Inna Samotveyeva, RN, who works in the ultramodern postpartum unit at Tri-City Medical Center in Carlsbad, Calif., near San Diego, thinks back to a time when she operated under a somewhat different care model.

"Before an operation, I would remind the patient not to forget to bring his own alcohol and gauze, and even medicine," she said. "Otherwise, we couldn't do the operation."

Samotveyeva, an ethnic Russian, worked as an ob/gyn nurse in Minsk, Belarus, before coming to the United States four years ago. She has found both obstacles and boons to working in this country-among them more high-tech equipment, abundant supplies and a language barrier she has largely overcome.

Yet in a shortage-wracked industry critically in need of her skills, Samotveyeva, along with many other recent immigrants with a health care background from Russia and the former Eastern bloc, has fit right in.

"Teamwork was the biggest change in terms of the work system," she said. "Here, I'm part of a team, but I still have independence. In the Russian system, you have the doctor also available, making rounds, making all the decisions, but here I can decide the proper care until the point when I need to call the doctor. This is better for the patient because I can work more efficiently."

Although the number of Russian immigrant nurses is difficult to gauge, the Washington-based Commission on Graduates of Foreign Nursing Schools reports that 17,285 foreigners took the council's licensing exam last year, compared with 91,425 domestic applicants. (The figures include those who were repeating the test.)

Not all states track applicants by nationality, but the California Board of Registered Nursing reported that from 1997 to March 2001, 681 Russians took the exams, in contrast to 2,987 Filipinos and 4,618 Canadians.

But across the board, one critical factor plays into the hireability of Russian nurses: their education-too little or too much.

"Russians who come here have a very hard time. Nursing education in Russia is more along the lines of LVN training in this country," said Quin Brunk, Ph.D., RN, a professor at the University of Texas at El Paso School of Nursing.

"They have no status or respect and defer to physicians in all things in that system. So we can't just expect them to come here and zip through the state boards."

Brunk, a Fulbright scholar at Sechenov Moscow Medical Academy in 1998-99, returns regularly to Russia to teach Western nursing skills such as more sensitive caregiving and critical thinking. She noted that Russians working in the United States have to surmount considerable linguistic and cultural obstacles.

"A case in point is that Russians believe a terminal patient should not be told about his condition. Even after a 1993 Russian law that was supposed to stop this practice, this basic belief is built into their culture. In the States, we involve the family and patient a lot more; no one is left out of decision-making."

Salpy Akaragian, MN, RN, director of the International Nursing Center at UCLA, agrees that nurses trained in the former Soviet Union can suffer from low expectations of their job and an over-reliance on physicians.

"Some of these nurses were around only to serve coffee to the doctors," Akaragian said. "Their nursing care skills were very basic. They had no anatomy or pharmacology training; the most they could do was give an enema. They didn't have the knowledge to communicate with doctors on an equal footing and have input on the patient's care.

"Also, the attitude toward knowledge is different in an authoritarian culture. If you have knowledge, you don't want to share it, because that might put others one step ahead of you; you might lose control. So you're even less likely to share any details about care with a patient."

On the other hand, Russian nurses-like many other immigrant health care workers-tend to take a more holistic approach to health care, which the American model could learn from, Brunk said.

Scarce medical and technological resources also have made these nurses more creative in finding alternatives to standard care, she added.

Other Russian nurses encounter difficulties in the United States because they have too much education. Under the Russian educational system, prospective doctors spend a year of medical school working as nurses before moving on to their specialties, Akaragian said. Those physicians who then try to find work in the United States as nurses (or any health care job) often receive a rude awakening from state and federal licensing boards.

"We've had to tell physicians from the former Soviet Union and Eastern bloc that they can't just assume they can work as RNs here, simply because they already have a doctor's degree in their home countries," said Silvia Pomponi, marketing specialist at the Commission on Graduates of Foreign Nursing Schools. "The training is different, the standards are different and they may require additional coursework."

But that's easier said than done. Many immigrant health care workers find the red tape so confusing and inconsistent from state to state that they wind up working as cab drivers or other menial laborers, their valued skills going to waste, said José Ramón Fernández-Peña, MD, MPA, coordinator for the Welcome Back program.

Funded by The California Endowment and in partnership with the City College of San Francisco and others, the initiative seeks to bring foreign caregivers into the U.S. workforce through intensive programs that teach them English, familiarize them with the industry and guide them through licensing procedures.

"We want to promote a positive image of the immigrant as someone with skills, who is eager and willing to contribute to society, not as someone who just came here to take and take," Fernández-Peña said. "But the needlessly lengthy and cumbersome process of re-entering the health care field is a big obstacle. "

Foreign workers add to the diversity of a still largely white and monolingual nurse population, Fernández-Peña said, but Kay McVay, RN, president of the California Nurses Association, noted that the United States already has many culturally diverse nurses within its borders who are citizens-it's just that the health care industry is unwilling to tap that resource.

"The powers-that-be don't go into the inner cities to find diversity. They never have made an honest effort to recruit African Americans, Latinas, Asians. Instead, we've had waves of Filipino RNs coming in every decade since the 1960s," McVay said.

Rather than spending so profusely on foreign recruitment drives, she said, hospitals should focus on domestic nurse retention, education and improvement in working conditions.

Bram Briggance, MA, assistant director of the California Workforce Initiative at the University of California, San Francisco Center for the Health Professions, agreed that the global nursing shortage will make foreign recruitment merely a short-term cure for the American crisis.

"We expect that particular source of labor to dry up before long, leaving California with a shortfall of at least 40,000 nurses by 2020," he said.

"It's not a matter of taking jobs away from anyone," Fernández-Peña said. "The fact is we do have a need for a diverse workforce provided, of course, that its members have the skills and the linguistic competency.

"But at some level, it's up to the employer to determine whether the candidate is a good worker or not."

Yuri Kamenetsky, RN, an ob/gyn nurse at Kaiser Permanente in Walnut Creek, Calif., agreed. Despite the different equipment and team system he deals with now, the goal of his practice is essentially unchanged since his days as an obstetrician in Russia. aren't several different ways to have a baby, really," he said.

"Many of the nurses I work with are foreigners, either Filipino or African or Latino," said Lyudmila Braginskaya, an LVN who works at the Guardian Ygnacio Nursing Home in Walnut Creek. "We are all in the same boat and we support each other. We are all eager to work.

"I felt nervous at first about my English, but with a good supervisor things worked out. Nurse managers know that Russian RNs work well; we have a good reputation for being educated and diligent."

Despite the pressures and controversies swirling around them, Russian nurses are often philosophical about their work in the United States. The main thing is to oblegchit stradanie-"relieve suffering," Braginskaya said.

Although trained as a doctor in Russia, she cannot afford to return to medical school in the United States, as she has a family to support.

"Nursing care is essentially the same in all countries," she said. "If you are an honest, spiritual person, you can help oblegchit stradanie."