attraction of foreign nurses is mostly financial. “We are saving a lot of money,” said Mary Tenney, director of human resources at Long Beach Community Hospital.

Long Beach Community has contracted with Nursing Management Services in Century City for 15 foreign nurses, 10 of whom have arrived from the British Isles.

Tenney said the foreign nurses are helping the hospital fill staff vacancies and lessen its dependence on nurse registries, which provide hospitals with temporary nurses. Not only are foreign nurses far cheaper than paying for a registry’s service, they provide greater continuity of medical care for patients, she said.

“Our goal is to have enough nurses so we can discontinue using the registries,” Tenney said.

Tenney said Long Beach Community recruited a number of Philippine nurses five years ago, and it is pleased with the results. About 20 of the original group have stayed, she said, including “some of our most competent nurses.”

Nursing Management Services has assumed responsibility for the qualifications and welfare of the foreign nurses it provides to Long Beach Community. Although it pays British nurses “substantially less” than their American counterparts, Tenney said the nurses receive free round-trip transportation to the United States, paid accommodations in nearby apartments and advisers who help them tackle such tasks as obtaining Social Security cards and opening bank accounts.

Shirley Cotton, vice president of marketing for Nursing Management Services, said her organization has 70 nurses on contract from Ireland, England, Wales and Scotland, and has started recruiting in Canada and Australia. She said most of the nurses are assigned to California hospitals.

Cotton said Nursing Management Services brings foreign nurses to California in groups and gives them a week’s review course before they take their state licensing tests. They are then flown back home to await the results. By prequalifying its nurses, Cotton said, the company reduces the risk to hospitals.

“They come in as fully licensed RNs, and the hospital doesn’t have to be concerned that the nurse may fail the exam and have to be sent out of the country,” she said.

Hospitals that decide to hire foreign nurses often discover that the process is risky, complicated and, above all, tediously slow. In many cases, a year may lapse between the time a hospital chooses a foreign nurse and the nurse’s arrival in the United States.

Foreign nurses who want to enter the country on temporary working visas must produce educational and foreign licensing credentials and pass the CGFNS test. Applications to take the daylong exam, given two times a year, must be made three months in advance. Then the nurses wait about five weeks to learn if they passed.

Nurses who want to work in California also must apply to the state Board of Registered Nurses for an interim permit to allow them to work until the next time a state licensing exam is given. They must pass the licensing test, which is given in California in February and July of each year, to continue practicing as registered nurses.

Besides putting up with the inconveniences of testing schedules, hospitals find they must help foreign nurses adjust to different cultures and health care delivery systems.

Some of the cultural contrasts are welcomed. “British nurses have a certain amount of charm,” Tenney said. “In labor, delivery and nursery departments, parents have liked them very much.”

Other cultural traits are disconcerting to patients and hospital personnel. For instance, nursing officials said Filipino nurses sometimes seem rude, in part because their native language, when translated into English, tends to sound abrupt.

St. Joseph Hospital in Orange, which does no foreign recruiting but has a substantial number of foreign nurses on its staff, recently hired a speech consultant to help foreign nurses reduce their accents and communicate more clearly.

Because of the expense and arduous process involved, some hospitals have decided against recruiting foreign nurses.

Karen Hart, executive director of the National Assn. of Health Care Recruitment, said only 47% of 158 association members surveyed at a conference in April said they had hired foreign nurses last year. A slightly smaller percentage said they planned to recruit overseas in 1988. She said many complained about the paper work and cultural difficulties.

Most observers agree that foreign recruiting will not satisfy America’s demand for nurses. It is, at best, a stopgap solution to the nursing shortage.

About 11% of U.S. nursing positions are unfilled. The country has 1.5 million practicing registered nurses and will need another 300,000 by the end of the century.

And there is a limit to the number of qualified foreign nurses.

International Medical Services in Laguna Hills, which specializes in recruiting Filipino nurses, has 140 job orders from American hospitals, most on the East Coast. Kenneth Miller, the firm’s national director, said he won’t take more orders until he can find more nurses.

Miller’s partner in the Philippines, Harry Lauer, said he pretests and provides tutoring to Filipino nurses to improve their chances of passing the CGFNS exam. This year, the company has pretested 4,000 Filipino nurses. About half performed so poorly that Lauer said he considers them “hopeless” as recruitment prospects.

And some American nursing officials are having second thoughts about overseas recruitment because of criticism that they are exacerbating nursing shortages in other countries.

Beverly Bonaparte, assistant vice president of corporate nursing at New York City Health and Hospitals Corp., said the nursing pools in some countries have begun to dry up.

She noted that many foreign nurses are choosing not to return to their countries with their savings and new skills and instead are staying in the United States. About 65% of the foreign nurses employed in the New York City hospital system ultimately convert their visas from temporary to permanent status.

NURSES: Philippines 1,414 Canada 361 India 252 England 208 Puerto Rico 119 Jamaica 101 Ireland 90 Korea 64 Taiwan 51 Nigeria 48 THE FOREIGN CONNECTION An increasing number of U. S. hospitals are recruiting nurses from overseas because of a shortage of domestic nurses. The advertisements at right are from Nursing Times, a British nursing magazine. The chart above provides evidence of the influx of foreign nurses. In July 1987, the latest date for which figures are available, 3,179 foreign educated nursing candidates took state license examinations in the U. S. for the first time, according to the National Council of State Boards of Nursing. The test given in all 50 states and 10 jurisdictions outside the U. S. Nursing candidates came from 85 countries, with the largest numbers coming from the nations above.